Every finding on record at Lotus Hospice

Upon patient record review, 1 of 5 (Patient #2) did not contain evidence that the Hospice had 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 #2: The 06/12/25 RN SOC assessment documented, "Patient is on Ensure." The 06/12/25 IDG POC included, "Continue Ensure Nutritional Supplement", without any associated details such as amount or frequency of such administration. The same RN SOC assessment documented, "Patient has difficulty swallowing, thick liquids used as a precaution." This pertinent nutritional information was not included on the POC.

Upon patient record review, 1 of 5 (Patient #1) did not contain evidence that a revised Plan of Care included information from the patient's updated comprehensive assessment(s): Patient #1: At the SOC 05/31/25, a verbal order was obtained for, "Ensure i pack T.I.D." The IDG POC dated 06/06/25 included, "Patient is on Ensure", with no associated amount or frequency of such administration. Additionally, the RN SOC assessment documented, "Patient has a right hand contracture. The in-home caregiver was instructed to use rolled cloth to prevent its breaking." This planned intervention was not included on the 06/06/25 IDG POC.

Upon patient record review, 3 of 5 (Patient #1, 4, and 5) did not contain evidence that the IDG had ensured that care and services were provided in accordance with the Plan of Care: Patient #1: SOC 05/31/25. The current POC ordered an SN visit frequency of 1x per week. There were no SN visits made/documented for the weeks of June 1-June 7, nor June 8-14, 2025. Patient #4: SOC 03/02/25. The current POC ordered an SN visit frequency of 1x per week. The LVN visit note from 05/23/25 had not yet been completed. There were no SN visits made/documented for the weeks of May 25- May 31, June 1-June 7, nor June 8-14, 2025. Patient #5: SOC 02/28/25. The Hospice Plan(s) of Care ordered a SW visit frequency of "One visit per benefit period." The SOC certification period 02/28/25 to 05/28/25 (beginning with a 2nd 90 day cert period) included an MSW visit within the 5 days after the SOC on 03/03/25. However, the next documented MSW visit was made on 05/27/25, and was documented as a "Recertification visit", as related to the SW assessment for the patient's need(s) during the next subsequent certification period. The Hospice representative reported that the visit was conducted too early, resulting in two SW visits during the 02/28/25 to 05/28/25 certification period.

Upon patient record review, 1 of 5 (Patient #2) did not contain evidence that all entries were clear/complete: Patient #2: The 06/12/25 RN SOC assessment documented, "Patient is a D.N.R." The MSW assessment dated 06/16/25 documented, "Patient wants to remain a Full Code". As of 06/17/25 the Hospice POC included, "Patient is a D.N.R." This is unclear documentation.

Upon patient record review, 6 of 14 (Patient #1,2,4,8,9,13) 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 1: Medication list has clotrimazole/betamethasone dipropionate 1-0.05% topical cream listed. Instructions state: apply thin layer to affected area twice daily for inflammation. There is no evidence of application site for this medication. Patient 2: Medication list has duplicate medications noted. First is voltaren gel 1%. Second medication is diclofenac 3%. While visiting patient’s home and reconciling medications, surveyor observed diclofenac 1% in home. Instructions for voltaren gel: apply thin layer directly to affected areas daily as needed. There is no evidence of application site or dose in the medication list. Instructions for diclofenac: apply thin layer directly to lower back daily as needed. Patient 4: Patient has oxygen listed in treatment section on the plan of care. There is no evidence of oxygen on the medication list. Patient has triple antibiotic ointment listed in supplies section on the plan of care. There is no evidence of this medication on the medication list. Patient 8: Patient has diclofenac sodium 1% on the medication list. Instructions for medication: Using dosing card, apply 2grams in a thin layer on the affected area (joints) daily as needed for pain. There is no evidence of instructions re: which joints for application. Patient 9: Patient has aspercream cream listed in supplies section on the plan of care. There is no evidence of this medication on the medication list. Patient 13: Patient has oxygen listed in treatment section on the plan of care. There is no evidence of oxygen on the medication list. Patient has metronidazole 0.75% topical cream on the medication list. Instructions for medication: apply thin layer to affected areas daily for skin redness. Mupirocin 2% is on the medication list. Instructions: apply thin layer to affected areas for skin infection. There is no evidence of application site for these 2 medications.

Upon patient record review, 5 of 14 (Patient #2,4,8,12,14) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient 2, 4, 8,12,14: There is no evidence of initial bereavement assessment in the medical record.

Condition of Participation: Interdisciplinary Group, Care Planning, and Coordination of Services. L536

Upon patient record review, 10 of 14 (Patient #1,2,3,4,6,9,10,11,13,14) 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 1: Identified needs with no evidence of problems, goals, interventions on the plan of care: bleeding risk related to ordered Eliquis 5mg twice daily; weakness/falls related to need identified in initial comprehensive assessment dated 10/10/2024. Patient 2,4,9,10,13,14: Physician’s visit frequency order for social work is once every certification period. There is no evidence of psychosocial plan of care with problems, goals, interventions in the medical record. Patient 3: It is observed that patient has oxygen precautions noted on the current plan of care. During admission on 4/22/25, patient declined oxygen when it was offered due to dyspnea. Patient 6: Identified needs with no evidence of problems, goals, interventions on the plan of care: anxiety, dyspnea, constipation-as noted in initial comprehensive assessment dated 3/2/25. Patient 9: Identified needs with no evidence of problems, goals, interventions on the plan of care: confusion/agitation, depression, edema-as noted in initial comprehensive assessment dated 2/4/25. Patient 11: Identified needs with no evidence of problems, goals, interventions on the plan of care: PICC care and maintenance, as patient was admitted 12/11/2024 with PICC in place. In addition, the patient was admitted 12/11/24 to routine care. Later in the day, the physician changed level of care to continuous care. There is no evidence the plan of care was updated to reflect the change in level of care. Patient 13: Identified needs with no evidence of problems, goals, interventions on the plan of care: wound care and maintenance, as patient admitted 3/16/24 with wounds. Also high risk for skin breakdown, as noted in initial comprehensive assessment dated 3/16/24.

Upon patient record review, 6 of 14 (Patient #1,2,4,8,9,13) 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 1: Plan of care has clotrimazole/betamethasone dipropionate 1-0.05% topical cream listed. Instructions state: apply thin layer to affected area twice daily for inflammation. There is no evidence of application site for this medication. Patient 2: Plan of care has duplicate medications noted in the plan of care. First is voltaren gel 1%. Second medication is diclofenac 3%. Instructions for voltaren gel: apply thin layer directly to affected areas daily as needed. Instructions for diclofenac: apply thin layer directly to lower back daily as needed. Patient 4: Patient has oxygen listed in treatment section on the plan of care. There is no evidence of oxygen in the medication section on the plan of care. Patient has triple antibiotic ointment listed in supplies section on the plan of care. There is no evidence of this medication in the medication section on the plan of care. Patient 8: Patient has diclofenac sodium 1% on the plan of care. Instructions for medication: Using dosing card, apply 2grams in a thin layer on the affected area (joints) daily as needed for pain. There is no evidence of instructions re: which joints for application. Patient 9: Patient has aspercream cream listed in supplies section on the plan of care. There is no evidence of this medication in the medication section on the plan of care. In addition, the initial comprehensive assessment and the initial IDG both state that the patient will have oxygen supplied and that the patient will use the supplied oxygen. There is no evidence that the order was written for this medication. Patient 13: Patient has oxygen listed in treatment section on the plan of care. There is no evidence of oxygen in the medication section on the plan of care. Patient has metronidazole 0.75% topical cream on the plan of care. Instructions for medication: apply thin layer to affected areas daily for skin redness. Mupirocin 2% is on the plan of care. Instructions: apply thin layer to affected areas for skin infection. There is no evidence of application site for these 2 medications.

Upon patient record review, 2 of 14 (Patient #2,13) 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 2: Patient’s physician ordered oxygen on 1/1/25. There is no evidence the plan of care was updated to include oxygen on this date. Patient 13: Patient admitted 3/16/24. Foley catheter was inserted on 3/19/24. There is no evidence the plan of care was updated to include care and maintenance of foley on this date.

Upon patient record review, 6 of 14 (Patient #4,5,6,10,12,13) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 4: Physician’s SN visit frequency order, written 10/11/2024 is twice weekly and 2 PRN. There is no evidence of a second SN visit during the weeks: 1/19/25; visit made 1/21/25. 2/2/25; visit made 2/4/25. 2/16/25; visit made 2/18. 3/2/25; visit made 3/4/25. 3/16/25; visit made 3/18. 3/30/25; visit made 4/3/25. 4/13/25; visit made 4/17/25. Patient 5: Physician’s SN visit frequency order, written 9/27/24 is weekly and 2 PRN. There is no evidence of SN visit: 3/28/25-4/11/25; 4/11/25-4/25/25. There is evidence of 2 SN visits during weeks: 11/24/24; LVN visits made 11/29 and 11/30/24. 12/1/24; Both LVN and RN visits made 12/6/24. 12/15/24; Both LVN and RN visits made 12/20/24. 1/12/25; Both LVN and RN visits made 1/17/25. 2/9/25; LVN visit made 2/10 and RN visit made 2/14/25. 2/23/25; LVN visit made 2/25 and RN visit made 2/28/25. 3/9/25; Both LVN and RN visits made 3/14/25. 3/23/25; LVN visit made 3/25 and RN visit made 3/28/25. Physician’s social work visit frequency order, written 10/1/24 is once per certification period and 1PRN. Documented social work visits: 10/1, 11/26/24. There is no evidence of social work visits for the other 2 certification period 13. Certification periods: 11 = 9/27/24-11/25/24. 12 = 11/26/24-1/24/25. 13 = 1/25/25-3/25/25. 14 = 3/26/25-5/24/25. Patient 6: Physician’s SN visit frequency order, written 3/2/25 is weekly and 2 PRN. There is evidence of 2 SN visits during weeks: 3/16/25; RN visit made 3/16, LVN visit made 3/21/25. 3/30/25; RN visit made 3/30 and LVN visit made 4/3/25. 4/13/25; RN visit made 4/13 and LVN visit made 4/16/25. Patient 10: Physician’s SN visit frequency order, written 3/2/25 is weekly and 2 PRN. There is evidence of 2 SN visits during weeks: 1/12/2025; RN visit made 1/12 and LVN visit made 1/14/25. 2/9/25; LVN visit made 2/11 and RN visit made 2/12/25. 3/9/25; Both RN and LVN visits made 3/12/25. 4/6/25; LVN visit made 4/8 and RN visit made 4/10/25. 4/20/25; LVN visit made 4/22 and RN visit made 4/24/25. Patient 12: Physician’s nursing visit frequency order, written 10/9/25 is weekly. There is no evidence of nursing visit: 10/11/24-10/23/24; 10/23/24-11/6/24. Patient 13: Physician’s social work visit frequency order is once per benefit period. Patient admitted 3/16/24 in benefit period 12, ending 5/15/24. Patient was discharged in benefit period 13, on 7/13/24. Documented social work visits: 3/18,4/17,5/17,6/14,6/17/24. These are outside the ordered visit frequency.

Upon patient record review 4 of 14 (Patient #1, 4, 6, 7) did not have evidence that the IDG ensures that the care and services provided are based on all assessments of the patient and family needs. Patient 1: In the 4/25/25 IDG, it is documented that the patient needs twice weekly aide visits. This note appears in the “other/physician” section of the IDG. There is no evidence that the order was written for these visits. Patient 4: There is no evidence of initial spiritual assessment in the medical record. Initial comprehensive nursing assessment documented that spiritual assessment was needed. It was also documented that a referral to SC was made. There is no evidence of a visit made. Patient 6: There is no evidence of initial psychosocial assessment in the medical record. Initial comprehensive nursing assessment documented that psychosocial assessment was needed. It was also documented that a referral to social work was made. There is no evidence of a visit made. Patient 7: There is no evidence of initial psychosocial or spiritual assessment in the medical record. Initial comprehensive nursing assessment documented that both spiritual and psychosocial assessment were needed. It was also documented that a referral to SC and social work were made. There is no evidence of a visit made.

Upon patient record review, 2 of 14 (Patient #2,13) 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 2: Hospice aide care plan with ordered oxygen precautions. Patient without evidence of ordered oxygen in the medical record. Patient 13: Hospice aide care plan tasks without evidence of assigned frequency: empty urinary collection bag, measure urinary output, 2-person transfer, record bowel movement, change linen, feeding assistance, encourage fluids, meal prep-snack, turn and reposition, bed rails up. The following task assignments are incomplete: assist with oral medications as per RN instruction; companion services as per RN instruction. These task assignments have no RN instruction included in the task assignments.

Upon patient record review 1 of 14 (Patient #2) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient 2: Physician’s aide visit frequency order is twice weekly. There is evidence aide visited patient only weekly during the time period 12/12/24-4/23/25.

Upon patient record review 1 of 14 (Patient #4) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs. Patient 4: There is no evidence of aide supervisory visit: 11/8-12/6/24 (28 days); 1/3-1/31/25 (28 days); 2/28-3/28/25 (28 days). Surveyor noted that RN opened aide supervisory visits on 1/17 and 3/14/25. Both these supervisory visits were blank.