Every finding on record at Lira Hospice, Inc.

Observed in HR File Review. In 1 of 7 HR files reviewed, the organization did not provide emergency management plan training at least every 2 years. On HR #6, there was no documentation to validate staff were provided emergency management training at least every 2 years. This was reviewed with the DCPS.

Observed in Emergency Management Session. On review of the Emergency Plan, the organization did not review and evaluate any exercises or actual emergencies because no exercises had been conducted. This was confirmed with the DCPS.

Observed in Record Review. On 1 of 10 active patient records reviewed, wound assessments were not completed per policy. Agency Ongoing Comprehensive Assessment policy 2-031, states on each visit the nurse will assess current treatment related to the identified symptoms and the patient’s response and document skin integrity. On RRNHV #1, patient has been on service for 7 months with stage 3 wound with 3 times per week dressing changes to the wound and wound measurements are not done on each visit and the last wound measurement was 3 months ago. This issue was discussed was discussed with the DCPS.

Observed in Record Review. In 5 out of 14 patient records reviewed, the organization failed to complete a bereavement assessment on admission. Organization's Bereavement Assessment policy 3-037 states that the nurse or MSW will do a bereavement risk assessment on admission. On RRNHV #1, RRNHV #3, RRNHV #6, RRNHV #7, and RRBR #2, it was noted the organization did not complete a bereavement risk assessment on admission. This finding was discussed with DCPS.

Observed in Record Review. In 9 out of 10 active patient records reviewed, that plan of care goals were specific and/or measurable for achieving goals. On RRHV #1, goals were not measurable and specific to the care with examples of “promote optimal orientation and communication skills” and “family will receive optimal teaching and support as cardio/pulmonary function change”. On RRHV #2, the goals were not measurable and specific to the patient with examples of “Optimal physical comfort” and “optimal treatment of terminal restlessness”. On RRNHV #2, it was noted that goals were not measurable or time specific with examples of “Optimal patient comfort” and “Optimal Hygiene”. On RRNHV #3, it was noted that goals were not measurable and specific with examples of “optimal level of pain and/or symptom management” and “optimal breathing patterns”. In addition, RRHV #3, RRNHV 4, RRNHV #5, RRNHV #6 and RRNHV #7 had goals that were not measurable or specific with examples of: “optimal patient orientation”, “achieve optimal grief reaction”, “maintain optimal physical comfort”, “optimal patient safety and prevention of injury”, “maintain optimal swallowing”, “optimal treatment of terminal restlessness“, and “optimal patient orientation and communication skills”. This was discussed and reviewed with the DCPS.

Observed in Record Review. In 4 of 10 active patient records reviewed, the organization failed to plan the patient's care. On RRHV #2, it was noted in assessment patient is a high aspiration risk with aspiration precautions including thick-it but there is no goals or interventions for this issue. In addition, the patient is bed bound and dependent on all care but no goals reflect this. On RRHV #3, it was noted in assessment that the patient had left hand edema but there were not goals or interventions for this issue. On RRNHV #1, it was noted in assessment that patient had Shortness of Breath, Poor Nutrition and is worried about her finances to be able to survive but these issues were not identified on the plan of care. On RRNHV #2, it was noted by the social worker assessment that the family had not made mortuary arrangements and wanted to take this unstable patient back to Guatemala to be cared for by family but there was no goals or interventions on the plan of care to reflect the social issues. This was discussed and reviewed with the DCPS.

Observed in Record Review. In 3 of 10 active patient records reviewed, the organization failed to plan the patient's care with interventions and treatments needed by the patient. On RRHV #1, patient observed by nurse surveyor to be on 3L of oxygen during the home but there were no orders on the plan of care for the oxygen. On RRHV #3, it was noted that patient had an oxygen tank in his room and listed on DME supplies but no order for the oxygen. On RRNHV #5, it was noted in the CTI and on the DME list that patient has oxygen but the Plan of care has no orders for the oxygen. This finding was reviewed with the DCPS. Observed in Record Review. In 8 of 10 active patient records reviewed, the hospice nurse surveyor noted medication orders were not clear and accurate. On RRHV #2, the plan of care had duplicate medication therapy for anxiety of Klonopin and lorazepam with no indication how to handle the duplicate therapy. On RRNHV # 1, the physician's orders in the plan of care documented both Lorazepam tablet and Lorazepam liquid; however, there was no indication how to handle the duplicate therapy. On RRNHV #2, the physician order in the plan of care documented Acetaminophen suppository and Acetaminophen Tablet to be given both for mild pain with no indication for how to handle the duplicate therapy. On RRNHV #3, there were multiple duplicate PRN medications for constipation, Dulcolax and Senna, with no indication how to handle the duplicate therapies. In RRNHV #4, the plan of care had duplicate PRN medications of Lorazepam and Haloperidol for anxiety and Senna and Bisacodyl for constipation with no indication how to handle the duplicate therapies. On RRNHV #6, there was duplicate PRN constipation medications of senna and Bisacodyl with no indication how to handle the duplicate therapy. On RRNHV #7, there was duplicate PRN constipation medications of ducolox and fleets with no indication how to handle the duplicate therapy. This was discussed with the DCPS.

Observed in Record Review. In 1 of 14 patient records reviewed, the organization did not document the review and revisions to the patient’s plan of care during their interdisciplinary team meeting. Agency IDG Meeting policy 2-050 states that the group will meet to discuss Plan of care, deaths, changes to care and admission recerts. On RRBR #3, it was noted that the patient had passed away but the post death IDG notes talked about the patient’s condition prior to death and didn’t even note the patient had passed away. This finding was reviewed with the DCPS.

Observed in Record Review. In 5 of 10 active patient records reviewed, the organization failed to document progress towards goals and update the plan of care. On RRHV #2, the plan of care had not been updated to reflect changes care needs of the patient the plan of care still has foley and wound supplies listed but there no wound or foley on this patient. On RRHV #3, the plan of care had not been updated to reflect changes in the plan and still had teaching goals from admission on a patient in a facility that have been on the plan since admission 8 months ago, with examples of: “caregiver will verbalize understanding of s/s of constipation” and “caregiver will verbalize understanding of signs/symptoms of UTI. On RRNHV #2, the nurse has failed to document the progress toward goals in order to update the plan of care for the last two months. On RRNHV #3, it was noted that patient was on the 5th benefit period and goals had not but updated to reflect progress with teaching goals still present with examples of “demonstrate proper and safe use of oxygen set-up”, and “verbalize understanding of nonpharmalogical measures to relieve shortness of breath episodes”. On RRNHV #6, it was noted that the patient has been on service for 7 months and goals have not been updated to reflect progress with teaching goals still present with the examples of: “Instruct patient/family in principles of maintaining skin integrity”, “Teach pt/cg signs/symptoms of urinary tract infection: burning, frequency, urgency, fever, foul odor, painful urination, cloudy urine, dark urine, and/or discharge” and, “Caregiver will verbalize understanding of notifying hospice for any falls or incidents”. This was discussed and reviewed with the DCPS.

Observed in Record Review. In 2 of 3 bereavement records reviewed, the organization did not follow the bereavement plan of care. On RRBR #1 and RRBR #2, it was noted that the 3 and 6 month mailings have not been sent to the patient. This finding was reviewed with the DCPS.

Observed in Data Session. On review of the organizations QAPI program they were unable to demonstrate operation of the program for 2025. As evidenced by the Leadership was unable to produce QAPI meetings and analysis of data for 2025. There has been administrator and DCPS changes in 2025 along with other staffing changes that has caused this aspect of the program to be overlooked. The organization has recently recognized the deficit and has several performance improvement plans started but there is no documented Qapi meetings. This observation was reviewed with the DCPS.

Observed in Data Session. During the Data session it was identified that the governing board of the organization did not review the performance improvement priorities annually. The governing body last met in January and there was no approval for the frequency and detail of data collection for 2025. This was reviewed with the DCPS

Observed in Tracer Activities. In review of Bereavement Services and discussion with the Coordinator and DCPS it was learned that the organization has not developed an organized bereavement program after the transition to a new EMR program 4 months ago. Bereavement was tracked and processes in place in their old system but as they transitioned to the new system they did not have a process in place to ensure that bereavement needs were carried over into the new EMR. In addition, the bereavement coordinator left due to the EMR change. The organization has since recognized the deficit and started a performance improvement plan as of August but no process is in place as of survey and mailings and follow-up is not resolved as of survey. This was discussed with the DPCS.

Observed in HR File Review. In 1 of 1 Home Health Aide HR records reviewed, 12 hours of yearly in-service education was not completed in 2024/2025. During review of HR#3, the Home Health Aide does not have 12 hours of education completed for the last year.. This was reviewed and validated with the DCPS.

Observed in HR File Review. In 1 of 1 Home Health Aide HR records reviewed, the organization did not make and annual visit with the aide to assess care provided. On HR #3 , it was noted that there was no annual competency for 2023 and 2024. This finding was discussed and reviewed with the DCPS.

Observed in Tracer Activities. The organization failed to provide services that meet the patient needs. During tracer activities for volunteer services, the Hospice Nurse Surveyor observed that the organization had not met the 5% volunteer hours for the last 3 years; however, the organization has an active performance improvement plan in place. This was discussed and reviewed with the DCPS.

Observed in Tracer Activities. There was no evidence that the governing body and leadership had established requirements to support patient care treatment and services as evidenced by a condition level finding at 418.58 and 418.56 as significant issues with care planning and quality improvement. This finding was reviewed with the DCPS. Observed in Leadership Session. On review of the organizations governing body minutes, the organization has not approved administrator for the change in employee that happened in 2025. This finding was reviewed with the Administrator and DCPS.

Observed in HR File Review. In 4 of 7 HR files reviewed, the surveyor noted the organization failed to provide infection control and standard precaution training annually as required by the organization's policy 1-011. On review of HR # 3 and HR #6 it was noted that there was no annual education for infection control and standard precautions for 2023 and 2024. On review of HR # 4 and HR #5 it was noted that there was no annual education for infection control and standard precautions for 2024. This was reviewed and validated with the DCPS. Observed in HR File Review. In 2 of 7 HR files reviewed, the organization did not document participation in ongoing education and training. Agency Policy 1-008 states that an annual skill pass off of skills. On HR #5 and HR #6, it was noted that the employee did not have an annual competency completed for the last 3 years. This finding was reviewed with the DCPS.

Observed in Record Review. In 1 of 14 patient records reviewed, the patient record did not contain information related to the patients care and treatment. Agency Death at Home Policy states that the Medical Director will pronounce the death. On RRBR #3, it was noted that the LVN did the death visit. The LVN documented he attended the death and which MD pronounced the death but did not document how he observed that the patient was deceased and did not document the details of the call with the physician of those observations in order to meet the agency policy that the physician pronounces the death. This finding was reviewed with the DCPS.

Observed in Record Review. In 1 of 2 live discharge patient records reviewed, the organization failed to provide a discharge summary to the physician when the patient revoked hospice. During record review for RRDC#2, the Hospice Nurse Surveyor observed the discharge summary was completed in the EMR but there was no documentation that it was sent to the patient's physician. This was discussed and reviewed with the DCPS.

Observed in Record Review. In 1 of 14 patient records reviewed the organization did not have and accurate and complete medical record. On RRDC #1, it was noted that the transfer summary and documentation of coordination with the receiving hospice was not in the EMR but was found during the survey process. This finding was reviewed with the DCPS.

Based on observation, interview and record review, the hospice agency (HA) staff failed to review all the medications in the comfort kit (a prescribed set of medications that are kept in a patient's residence in the event of an emergency) compared the medication profile for one of 5 sampled patients (Patient 4). This deficient practice had the potential to put the patient at risk due to lacking emergency medications when needed. --- A review of Patient 4's clinical record indicated a start of care date of 1/17/2023, with primary diagnosis of ischemic cardiomyopathy. On 5/11/2023, at 2:30 p.m., during Patient 4's home visit with Registered Nurse 1 (RN 1) at the skilled nursing facility (SNF), Patient 4 was observed sitting in a wheelchair outside of the building. At 3:15 p.m., when Patient 4s medications were reviewed with Licensed Vocational Nurse 1 (LVN 1 at the SNF) compared with the agencys ";Current Treatment/Medication/DME List", LVN 1 (at the SNF) was not able to locate the patients following medications (order dated 1/23/2023): Lorazepam (2 mg/ml) 0.5 ml sublingually every 6 hours as needed Haloperidol (2 mg/ml) 0.5 ml sublingually every 6 hours as needed Atropine 1 percent 2 gtt (drop) sublingually every 4 hours as needed During an interview with RN 1 at 3:30 p.m., she stated Patient 4 did not have Lorazepam 0.5 ml and Haloperidol 0.5 ml at the SNF because those medications were not sent to the SNF. RN 1 stated Patient 4 did not give consent to use Lorazepam 0.5 ml and Haloperidol 0.5 ml., and the SNF wouldnt give those medication without consent from Patient 4. RN 1 stated when the patient's medications were delivered to the patient, the agency's nurse would instruct/communicate the SNF nurse. RN 1 stated if there were any discrepancies with the physician's order, the agency nurse should clarify with the physician and correct accordingly. RN 1 stated she should have deleted Lorazepam 0.5 ml and Haloperidol 0.5 ml from the physicians order. When asked about Atropine, RN 1 stated Patient 4 should have Atropine and the SNF nurse should have reordered Atropine when it ran out. RN 1 stated she had checked the patient's medications verbally with the SNFs nurse, but she had not checked the patients medications physically. On 5/12/2023, at 4:15 p.m., when requested the agency's policy regarding comfort kit management for the patients who reside in the SNF, the Director of Patient Care Services (DPCS), stated the agency did not have it. A review of the agencys policy titled ";Provision of Care to Residents of SNF/NF or ICF/IID" revised in October 2016 indicated the hospices responsibilities included providing medical supplies, durable medical equipment and drugs necessary for the palliation of pain and symptoms associated with terminal illness. A review of the agencys policy titled ";Medication Profile" revised in November 2017 indicated the medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications. During subsequent hospice visits, the medication profile will be used as a care planning and teaching guide to ensure that the patient and family/caregiver, as well as other clinicians, understand the medication regimen. Using the medication profiles as a communication tool for other clinicians involved in care.

Based on observation, interview and record review, the home health agency (HHA) nursing staff failed to manage the patient's pain by not assessing pain level after providing pain management, to identify effectiveness of the pain intervention, for 1 of 5 sampled patients (Patient 4). This deficient practice had a potential for not identifying the effectiveness of the pain management that could place the patient for unrelieved pain and ineffective pain management. --- On 5/11/2023, at 2:30 p.m., during a joint home visit with Registered Nurse 1 (RN 1) at the skilled nursing facility (SNF), Patient 4 was observed sitting in a wheelchair outside of the building. A review of Patient 4's clinical record indicated a start of care date of 1/17/2023, with primary diagnosis of ischemic cardiomyopathy. A review of the Comprehensive Nursing Assessment by the Registered Nurse (RN), dated 1/16/2023, indicated Patient 4 was alert and oriented, was uncomfortable because of pain. A review of Patient 3's plan of care (POC)/Interdisciplinary Group (IDG) dated 1/17/2023 indicated the Skilled Nurse (SN) visit frequency was once a week and three time as needed visit. The medical social worker and the spiritual counselor were to visit once a month, and the hospice aide visit was three times per week. There was a plan of care developed for the chest pain. One of the interventions was to monitor/assess effectiveness of current and new medication/treatment. A review of the ";Current Treatment/Medication/DME List" indicated the patient had following medications for pain: 1. Morphine Sulfate (20 mg/ml) – 0.25 ml sublingually every 1 hour as needed for chest pain, 7-10 on a pain scale from zero to ten (7-10/10) (order dated 1/23/2023). 2. Methadone Hydrochloride 10 mg one tablet at 12 p.m. routinely for chronic pain 6-10/10 (order dated 4/26/2023). 3. Methadone Hydrochloride 10 mg two tablet at twice daily in the morning and in the afternoon for chronic pain 6-10/10 (order dated 4/26/2023). 4. Dilaudid 4 mg one tablet every 8 hours three times a day for severe pain 7-10/10 (order dated 4/26/2023). 5. Nitrostat 0.4 mg sublingual one tablet for chest pain (order dated 3/17/2023) 6. Lidocaine 4 percent topical pain patch daily for 12 hours then remove for 2 weeks (order dated 4/7/2023). There was a RN visit note dated 4/4/2023 which indicated as follows: "Called after pt fall outside trying to ambulate. Pt seen hunched over in very slow, painful movement for wc. Still going out to smoke? take to room and assess wound and dressings on arm wounds. Convince pt to cooperate to assess back and hip. no site tenderness or bruising. Pt says 8/10 pain whole area. Save PRN morphine if pt agreed to lay down for a while -- pt complied. Pt did not strike head or lose consciousness, and pt mostly wants to get back outside and smoke." There was no documentation that the pain level was assessed after Morphine was administered/pain intervention was implemented. A review of the RN visit note dated 4/5/2023 indicated the patient stated the pain of 8/10 was in right lower-mid back to flank. The patient agreed to try Lidocaine pain patch, call was made to the physician for, and order was written. It indicated the nurse applied one before she left. However, there was no documentation pain level was assessed after Lidocaine patch was administered. During an interview with the DPCS on 5/12/2023, at 11:05 a.m., she was not able to provide the documented evidence pain level was assessed after Morphine was administered/pain intervention was implemented on 4/4/2023, and pain level was assessed after Lidocaine patch was administered on 4/5/2023. The DPCS stated the pain assessment should have been done after 1 hour later the pain medication was administered/intervention was implemented. A review of the agencys policy and procedure revised November 2013 indicated the patients who report pain will receive further assessment and appropriate management and changes to the plan of care will be made as part of the comprehensive assessment.

Based on record review and interview the Hospice Agency (HA) failed to report a change of condition for one of 5 sampled patients (Patient 1). This deficient practice placed the patient at risk for not receiving proper medical care and treatment. --- A review, Patient 1s clinical record indicated Patient 1 was admitted to hospice agency (HA) on 11/18/22 with a primary diagnosis of Parkinsons disease (progressive disease of the nervous system marked by tremor, muscular rigidity, and slow movements). A review of the agencys document entitled Plan of Care dated 3/1/23 indicated Skilled Nurse visits once per week. The Medical Social Worker (MSW) to visit twice per month, and the Spiritual Counsellor (SC) to visit twice per month and HHA visits 3 x per week. A review of the HA document entitled ";Visit Note RN", dated 3/9/23, indicated Patient 1 was refusing food and spitting out medications. A review of the agencys document entitled ";communication log" indicated no attempt at communicating Patient 1s change of condition to hospice physician during the following dates: 3/9/23, 3/10/23, 3/11/23, 3/12/23, and 3/13/23. A review of the SNF nursing notes dated 3/9/23, 3/11/23, 3/12/23 and 3/13/23 indicated Patient 1 was noncompliant with medication regimen and spit out or refused medications during these days. Notes indicated that hospice agency was notified and aware of each event. On 5/12/23 at 3:50 p.m., during an interview conducted in the agency's conference room with Registered Nurse 1 (RN1) stated, she was part of the Interdisciplinary Group (IDG), but could not answer if MD was notified of change of condition that occurred on 3/9/23. During a review of the agencys policy entitled monitoring Patients response/ Reporting to Physician", dated October 2015, indicated the policy provides guidelines for monitoring the patients response to hospice care and for reporting to the patients physician. The policy further indicates clinicians will establish and maintain ongoing communication with the patients physician and the hospice medical director to ensure safe and appropriate care for the patient. The patients physician and/or medical director will be contacted on the same day when there is a change in the patients condition or any changes in the patients expected response to hospice care or medications.

Based on observation, interview and record review, the hospice agency (HA) staff failed to ensure care followed the written plan of care by not assessing opened tumor growth wound on the left clavicle area for one of five sampled patients (Patient 3). This deficient practice placed the patient at a potential risk for delayed wound healing and potential for wound infection. --- A review of Patient 3's clinical record indicated a start of care date of 1/6/2023, with primary diagnosis of malignant neoplasm of kidney. A review of the Comprehensive Nursing Assessment by the Registered Nurse (RN), dated 1/6/2023, indicated Patient 3 was alert and oriented, was ambulatory using a cane, and had a tumor growth related to kidney cancer at left clavicle sized 2.2 centimeters (cm) by 4.0 cm. A review of Patient 3's plan of care (POC)/Interdisciplinary Group (IDG) dated 1/10/2023 indicated the Skilled Nurse (SN) visit frequency was twice a week and one time as needed. The medical social worker and the spiritual counselor were to visit once a month, and the hospice aide visit was three times per week. There was a plan of care developed for the broken skin and blister like discharge on tumor sites. The interventions were to provide wound treatment (cleanse with normal saline, pat dry, apply 10 percent of betadine solution cover with Xeroform occlusive gauze patch, wrap with Kerlix, apply tape over bandage roll), and to assess/monitor effectiveness of wound treatment. On 5/11/2023, at 1:35 p.m., during a joint home visit with Registered Nurse 1 (RN 1) at the skilled nursing assistant (SNF), Patient 3 was observed lying in a bed. Patient 3 was alert and oriented, and able to communicate. At 1:50 p.m., when RN removed old dressing of the left clavicle, a big mass with opened wound was observed on the patients left clavicle. Upon request, RN 1 measured the patients wound/mass on the left clavicle and stated the circumference of the mass was 34.5 cm around and the opened wound of the mass was 3.5 cm by 2 cm. A review of Patient 3s clinical record from 1/6/2023 to 5/10/2023 indicated there was no documentation that the Skilled Nurse (SN) measured the size of mass and opened skin wound for the left clavicle wound except on 1/6/2023, 3/21/2023, and 4/24/2023. During an interview with the Director of Patient Care Services (DPCS), she was not able to provide the documented evidence that the Skilled Nurse (SN) measured the size of mass and opened skin wound for the left clavicle wound except on 1/6/2023, 3/21/2023, and 4/24/2023. The DPCS stated the SN should have assessed the skin condition of the patient including measurement on every visit. A review of the agencys undated policy of ";Wound Assessment and Documentation" indicated to assess the wound location and its size: measure the length, width, and depth. It also indicated to document the Stage the wound weekly.

Based on record review and interview the facility failed to coordinate and ensure the transfer of comfort kit medications for one of 5 sampled patients (Patient 1). This deficient practice had the potential to cause unnecessary pain and discomfort for the patient. --- A review of Patient 1s clinical record indicated, Patient 1 was admitted to the hospice agency (HA) on 11/18/22 with a primary diagnosis of Parkinsons Disease (progressive disease of the nervous system marked by tremor, muscular rigidity, and slow movements). During a review of the agencys document entitled Plan of Care dated 3/1/23 indicated Skilled Nurse visits once per week. The Medical Social Worker (MSW) to visit twice per month, and the Spiritual Counsellor (SC) to visit twice per month and HHA visits 3 x per week. During a review of the agencys document entitled ";current treatment/medication/DME list" indicated a comfort kit which included medications to address pain, nausea, vomiting, and breathing as needed was ordered on 11/18/22. Comfort kit medications were at the Skilled Nursing Facility (SNF) prior to the patients transfer to an isolation unit. On 5/12/23 at 3:50 p.m., during an interview with RN1. She stated that that Patient 1 was transferred to another floor of the SNF facility due to being positive from Covid. RN1 further stated that the transfer of all medications were handled by staff from the SNF. RN1 stated she did not physically do a medication reconciliation to verify that all of PT1s medications were transferred to the isolation unit at SNF. RN1 stated that she never had a reason not to trust SNF staff but stated ";in retrospect, I would do it differently". A review of the agencys policy titled ";Provision of Care to Residents of SNF/NF or ICF/IID" revised in October 2016 indicated the hospices responsibilities included providing medical supplies, durable medical equipment and drugs necessary for the palliation of pain and symptoms associated with terminal illness.

Observed in Patient Home. In 1 of 3 home visits conducted, the hospice nurse surveyor noted that the organization had not completed a review of all current medications. Agency Medication review policy (3-002.1) states, the medication profile will be used as care planning and teaching on each visit. During HSHV #1, the RN did not complete a review of the medication list used by the veterans facility during the visit. This was discussed with and confirmed by the DON.

Observed in Record Review. In 6 of 13 patient records reviewed, Hospice surveyor noted some of the goals in patient records were either not measurable or not present for issues that patient has. On review of HSHV #1, the patient is on puree's food, has nebulized resp treatments and on oxygen and no goals identified on POC towards those issues. On review of HSHV#3, the patient has bowel cancer and is on oxygen, pain and bowel medications but there are no goals to address those active issues. On review of HSRR #4, patient has a tracheostomy tube in place on no goals developed to address keeping a patent airway or care goals for the tracheostomy, On review of HSRR #5, patient noted to have nebulizer medications and pureed diet and no goals established to address those issues. On review of HSRR #8, the goals were not measurable of ADL's met to optimal level, Optimal bowel elimination, Increase strength/energy for optimal functional activities, and Optimal Spiritual Enviroment. On review of HSRR #10, the goals were also noted to not be measurable and specific to the patient including having a pain goal that stated Pt. pain will remain in comfortable level during care. This finding was reviewed with the DON.

Observed in Patient Home. In 1 of 3 Hospice Home visits the registered nurse did not follow manufacture guidelines to reduce the risk of infections associated with supplies/equipment. During HSHV #1 the Register Nurse used Saniwipes wipes to clean equipment in the patient home after use and did not follow wet time of 2 minutes as specified by manufacturer's guidelines.

Observed in Patient Home. In 1 out of 13 patient records reviewed, that had ordered aide services, the Aide Care Plan did not have specific instructions for the aide. During record review of HSHV #2, the assigned tasks did not include specific instructions for the aide to follow. For example,, instructions for placement of wedge, ankle and hand cushions on a patient with contractures, instructions of care/observation of a skin condition of the back that had barrier cream ordered for it. This finding was reviewed and validated with the DON.

Observed in Record Review. In 2 of 8 patient record reviews, that had aide services ordered, the organization did not conduct a hospice aide supervision every 14 days. During record review of HSRR #5, there has is not a current aide supervision completed and it is 17 days past due. On review of HSRR#8, there had not been an aide supervision done on the patient for a 21 day gap in August and July. This finding was reviewed and validated with the DON.

Observed in Record Review. In 13 of 13 patient records reviewed, all entries were not appropriately authenticated and dated in accordance with hospice policy and currently accepted standards of practice. Agency policy (5-006.2) states that all documentation will have the signature and credentials of the clinician. In all records reviewed there were multiple records in each chart that had not been electronically signed by the clinician including discharged records. This was reviewed and validated with the DON.