Every finding on record at Miracle City Hospice, LLC

Upon personnel record review, 3 of 14 (Personnel #6,7,8) did not have evidence Emergency Preparedness training including: • Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles • Demonstrate staff knowledge of emergency procedures • Provide emergency preparedness training at least annually • Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others • Maintain documentation of all emergency preparedness training Personnel 6,7,8: The contracted personnel did not have evidence of emergency preparedness training.

Upon patient record review, 5 of 19 (Patient #1,3,4,12,13) 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 t Patient 1: The medication profile contains Miralax with no diluent. Corrected on site. Patient 3: resides in ALF. Facility Med profile did not "mirror" the Hospice Med profile as follows: Facility profile for "ABH Gel (Ativan 1mg+Benadryl 25mg+Haldol1mg) Apply 1ml to inner wrists topically every 4 hours as needed for anxiety/restlessness" Hospice profile, "Lorazepam 1mg tablet, instructions: ABH Gel (Ativan 0.5mg, Benadryl 12.5mg, Haldol 0.5mg) Apply 1ml to inner wrists every 4 hours as needed for anxiety/restlessness". Facility profile, "Docusate Sodium Liquid 50mg/5ml, give 100mg by mouth two times a day for constipation" Hospice profile, "Docusate Sodium 100mg capsule, 1 capsule two times daily orally for constipation". Facility profile, "Hydrocortisone External Cream 1%, apply to affected areas topically every 6 hours as needed for itching" Hospice profile, "Hydrocortisone 1% topical cream, apply 1 inch to affected area twice a day for itching". Facility profile, Alprazolam tablet 0.25mg, 1 tablet orally every 6 hours as needed for anxiety, max of 3 in a day" Hospice profile, Alprazolam 0.25mg tablet, 1 tablet orally every 6 hours as needed for anxiety/restlessness". Corrected on site. Patient 4: Resides in ALF. facility Med profile did not "mirror" Hospice profile as follows: Facility Profile contained the following med orders that were not on the Hospice med profile: "Acetaminophen 650mg Suppository, insert 1 suppository Rectally every 4 hours as needed for pain or fever"- "Imodium A-D 2mg Caplet, take 1-2 caplets by mouth after first loose stool event, then 1 caplet by mouth after each loose stool event, Max daily dose 4 caplets"-"Aspercreme w/Lidocaine, apply topically to lower back once daily"- "Robitussin Syrup, Take 5ml by mouth every 4 hours as needed for cough/congestion"- "Clotrimazole 1% Cream, apply topically to affected area 2 times daily as needed for rash".---The Hospice med profile contained the following orders that were not on the Facility med profile: "Senna Plus 8.6mg-50mg capsule , 1-2 capsules PO BID PRN constipation" and "Tramadol 50mg tablet PO two times daily PRN Pain"- Dosage discrepancy for the following: Facility profile , "Amlodipine Besylate 10mg tablet, take 1 tablet by mouth daily" Hospice profile "Amlodipine 5mg Tablet, take 1 tablet oral daily" Patient 12: The medication profile contains an order for Nitrostat PRN with the indication of “bst pay”. Corrected on site. Patient 13: The medication profile contains an order for Sodium Chloride with a route of Miscellaneous and Milk of Mag ordered PRN with no frequency. Corrected on site.

Upon patient record review, 5 of 19 (Patient #1,3,4,12,13) 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: The medical record contains an order for Miralax with no diluent. Patient 3: resides in ALF. Facility orders did not "mirror" the Hospice POC as follows: Facility order for "ABH Gel (Ativan 1mg+Benadryl 25mg+Haldol1mg) Apply 1ml to inner wrists topically every 4 hours as needed for anxiety/restlessness" Hospice POC, "Lorazepam 1mg tablet, instructions: ABH Gel (Ativan 0.5mg, Benadryl 12.5mg, Haldol 0.5mg) Apply 1ml to inner wrists every 4 hours as needed for anxiety/restlessness". Facility order, "Docusate Sodium Liquid 50mg/5ml, give 100mg by mouth two times a day for constipation" Hospice POC, "Docusate Sodium 100mg capsule, 1 capsule two times daily orally for constipation". Facility order, "Hydrocortisone External Cream 1%, apply to affected areas topically every 6 hours as needed for itching" Hospice POC, "Hydrocortisone 1% topical cream, apply 1 inch to affected area twice a day for itching". Facility order, Alprazolam tablet 0.25mg, 1 tablet orally every 6 hours as needed for anxiety, max of 3 in a day" Hospice POC, Alprazolam 0.25mg tablet, 1 tablet orally every 6 hours as needed for anxiety/restlessness". Corrected on site. Patient 4: Resides in ALF. facility order did not "mirror" Hospice POC as follows: Facility order contained the following med orders that were not on the Hospice POC: "Acetaminophen 650mg Suppository, insert 1 suppository Rectally every 4 hours as needed for pain or fever"- "Imodium A-D 2mg Caplet, take 1-2 caplets by mouth after first loose stool event, then 1 caplet by mouth after each loose stool event, Max daily dose 4 caplets"- "Aspercreme w/Lidocaine, apply topically to lower back once daily"- "Robitussin Syrup, Take 5ml by mouth every 4 hours as needed for cough/congestion"- "Clotrimazole 1% Cream, apply topically to affected area 2 times daily as needed for rash".---The Hospice POC contained the following orders that were not on the Facility orders: "Senna Plus 8.6mg-50mg capsule , 1-2 capsules PO BID PRN constipation" and "Tramadol 50mg tablet PO two times daily PRN Pain"- Dosage discrepancy for the following: Facility orders, "Amlodipine Besylate 10mg tablet, take 1 tablet by mouth daily" Hospice POC "Amlodipine 5mg Tablet, take 1 tablet oral daily" Patient 12: The POC 7/12/24 contains an order for Nitrostat PRN with the indication of “bst pay”. Patient 13: The POC contains an order for Sodium Chloride with a route of Miscellaneous and Milk of Mag ordered PRN with no frequency.

Upon personnel record review, 3 of 14 (Personnel #6,7,8) did not have evidence the hospice employees and contract employees have received orientation on the hospice philosophy. Personnel 6,7,8: There was no evidence the personnel had received an orientation to hospice philosophy.

Upon personnel record review, 3 of 14 (Personnel #6,7,8) did not have evidence that a skills competency assessment, specific to each discipline had been conducted for all personnel including volunteers initially during orientation. Personnel 6,7,8: The contracted personnel did not have evidence of a skills competency assessment.

Upon patient client record review, 2 of 19 (Patient #1,13) did not have evidence that each patient record contains responses to medications, symptom management, treatments, and services. Patient 1: The SN documented 6/18/24 "cleansed with NS, patted dry and covered to protect"however, did not include how the wound care was tolerated by the patient. Patient 13: The SN documented on 7/21/24 and 7/22/24 “Wound care completed as ordered” and did not document how the pt tolerated the wound care.

Upon patient client record review, 6 of 19 (Patient #1,5,8,9,13,14) 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 1: The SN documented 6/18/24 "cleansed with NS, patted dry and covered to protect". The documentation is unclear of what the wound was covered with. Patient 5: The SN documented on 5/31/24 the following unapproved abbreviations in the narrative: Freq, Dep, Indep, CTAB. On 7/26/24 the SN documented “FSTNA” This is not an approved abbreviation. Patient 8: The SN documented on 2/27/24 "N.O. obtained". The approved abbreviation per agency policy for new order is N/O. Patient 9: The SN documented the following unapproved abbreviations on 5/13/24: OCC, APPROX, INDEP, FREQ. Patient 13:The SN documented on 7/17/24 “DOW”. This is not an approved abbreviation. In addition, The SN documented on 7/21/24 and 7/22/24 “Wound care completed as ordered”. The order for the wound care was written above but it is not in past tense so it is unclear what wound care the nurse performed. Patient 14: The SN documented on 7/24/24 the following unapproved abbreviations: Req’d, Freq, LS.

Upon client record review, 1 of 19 (Patient #15) 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: Patient 15:There is no evidence in the patient record that a discharge summary was sent to attending physician.

Upon client record review, 1 of 19 (Patient #5) 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 5: The SN documented on 8/1/24 “SN educated FN to continue to place ice to wrist on 20 minutes and off 20 minutes”. There is no evidence of an order for this modality.

Upon patient record review, 1 of 11 (Patient #5) did not contain evidence of a current/complete Medication Profile. The IDG POC listed, "Symptom management with p.r.n. Oxygen in place." The POC dated 09/19-12/27/21 listed, "Hospice nurse to instruct and monitor in use of Oxygen." Per nursing note dated 09/20/21, the patient was using Oxygen 2-4 liters p.r.n. Oxygen was not included on the Medication Profile.

Upon patient record review, 1 of 11 (Patient #2) did not contain evidence that a Registered Nurse was designated to ensure the continuous assessment of the patient and family's needs, and to coordinate activities with other members of the interdisciplinary group (IDG). A verbal order was obtained on 09/13/21 for, "Nystatin Cream to head of penis B.I.D. x5 days". Hospice nursing visits were subsequently made on 09/14 and 09/16/21, without any mention of the status of this area of patient concern.

Upon patient record review, 5 of 11 (Patients #2, 4, 5, 8, and 9) did not contain evidence that the Plan of Care included all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments: Patient #2: A verbal order was obtained on 09/13/21 for, "Nystatin Cream to head of penis B.I.D. x5 days"; without identifying who in this patient's home/ALF was responsible for such treatment/administration. Patient #4: A verbal order was obtained on 06/24/21 for, "SN to cleanse with Normal Saline, apply Dermoseptine, and leave open to air." This is not a complete wound order, as it does not identify the location on the body where such wound care is to be provided, nor does it include a frequency for such treatment. Patient #5: The IDG POC listed, "Symptom management with p.r.n. Oxygen in place." The POC dated 09/19-12/27/21 listed, "Hospice nurse to instruct and monitor use of Oxygen." These are not complete Oxygen orders. Per nursing note dated 09/20/24, the patient was using Oxygen 2-4 liters p.r.n. Additionally, the initial skilled nursing assessment documentation, dated 09/19/21, included, "Pressure Ulcer" in the Integumentary section. The IDG POC dated 09/22/21 included, "Wounds and Treatments: Pad and protect to coccyx." This is an incomplete wound order, as it does not delineate 'who', 'how often', nor the details of such wound care intervention. Patient #8: A verbal order was obtained 08/27/21 for, "Calmoseptine topical to coccyx wound daily, and p.r.n. skin protection." This is an incomplete wound order, as it does not clarify 'who' is to provided this daily wound care. Patient #9: The Physician CTI references, "Tube feedings of 4-6 cans of supplement at bedtime." The RN Initial Assessment notes, "Isosource supplement to be run at 110 ml per hour, overnight, per PEG tube", with rate later changed to a bolus infusion. There was no Physician order located on the most current Hospice POC, dated 04/28-07/26/21, related to this patient's PEG Tube, to include details such as who was responsible for providing this infusion, and any monitoring/maintenance of the insertion site.

Upon personnel record review, 1 of 9 applicable (Personnel #3) did not contain evidence that all Hospice employees, and contract clinicians, had received an orientation on the Hospice Philosophy. Personnel #3 was a contracted Physical Therapist who had provided care/services to a Hospice patient. There was no documented evidence of her having received orientation on the Hospice Philosophy of care.

Upon personnel record review, 1 of 9 applicable (Personnel #3) did not contain evidence that a Skills Competency Assessment, specific to each discipline, had been conducted for all personnel, including Volunteers, initially during orientation, prior to independently providing care/services to patients. Personnel #3 was a contracted Physical Therapist who had provided care/services to a Hospice patient. There was no documented evidence of her having received a Skills Competency Assessment, by a qualified clinician, prior to her provision of independent care/services.

Upon patient record review, 1 of 11 (Patient #5) did not contain evidence that all entries are clear and complete. The initial skilled nursing assessment documentation, dated 09/19/21, contained, "Pressure Ulcer" in the Integumentary section. The IDG POC dated 09/22/21 included, "Wounds and Treatments: Pad and protect to coccyx." The 09/20/21 nursing visit entry, in the Integumentary section, listed, "No problems noted." Documentation was unclear as to the patient's skin status, and how it was to be treated.