Every finding on record at Hygieia Health Systems, Inc.

Observed in Record Review. In 1 of 2 discharge records, the organization did not involve the patient and caregivers in making decisions about their care, treatment, or services in a timely manner. Example: In RRDC#2, the Notice of Medicare Noncoverage was not presented to patient at least 2 days prior to discharge. Instead, the notice was presented and signed on the date of discharge. This was confirmed by the DPCS.

Observed in Record Review. In 2 of 7 records, the hospice’s interdisciplinary group, in consultation with the patient’s attending physician did not complete the comprehensive assessment no later than five calendar days after the election of hospice care. Example in RRHV#1, the initial SW assessment was not completed until 81 days after the election of hospice care. In RRBR#1, the initial psychosocial assessment was completed 11 days after admission. This was confirmed with the DPCS.

Observed in Tracer Visit. In 2 of 2 home visits, medication reconciliation was not being done per policy. Examples: In RRHV#1 during the medication reconciliation, the nurse did not inquire about the duplicate Tylenol medications in the patient's medication bin. One was noted in the Hospice prescribed bubble packet and second was in an OTC bottle. When asked, the caregiver informed the surveyor that the patient has been taking Tylenol 1 tablet twice a day from the OTC bottle for years. This was not on the patient's medication profile. The Comfort kit meds in RRHV#1 were not currently in the home due to the nurse discovering they were all expired during her last visit. In RRHV#2, the comfort kit medication Zofran expired 8/31/25. In RRHV#2, the nurse performing the reconciliation did not use a medication list within the EMR or the patient's home for comparison. Instead the nurse only visualized the bottles and Med packs provided by the caregiver. This was confirmed by the nurse making the home visit.

Observed in Tracer Visit. In 2 out of 9 charts, the initial bereavement assessment of the needs of the patient's family and other individuals was not conducted per policy. Example: In RRHV#1, the initial bereavement assessment was not completed. In RRBR#1, the initial BR assessment was completed 11 days after admission. This was confirmed with the DPCS.

Observed in Record Review. In 7 out of 10 records, the written plan of care did not include psychosocial goals based on the patient’s identified needs. Examples: In RRNHV#1, RRNHV#2, RRNHV#4, RRNHV#5, RRNHV#6, RRNHV#7, and RRHV#1, the plan of care did not include psychosocial goals. This was confirmed by the DPCS.

Observed in Tracer Visit. In 5 out of 5 records, the plan of care did not include all services needed for the palliation and management of the terminal illness and related conditions. Examples: In RRHV#1, RRHV#2. RRHV#3, RRNHV#1, and RRNHV#2 the plans of care did not include the patient's oxygen orders. In RRNHV#1, the POC did not include the patient's CPAP that was ordered for PRN use. This was confirmed by the DPCS.

Observed in Tracer Visit. In 1 out of 7 records, the plan of care included prn visits without an indication as to when the PRN visit would be initiated. Example In RRHV#1, the MSW and CH orders included prn visits without an indication as to when the PRN would be initiated. This was confirmed with the DPCS.

Observed in Record Review. In 5 out of 5 records, the organization did not provide the patient with care, treatment, or services according to the patient's individualized plan of care. Examples: In RRHV#1 during weeks 2 and 3 of benefit period 10, the RN made 1 extra visit per week. There was 1 missed monthly SW visit during the last month of benefit period 10. In RRHV#2, there was 8 missed aide visits (2 during week 1 of benefit period 13 and 1 every week during weeks 2- 7 of benefit period 13. In RRHV#3, there was 1 missed aide visit during week 1 of benefit period 2. In RRNHV#1, there were 2 missed aide visits during week 1 of benefit period 1. In RRHV#2, there was 1 missed aide visit in week 1 of admission. This was confirmed by the DPCS.

Observed in Record Review. In 1 of 7 records, the medication list in the patient record was inaccurate. Example: In RRNHV#1 the Oxygen was listed as 2-5 LPM prn. Per the MD IDG notes, the O2 was to be continuous @ 5 LPM. This was confirmed by the DPCS.

Observed in Record Review. In 1 of 2 live discharge records, the hospice did not provide the receiving facility of which the patient was transferred with a copy of the hospice discharge summary and, if requested, a copy of the patient’s clinical record. Example: In RRDC#1, a transfer summary was not sent to the receiving facility. This was confirmed with the DPCS.

Observed in Record Review. In of 1 of 2 records, the hospice did not provide the patient’s attending physician with a copy of the hospice discharge summary and, if requested, a copy of the patient’s clinical record. Example: In RRDC#1, the discharge summary was not sent to the attending MD after discharge. This was verified with the DPCS.

Observed in Individual Tracer. In 1 of 3 home visits conducted, Hospice surveyor noted the patients medication profile did not contain a complete and accurate list of the medications the patient was taking. The medication profile only contained the medications the hospice was providing under the hospice benefit. This was confirmed by the Administrator.

Observed in Record Review. In 2 of 5 patient records reviewed, Hospice surveyor noted for home visit #1, the patient goals on the plan of care were not measurable. For example, Patient will have adequate food and fluids and Patient will have control over anxiety. The target dates to achieve the goals were not individualized based on the problem but rather all the same date tied to the recertification period. This was confirmed by the Administrator.

Observed in Tracer Visit. In 1 of 3 home visits conducted, Hospice surveyor noted for home visit #2, the nurse turned the faucet off after performing hand hygiene with her bare hands.

Observed in Document Review. Hospice surveyor noted the SNF contract did not include the following clause : A provision that the hospice may use the SNF/NF or ICF/IID nursing personnel where permitted by State law and as specified by the SNF/NF or ICF/IID to assist in the administration of prescribed therapies included in the plan of care only to the extent that the hospice would routinely use the services of a hospice patient’s family in implementing the plan of care. This was confirmed by the Administrator.

Observed in Document Review. Hospice surveyor noted the following clause was not included in the SNF contract: A provision stating that the hospice must report all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by anyone unrelated to the hospice to the SNF/NF or ICF/IID administrator within 24 hours of the hospice becoming aware of the alleged violation. This was confirmed by the Administrator.