Every finding on record at Islands Hospice, Inc

Upon patient record review, 4 of 29 (Patient #3, 5, 7, 11) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient 03: The medication profile includes Hydrocortisone 2.5% "apply to affected area BID as needed for rash" it does not include an application site. The medication profile includes Lidocaine patch 4% "apply one patch TP to affected area daily, PRN pain" it does not include an application site. Patient 05: The medication profile includes Miralax 17G/scoop oral powder 1 timer per day as needed for constipation, it does not include a mixing diluent. Patient 07: The medication profile includes Calmoseptine 0.44-20.6% topical ointment, "apply to affected area" it does not include an application site. Patient 11: The medication profile includes Clotrimazole-Betamthasone 1.0-05% apply topically BID to affected area, do not include an application site.

Upon patient record review, 4 of 29 (Patient #8, 9, 11, 13) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient 08: The patient was admitted on 12/9/24 with a primary diagnosis of chronic kidney disease, stage V with evidence of significant weight loss, malnutrition and dysphagia. The plan of care does not include a problem statement with interventions and goals for the nutritional deficiencies. (Plan of care updated on site.) Patient 09: The patient was admitted on 11/14/24 with a primary diagnosis of cerebral palsy with a history of seizure disorder requiring levetiracetam for management, the plan of care does not include seizure precautions or interventions and goals for assessing the neurological condition. The patient is identified as deaf and non-verbal, the plan of care does not include interventions and goals for other means of communication. (Plan of care updated on site.) Patient 11: The patient was admitted on 10/18/24 for neurocognitive disorder with Lewy Body dementia, she has evidence of agitation, screaming and hallucinations. The plan of care does not include a problem statement with intervention and goals related to the neurological condition and symptom management. (Plan of care updated on site.) Patient 13: The patient was admitted on 8/21/24 with a primary diagnosis of malignant neoplasm of the colon, with a secondary condition of a colostomy. The plan of care does not include a problem statement with interventions and goals related to the altered bowel or colostomy care.

Upon patient record review, 6 of 29 (Patient #3, 4, 5, 7, 11, 12) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient 03: Medication orders on 2/19/24 for Hydrocortisone 2.5% "apply to affected area BID as needed for rash" does not specify an application site. Orders on 8/27/24 for Lidocaine patch 4% "apply one patch TP to affected area daily, PRN pain" it does not include an application site. (Order correction entered on site.) Patient 04: The patient record includes documentation entered by the nurse practitioner on 10/29/24 that the patient has a deep tissue injury to the left heel being covered with a foam dressing, the record does not include wound care orders for the left heel. (Order correction entered on site.) Patient 05: Medication orders on 11/17/24 for Miralax 17G/scoop oral powder 1 timer per day as needed for constipation, does not include a mixing diluent. (Order correction entered on site.) Patient 07: Medication orders on 12/16/24 for Calmoseptine 0.44-20.6% topical ointment, "apply to affected area" does not include an application site. Medication orders on 12/19/24 for Cephalexin 500mg PO 3 times a day for 7 days have not been discontinued. (Order correction entered on site.) Patient 11: Medication orders on 10/18/24 for Clotrimazole-Betamthasone 1.0-05% apply topically BID to affected area, it does not include an application site. (Order correction entered on site.) Patient 12: Orders for wound care to coccyx on 10/5/24 do not indicate frequency of wound care, indications for PRN care, or who will provide wound care. (Order correction entered on site.)

Upon patient record review, 4 of 29 (Patient #2, 4, 13, 19) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient 02: Upon admit it is noted that the patient utilizes a walker for ambulation the plan of care includes instructions for safe ambulation using a walker, this is not listed in the DME. (Corrected and updated on site.) Patient 04: The patient record includes orders for oxygen 1-5LPM as needed for dyspnea as needed, the record does not include an oxygen concentrator or tanks in the DME supplies. The patient record includes orders for wound care to the sacrum and rt buttock to include a foam dressing, the supplies are not included in the plan of care. (Corrected and updated on site.) Patient 13: The patient has a stoma and requires colostomy supplies which are not included on the plan of care. (Corrected and updated on site.) Patient 19: The patient records indicates that the patient is incontinent of bladder and bowel, the plan of care does not include incontinent supplies. (Corrected and updated on site.)

Upon patient record review, 4 of 29 (Patient #2, 6, 7, 21) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient 02: The patient was admitted to hospice on 5/31/24 with a diagnosis of mandibular cancer, her weight at the time of admit was documented as 105 lbs. Her current weight is entered as 74.8lbs and the patient has difficulty with chewing/swallowing foods due to disfigurement and pain related to the hospice diagnosis, the plan of care does not include a problem statement with interventions and goals to address the nutrition of the patient. (Plan of care updated on site.) Patient 06: The patient record indicates evidence of progressive and increasing edema as noted on 12/31/24 of 1+ edema upon assessment, 2+ edema as assessed and documented on 1/3/25 and 3+ pitting edema assessed and documented on 1/6/25, the plan of care has not been updated to include a problem statement with intervention and goals to address the problem. (Plan of care updated on site.) Patient 07: Upon admit on 12/12/24 it was identified that the patient has bilateral upper and lower body edema, patient continues to show evidence of increasing edema as noted on 1/6/25 with 3+ pitting edema documented, the plan of care does not include a problem statement with interventions and goals for the management of the edema. (Plan of care updated on site.) Patient 21: The patient is admitted to services with a primary diagnosis of chronic diastolic (congestive) heart failure and a secondary diagnosis of atrial fibrillations and is prescribed Eliquis 5 mg by mouth twice a day. The plan of care does not include a cardiovascular problem statement with interventions and goals and does not include safety precautions for bleeding risks. (Updated on site.)

Upon client record review, 1 of 29 (Patient #10) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 10: Frequency orders for skilled nursing is entered as 1 visit per week and 1 PRN, the patient was seen on 12/29/24, 12/31/24, 1/2/25 and 1/3/25

Upon patient record review, 3 of 29 (Patient #5, 8, 15) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient 05: The hospice aide task assignment for nail care, oral care, perineal care, skin care and providing companionship does not include a frequency. Patient 08: The hospice aide task assignment for linen changes, nail care, oral care, skin care, perineal care, provide companionship and cleaning surrounding area does not include a frequency for the task. Patient 15:The hospice aide task assignment for nail care, oral care, perineal care, skin care and providing companionship does not include a frequency.

Upon observation, there was no evidence the annual report documents the use of volunteers providing day to day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract personnel. The documentation of volunteer hours does not provide evidence that the agency volunteer services equals 5 percent of the total patient care hours.

Upon patient client record review, 1 of 29 (Patient #19) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient 19: The patient was admitted on 1/26/24, the initial comprehensive nursing assessment was not signed and authenticated by the RN until 1/31/24.

Upon client record review, 1 of 29 (Patient #24) did not have evidence that if a patient revokes the election of hospice care or is discharged from hospice in accordance with §418.26, the hospice must forward to the patient's attending physician: • A copy of the hospice discharge summary • The patient's clinical record, if requested Patient 24: The patient elected to revoke the hospice benefit on 10/24/24, the record does not include evidence the hospice discharge was provided to the attending physician.

Upon observation, there was no evidence construction, maintenance, and safety equipment at the facility is provided consistent with the 2012 editions of the LSC of the National Fire Protection Association and NFPA 99. The provisions of the adopted edition of the Life Safety Code do not apply in a State if CMS finds that a fire and safety code imposed by State law adequately protects patients in hospices. (Reference inpatient kitchen) Existing Construction According to 19.3.2.5.3* Section 9: The kitchen located at the agency in patient facility (Maui) does not meet the following conditions: *A switch meeting all of the following is provided: a. A locked switch, or a switch located in a restricted location, is provided within the cooking facility that deactivates the cooktop or range. b. The switch is used to deactivate the cooktop or range whenever the kitchen is not under staff supervision. c. The switch is on a timer, not exceeding a 120- minute capacity, that automatically deactivates the cooktop or range, independent of staff action.

Upon patient record review, 5 of 20 (Patient #1, #15, #18, #19 and #20) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. Patient #1 order for Oxygen 2LPM NC prn dyspnea/comfort. No evidence of Oxygen on medication profile. Patient #15 initial plan of care included Oxygen 3LPM continuous NC. No evidence of Oxygen on medication profile. Patient #18 initial plan of care included Oxygen 2LPM NC prn dyspnea/comfort. No evidence of Oxygen on medication profile. Patient #19 medication profile included Oxygen 2LPM NC. RN visits on 8/2/21 and 8/3/21 documented Oxygen at 4LPM NC. No evidence of Oxygen 4LPM NC on medication profile. Patient #20 order dated 7/4/21 included Oxygen 2-5LPM NC prn comfort. No evidence of Oxygen on medication profile.

Upon patient record review, 1 of 20 (Patient #19) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient which includes all problems identified in the initial and/or comprehensive assessment. Patient #19 terminal diagnosis of cerebrovascular disease, seizures, and stroke. No evidence of goals and interventions related to neurological problems identified.

Upon patient record review, 1 of 20 (Patient #19) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #19 initial plan of care dated 7/16/21 included Oxygen 2LPM NC. RN visits on 8/2/21 and 8/3/21 documented Oxygen at 4LPM NC. No evidence of an order for Oxygen 4LPM NC.

Upon client record review, 3 of 20 (Patient #9, #16 and #17) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #9 initial plan of care stated Chaplain services declined. Chaplain visits made on 8/10/21 and 8/18/21. No evidence of an order for the visits. Patient #16 plan of cares dated 7/13/21 and 10/11/21 included social work visit frequency of 1x/month and 1prn. No social work visits made after 6/15/21 and no evidence of refusal of visits. Patient #17 initial plan of care stated Chaplain services declined. Chaplain visit made on 9/15/21. No evidence of an order for the visits.

Upon patient record review, 7 of 18 applicable (Patient #2, #3, #6, #13, #14, #15 and #19) did not have evidence in the patient record that hospice aide assignments and duties include the tasks to be provided and the frequency of those tasks. Patient #2,#6 identified as high fall risk. No evidence of fall precautions on aide care plan. Patient #3,#13,#14,#15 identified as high fall risk and aspiration risk with dysphagia. No evidence of fall or aspiration precautions on aide care plan. Patient #19 identified as high fall risk, aspiration risk with dysphagia, and seizures. No evidence of fall, aspiration, or seizure precautions on aide care plan.

Upon client record review, 1 of 4 applicable (Patient #6) did not have evidence that a written hospice plan of care is established and maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided is in accordance with this hospice plan of care. Patient #6 plan of care orders dated 8/5/21 included Social work visit frequency of 3xm and 3prn. Routine social work visits made on 9/7/21, 9/14/21, 9/21/21, and 9/28/21.