Every finding on record at Magnolia Hospice Care, LLC

Upon patient record review, 1 of 19 (Patient #18) 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 #18: The comprehensive assessment dated 11-02-24 indicated the patient had a "suprapubic catheter with frequent UTIs", but there was no evidence of associated plan of care for GU interventions.

Upon patient record review, 1 of 19 (Patient #19) 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 #19: Per the MSW note dated 12-03-25, the patient fell "multiple times in the past 2 days", but there was no update to the plan of care nor were fall precautions added to the plan of care.

Upon patient record review 2 of 19 (Patient #2, #15) 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 #2: An aide supervisory visit was completed on 07-01-25 and not again until 07-16-25 which is greater than 14 days. Patient #15: There was no evidence of a supervisory visit completed during the period when aide started on 07-02-25 and the last aide visit on 07-17-25 which is greater than 14 days.

Upon observation, there was no evidence the organization follows their policies and procedures to maintain the the patient's clinical record in confidential manner. Patient #15: The IDT summary by the RN dated 07-03-25 addressed an unidentified, "75 year old female with breast cancer", though this patient was a male with COPD. COS by removing the IDT update from the incorrect chart and placing in the correct chart.

Upon patient record review, 1 of 19 (Patient #4) did not have evidence that the hospice plan of care identifies the care and services that are needed and specifically identify which provider (nursing facility or hospice) is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care. Patient #4: There was no evidence of a determination of who was to provide the stated interventions within the plan of care specifically regarding pain medication administration and safety precautions.

Upon patient record review 2 of 11 records (Patient #2, #6) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patients #2 and 6: There is no evidence of a psychosocial comprehensive assessment completed.

Upon patient record review, 2 of 11 records (Patient #1, #2) 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. Patients #1 and 2: There is no evidence that the Bereavement Assessment was completed within 5 days.

Upon patient record review, 6 of 11 records (Patient #4,#5,#6,#7,#8,#9) 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. Patients #4, 5, 6, 7, 8, 9: There is no evidence that a written care plan has been developed for the patients spiritual needs to include goals and interventions. The chaplain is involved with the patient.

Upon client record review, 6 of 11 records (Patient #3,#4,#7,#8,#9,#10) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #3: There is no evidence in the patient record that there has been a frequency established/ordered within the IDG plan of care for the Nurse, Aide, and Chaplain, however routine visits are being made weekly. Patient #4: There is no evidence in the patient record that there has been a frequency ordered for the Medical Social Worker for the 7/24 recertification period. The MSW visits monthly. Patient #7: Orders for MSW stated 1 time a week for 1 month; however only went for the psychosocial assessment. Patient #8: Orders for MSW states 1 time a week however the MSW missed visits on week of 7/10 and 7/17. Patient #9: The patient was admitted on 6/29. There is no evidence in the patient record that there has been a frequency established/ordered for the MSW or the Chaplain who make routine visits. Patient #10: Orders for Chaplain 1 time a month, however the Chaplain visited 1 time a week.

Upon observation, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient #1: Upon observation in the home, the LVN utilized a hand tote for a nursing bag that does not close so it remained open during the visit. The patient's dog jumped up on the clean area and entered the bag. Per Bag Technique policy IC.12 section G; "After cleansing hands, the supplies and/or equipment needed for the visit are removed from the bag. Close bag before performing patient care". Patient #2: Upon the home visit conducted with the aide, the handwashing policy was not followed. When the aide washed her hands, she used a towel hanging in the bathroom to dry hands and turned off the faucet with hand. Per agency Hand Hygiene Procedure IC.3; "Staff will dry hands and wrists thoroughly with a clean paper towel. They will use a paper towel to turn off the faucet".

Upon patient record review 1 of 10 applicable (Patient #5) 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 #5: Upon admission on 6/1, the aide frequency was ordered for 1 time a week for one week then 3 times a week thereafter; however there was no aide visit for the first week.

Upon client record review, 2 of 2 applicable (Patients #3, #4) did not have evidence that the hospice plan of care identifies the care and services that are needed and specifically identify which provider (nursing facility or hospice) is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care. Patient #3: There is no evidence that the hospice plan of care identifies which provider is responsible for performing the specific nursing tasks within in the hospice plan of care such as wound care, trach care, Foley Catheter care, PEG tube care/feedings. Documentation under the "coordination of care" with the facility representative and patient or family is blank. Patient #4: There is no evidence that the hospice plan of care identifies which provider is responsible for performing specific nursing tasks within the plan of care such as the multiple wound care. The "coordination of care" section of the plan of care is blank in regards to coordinating the plan of care with the facility representative.

Upon patient record review, 1 of 1 applicable (Patient #3) did not have evidence that the hospice provided the following information: • The most recent hospice plan of care specific to each patient • Hospice election form and any Advance Directives specific to each patient • Physician certification and recertification of the terminal illness specific to each patient • Names and contact information for hospice personnel involved in hospice care of each patient • Instructions on how to access the hospice's 24-hour on-call system • Hospice medication information specific to each patient • Hospice physician and attending physician (if any) orders specific to each patient Patient #3: Upon survey visit to the patient in the Skilled Nursing Facility, there was no evidence that the hospice had provided any of the required documentation such as consent, plan of care, certification, contact information, etc. There was no hospice record. There was a "home" folder left which only contained educational material. * The agency compiled a hospice chart with the required documentation and took back to the facility while on-site.