Every finding on record at Journey Hospice Services, Inc.

Observed in Record Review. In 10 of 10 active patient records reviewed, a review of the hospice plan of care revealed that patient goals were documented in general terms and were not measurable, making it difficult to evaluate patient progress or the effectiveness of interventions. Goals such as (HOSRRHV#1) patient/cregiver will understand/express understanding of medication/treatment orders and side effects; (HOSRRHV#2) patient/caregiver will understand/express understanding of medication/treatment orders and side effects; (HOSRRHV#3) patient/caregiver will verbalize/express understanding of medication treatment and side effects; To achieve and maintain peripheral circulation for patient comfort; (HOSRRNHV#4) PCG will verbalize having elimination needs met at an acceptable level. (HOSRRNHV#5) PCG will verbalize understanding of treatment orders; (HOSRRNHV#6) PCG will verbalize understanding of non-verbal signs of pain, (HOSRRNHV#7) PCG will be kept clean and dry at all times (HOSRRNHV#8) To maintain mobility and independence. (HOSRRNHV#9) Patient/PCG will verbalize confidence in the management of pain; (HOSRRNHV#10) Patient/PCG will verbalize having urinary elimination needs met at an acceptable level. These goals were documented without defining measurable criteria, or observable outcomes. This finding was discussed and validated by the hospice management team.

Observed in Record Review. In 7 of 10 active patient records, it was noted the organization failed to provide care, treatment, or services according to the patient's individualized plan of care. For example, a review of the clinical record HOSRRHV#1 revealed that hospice aide services ordered at 1 visit per week were not provided as scheduled during the 3rd week of December 2025. Also noted for LVN 1 visit per week were not provided during the 4th week of October 2025 and 2nd week of November 2025. No documentation of patient’s refusal or MD order change. HOSRRHV#2 revealed that hospice aide did not obtain and document vital signs as indicated in the aide care plan. In addition, hospice aide services were ordered two times per week, however only one visit was completed during the fourth week of December 2025. HOSRRNHV#4 revealed that hospice aide services were ordered once per week to provide assistance with activities of daily living (ADLs) beginning the second week of January 2026. However, no hospice aide visits have been completed for more than two weeks following the start date. HOSRRNHV#5 revealed that skilled nursing services by an LVN were ordered once per week. However, no LVN visits were completed during the third week and the fifth week of December 2025. HOSRRNHV#6 revealed that RN supervision of the hospice aide was ordered to occur every 14 days. However, no RN hospice aide supervisory visits were documented during the months of November 2025 and December 2025. HOSRRNHV#8 revealed that skilled nursing services by an LVN were ordered once per week. However, no LVN visits were completed during the last week of October 2025, and the fourth week of December 2025. HOSRRNHV#10 revealed that RN supervision of the hospice aide was ordered to occur every 14 days. However, no RN hospice aide supervisory visits were documented during the third week of December 2025. This finding was discussed and validated by the hospice management team.

Observed in Patient Home. In 5 of 9 active patient records with hospice aide services reviewed,, it was noted the organization had failed to ensure that the 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. A review of hospice aide assignments revealed missing written instructions regarding patient precautions related to prescribed blood thinner medication. For example HOSRRHV#1 and HOSRRHV#3, patient prescribed Xarelto 10 mg PO daily; HOSRRHV#2, HOSRRNHV#6, and HOSRRNHV#7, patient prescribed Plavix 75 mg PO daily. This finding was discussed and validated by the hospice management team.

Observed in Record Review. In 4 of 9 active patient records with hospice aide services,, it was noted the organization failed to ensure that the hospice aide provides services that are ordered by the physician in the plan of care consistent with the aide's training. A review of the clinical record revealed that the RN provided a written instruction for the hospice aide to obtain and document vital signs at every visit. However for record HOSRRHV#3, the hospice aide did not check or document the patient’s temperature, pulse , and respiration during the visit in the last week of December 2025. For records HOSRRNHV#6, HOSRRNHV#7, and HOSRRNHV#9, the hospice aide was ordered to check and document vital signs at each visit. However, there was no evidence in the record that vital signs were obtained or documented as required. This finding was discussed and validated by the hospice management team.

Observed in Record Review. In 6 of 9 patient records with hospice aide services reviewed, it was noted the organization failed to ensure that the registered nurse supervises the hospice aide no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide. For example, a review of clinical record of HOSRRHV#1 revealed that required RN supervision of the hospice aide was not completed within the mandated 14-day timeframe. A gap of 37 days identified between documented RN supervisory visits (between the 3 week of October and rt week of November); For HOSRRHV#2, a gap of 28 days between 3rd week of August 2025 and 2nd week of September 2025, and 28 days gap between 2nd week of November 2025 and 1st week of December 2025. HOSRRHV#3, a gap of 26 days from the time the hospice aide started during the 4th week of December 2025. For HOSRRNHV#6, no evidence documented of the hospice aide supervision. For HOSRRNHV#9, a gap of 28 days between 2nd week of December 2025 and 2nd week of January 2026. Lastly, for HOSRRNHV#10, a gap of 28 days between 1st week of December 2025 and 5th week of December 2025. This finding was discussed and validated by the Hospice Management team.

Observed in Record Review. In 11 of 11 patient records reviewed, The HCO did not ensure patient care plan goals were attainable, measurable, relevant, specific and individually timed. For example, the surveyor noted in every record reviewed goals such as, “Pt will express decreased episodes of SOB during activities. Patient`s family will verbalize understanding on oxygen use safety within next 5 days, demonstrate stable cardio rhythm and rate within patient`s normal range AEB HR will be <100 and >60 -Demonstrate stable blood pressure AEB SBP will be <160 and >90. Family/pcg will verbalize/express understanding of medication /treatment orders and side effects within next 7 days, Family/caregivers will verbalize understanding on frequent orientation and anxiety/agitation management using non pharmacological methods within next 7 days. Patient will not experience discomfort while ambulating within next 7 days, Patient`s family will verbalize no episode of anxiety/agitation within next 7 days, Pt will have adequate food and fluids to maintain comfort as exhibited by expressed verbal and non-verbal communication. --Patient will not develop any episodes of aspiration within next 7 day, Pt/pcg will verbalize/express at least 75% understanding of medication /treatment orders and side effects by next IDG, Right buttock wound will be free from infection within next 2 weeks, PCG will verbalize/express 75% understanding of non-pharmacological pain management by next IDG -Pcg will verbalize/express at least 75% understanding of medication /treatment orders and side effects by next IDG- Pt will have decreased anxiety related to respiratory changes, Pt will not develop any episodes of respiratory crisis, Patient will tolerate at minimum 60% of meals within next 8 days, Increase strength/energy for optimal functional activities AEB the patient will not experience musculoskeletal discomfort with activities within next 2 weeks. Prevent physical and emotional stress due to injuries. Pt/pcg will be at least 75% competent with blood pressure monitoring methods validated by SN by next IDG -Demonstrate stable cardio rhythm and rate within patient`s normal range AEB HR will be <100 and >60 bpm.” These stated goals are not realistic and do not contain information that can be accurately measured to assist organizational staff in determining whether the patient is progressing towards achieving their goals. These findings were reviewed, discussed, and validated with the organization’s Administrator and Quality Coordinators.

Observed in Record Review. The HCO staff failed to provide patient care at the ordered frequency. For example, the surveyor noted on RR #7, the skilled nurse visit frequency was ordered for one time a week. There was a missed visit for the week of 12/18/2022-12/24/2022. There was no communication or physician order, addressing the deviation. Standards require patient care be provided according to the patient’s individualized plan of care. These findings were reviewed discussed and validated with the organization’s Administrator and Quality Coordinators.

Observed in Data Tracer. The HCO failed to collect and analyze data specific to quality and palliative care measures. For example, the surveyor noted pain management and response to opioids was not included in its quality assessment and performance improvement demonstrates program data collection, analyzation, or meeting discussions. Standards require the organization to use the data collected to monitor the effectiveness and safety of services and the quality of care. These findings were reviewed, discussed and validated with the Administrator and Quality personnel.

Observed in Patient Home. The HCO staff failed to complete hand hygiene at times required by the organization's policies. For example, on HV #3/RR #3, the surveyor observed the registered nurse conducting the patient’s physical assessment, moving back and forth between unclean areas, such as the patient’s brief and perineal areas and handling items at the bedside, including the patient’s water bottle without changing gloves and conducting hand hygiene in between. The organization’s policies require standard precautions be used, including completing hand hygiene and glove change between direct patient contact and touching equipment or other items. These findings were reviewed, discussed, and confirmed with the Administrator.