Every finding on record at New Hope Hospice Care

Upon patient record review, 5 of 14 (Patient #1,2,5,8,9) did not contain evidence 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: In the home; Gabapentin was in a bottle with no label. Per patient she takes 2 caps in the afternoon and 2 at night. Medication record reflects that she takes 1 "tab" 2 times daily. Atorvastatin Calcium 40mg tab reflects this to be taken at bedtime but medication record reflects "daily". Mirtazapine 15mg tab on medication record was not found in the home. Patient is on 3L continuous oxygen via NC and this is not on her medication record. Patient also reported and bottles found for vitamins and medication that she takes that are not on medication record; Beet Root 500mg, Immune support, Alpha lipoic Acid 200mg, Advance Multi 50+ Her, B12 1000mcg, MK7 K2 100mcg, GHR Platinum, Herbavision Gold, Melatonin 6mg, Magnesium Glycinate 200mg, B-Complex with Vit C, Advil Dual Action 250mg acetaminophen with 125mg NSAID. Patient #2: In the home; meclizine 25mg tab reflects one tablet once daily as needed but medication record reflects "1 tab twice daily by mouth." Olmesartan Medoxomil 40-25mg tab reflects one tablet daily but medication record reflects "1 tab daily by mouth as needed." Pantoprazole Chloride 10mEq cap reflects one capsule in the morning 30 mins before breakfast but medication record reflects "once a day." Sertraline Hydrochloride 100mg tab reflects one tablet at bedtime but medication record reflects "1 tab daily by mouth." Vascepa 1gm cap reflects twice daily but medication record reflects "1gm2 twice daily." Patient #5: Diclofenac 1% gel ordered on 10/31/25; does not indicate where to be applied to. Arthritis Pain Reliever 1% ointment ordered on 11/06/25; listed as PRN but does not indicate how often it can be used nor does it indicate where to be applied to. Miconazole Nitrate 2% Antifungal Cream ordered on 11/06/25; listed as PRN but does not indicate how often it can be used nor does it indicate where to be applied to. Patient #8: All ordered on 10/11/25: Diclofenac 1% gel listed as PRN but does not indicate how often it can be used and does not indicate where to be applied to. Icy Hot Maximum Strength listed as "As needed" but does indicate how often it can be used nor does it indicate where to be applied to. Proctozone-HC 2.5% cream does not indicate where to be applied to. Triamcinolone Actinide 0.025% ointment does not indicate where to be applied to. Duplicate drug therapy - both Pantoprazole sodium 40mg delayed-release tablet to be taken "one tablet 30 mins before breakfast" and Prilosec 20mg delayed-release tablet to be taken "once a day." Patient #9: All ordered on 09/30/25: Acyclovir 800mg tab indicated as "!tab" 5 times per day for 10days. It did not contain a discontinued date and still showing as active on current medication list. Hydrocortisone 2.5% did not indicate where to be applied to.

Upon patient record review, 5 of 14 (Patient #1,2,5,8,9) did not contain evidence that plan of care included all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #1: The initial POC/IDG dated 12/01/25 did not have any medications listed on it at time of survey. Gabapentin in home was in a bottle with no label. Per patient she takes 2 caps in the afternoon and 2 at night. Medication profile reflects that she takes 1 "tab" 2 times daily. Atorvastatin Calcium 40mg tab in home reflects this to be taken at bedtime but medication record reflects "daily". Mirtazapine 15mg tab on medication record was not found in the home. Patient is on 3L continuous oxygen via NC and this is not on her medication record. Patient also reported and bottles found for vitamins that she takes that are not on medication record; Beet Root 500mg, Immune support, Alpha lipoic Acid 200mg, Advance Multi 50+ Her, B12 1000mcg, MK7 K2 100mcg, GHR Platinum, Herbavision Gold, Melatonin 6mg, Magnesium Glycinate 200mg, B-Complex with Vit C, Advil Dual Action 250mg acetaminophen with 125mg NSAID. Patient #2: Initial POC and all updated POCs following - In the home; meclizine 25mg tab reflects one tablet once daily as needed but medication record reflects "1 tab twice daily by mouth." Olmesartan Medoxomil 40-25mg tab reflects one tablet daily but medication record reflects "1 tab daily by mouth as needed." Pantoprazole Chloride 10mEq cap reflects one capsule in the morning 30 mins before breakfast but medication record reflects " once a day." Sertraline Hydrochloride 100mg tab reflects one tablet at bedtime but medication record reflects "1 tab daily by mouth." Vascepa 1gm cap reflects twice daily but medication record reflects "1gm2 twice daily." Patient #5: Initial POC and all updated POCs following - Diclofenac 1% gel ordered on 10/31/25; does not indicate where to be applied to. POCs updated following order date of 11/06/25 - Arthritis Pain Reliever 1% ointment listed as PRN but does not indicate how often it can be used nor does it indicate where to be applied to. POCs updated following order date of 11/06/25 - Miconazole Nitrate 2% Antifungal Cream ordered listed as PRN but does not indicate how often it can be used nor does it indicate where to be applied to. Patient #8: Initial POC and all updated POCs following - All ordered on 10/11/25: Diclofenac 1% gel listed as PRN but does not indicate how often it can be used not does it indicate where to be applied to. Icy Hot Maximum Strength listed as "As needed" but does indicate how often it can be used nor does it indicate where to be applied to. Proctozone-HC 2.5% cream does not indicate where to be applied to. Triamcinolone Actinide 0.025% ointment does not indicate where to be applied to. Duplicate drug therapy - both Pantoprazole sodium 40mg delayed-release tablet to be taken "one tablet 30 mins before breakfast" and Prilosec 20mg delayed-release tablet to be taken "once a day." Patient #9: Hydrocortisone 2.5% did not indicate where to be applied to.

Upon patient record review, 11 of 14 (Patient #2,3,4,5,6,7,8,9,10,11,13) 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 #2,3,4,5,6,7,10: Initial POC and all subsequent reflect MSW, SC and BC "initial comprehensive within 5 days" with no further updates. Patient #8: Initial POC and all subsequent reflect MSW, SC and BC "initial comprehensive within 5 days" with no further updates. Patient #9: Initial POC and all subsequent reflect MSW, SC and BC "initial comprehensive within 5 days" with no further updates. Patient #11 and #13: Initial POC reflects MSW, SC and BC "initial comprehensive within 5 days" with no further updates.

Upon client record review, 1 of 14 (Patient #8) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #8: The Initial POC and all subsequent indicated RN visits every 2 weeks. However, there were no visits made between the visit dated 10/13/25 and the next one on 11/21/25.

Upon patient record review 7 of 14 (Patient #2, 3,6,7,8,9,10) did not contain evidence that the IDG ensured that the care and services provided were based on all assessments of the patient and family needs. #2: MSW assessment 11/19/25 reflected "MSW recommends ongoing psychosocial support for the patient, including counseling sessions to address emotional challenges, promote adaptive coping, and encourage expression of feelings. The caregiver should be provided with resources for respite care, education on caregiver self-care, and access to support groups to manage stress. The MSW will continue to provide emotional support, access to coping patterns and connect the family to available hospice and community resources as appropriate." There was no indication of visit frequency and no further visits have been made since assessment. #3: MSW assessment 11/09/25 reflected "MSW recommends ongoing psychosocial for both the patient and PC through regular counseling, emotional check-ins, and access to community resources such as support groups and volunteer assistance. Respite care options should be discussed to help alleviate caregiver strain. Collaboration with the family, healthcare team, an community programs will ensure a comprehensive and sustained support network for both the patient and caregiver." There was no indication of visit frequency and no further visits have been made since assessment. #6: MSW assessment 11/02/25 reflected "MSW will continue providing ongoing psychosocial support, coordinate with interdisciplinary team and explore community resources and support groups to ensure comprehensive care for both the patient and caregiver." There was no indication of visit frequency and no further visits have been made since assessment. #7: MSW assessment 10/28/25 reflected "MSW recommends ongoing emotional support, counseling, and caregiver education. Collaboration with hospice counselling services, support groups, and community resources will be encouraged to strengthen coping and maintain emotional well-being for both the patient and caregiver." There was no indication of visit frequency and no further visits have been mase since assessment. #8: The chaplain's assessment 10/11/25 indicated the need for monthly visits. However, there were no further visits noted in the clinical record having been made. #9: The chaplain's assessment 09/30/25 indicated the need for reassessment with each recertification. However, there has not been any reassessments made prior to or since recertification on 11/25/25. MSW assessment 10/01/25 reflected "MSW will continue collaboration with the interdisciplinary team and explore community-based resources such as caregiver support groups, bereavement counselling, and volunteer assistance programs to ensure a strong support system for both the patient and caregiver, promoting emotional stability and overall well-being throughout the hospice journey." There was no indication of visit frequency and only one visit as made since initial assessment for the recertification assessment. The recertification assessment 11/26/25 stated the same thing, "MSW will continue collaboration with the interdisciplinary team and explore community-based resources such as caregiver support groups, bereavement counselling, and volunteer assistance programs to ensure a strong support system for both the patient and caregiver, promoting emotional stability and overall well-being throughout the hospice journey." However, no visit frequency given. #10: MSW assessment 06/21/25 reflected "MSW will collaborate with interdisciplinary team to ensure continued emotional support, caregiver education, and access to counseling, support groups and community resources to improve the overall quality of life for both the patient and caregiver." There was no indication of visit frequency and the only other visits made since initial assessment were for the recertification assessments. Recertification assessment 09/12/25 reflected "Collaboration with the interdisciplinary will continue to ensure support, caregiver education and access to supportive services that promote comfort and quality of life." Recertification assessment 11/16/25 reflected "The Medical SW completed a monthly assessment call via phone via PCG. PCG declined home visit at this time." There is no visit frequency but assessment from 11/16/25 indicated "monthly assessment call via phone."

Upon patient record review, 1 of 6 (Patient #6) 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 #6: Medication Profile: Basaglar is prescribed. It is inadvertently identified as being in the class of hyperlipidemia. Novalog Flex is ordered and it is inadvertently identified as anti hypertensive.

Upon personnel record review, 1 of 1 applicable (Personnel #4) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) ·Safe transfer techniques and ambulation. ·Appropriate and safe techniques in personal hygiene and grooming that include-- ·(C) Shampoo, sink, tub, and bed Personnel #4: The competency for sink shampoo was not marked as completed.

Upon personnel record review, 2 of 9 applicable (Personnel #1, 2) did not have evidence the hospice employees have received orientation on the hospice philosophy.

Upon personnel record review, 4 of 8 applicable (Personnel #1, 2, 3, 4) 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 #1, 2, 3, 4 competency skills list utilized for these employees is not consistent with agency policy 3-002.A. The skills list used for nurses and aide are specific to general skills (physical assessment, IV therapy, wound care, urinary catheter, med management for example for nurses), The agency policy requires hospice specific orientation and competencies (Admission process, Medicare Hospice Benefit, Concepts of Death and Dying, Hospice Concept and Philosophy) that are not validated with the list currently utilized. The agency's policy specific competency list was utilized for other staff. Also the nurses have a self assessment list only.