Every finding on record at Nexus Hospice Care Inc

Upon patient record review, 1 of 5 (Patient #2) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual's attending physician, if any) • Changes that have taken place since the initial assessment • Information on the patient's progress toward desired outcomes • Reassessment of the patient's response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days Patient #2: Patient is scheduled for SN visits 1-2 times weekly, which has been met, however, there has not been a comprehensive nurse assessment completed on the patient since 06/27/25 (24 days).

Upon patient record review, 4 of 5 (Patient #2, 3, 4, 5) 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 #2: The admission orders include orders to suction the patient either orally or nasally prn. There are no interventions or goals related to suction on the POC. Patient #3: The admission orders include orders to suction the patient either orally or nasally prn. There are no interventions or goals related to suction on the POC. The patient has a nebulizer along with comfort medications ordered for it with no interventions or goals related to use of a nebulizer on the POC. Patient #4: The admission orders include orders to suction the patient either orally or nasally prn. There are no interventions or goals related to suction on the POC. Patient #5: The admission orders include orders to suction the patient either orally or nasally prn. There are no interventions or goals related to suction on the POC.

Upon patient record review, 3 of 5 (Patients #2, 3, 4) 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 equipment and supply needs. Patient #2: There are orders for suctioning. There is no suction machine on the DME list. Patient #3: There are orders for suctioning. There is no suction machine on the DME list. Patient #4: There are orders for suctioning. There is no suction machine on the DME list.

Upon patient record review 5 of 5 (Patient #1,2,3,4,5) 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. Patient #1,2,3,4,5, SC service were declined. No evidence RN completed a comprehensive assessment of spiritual needs during initial assessment.

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

Upon patient record review, 5 of 5 (Patient #1,2,3,4,5) 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, Bleeding precaution identified with physician order. No evidence of bleeding disorder interventions or goals noted on plan of care. Patient #2, Patient is a full code and does not have funeral home identified. No evidence of psychosocial care plan identifying interventions and goals for full code status and plan for funeral home arrangements. No evidence of care plan identifying nephrostomy tube care. Patient #3, Patient terminal diagnosis is cardiac disease. No evidence of initial care plan with interventions and goals for cardiac. Patient has no funeral home identified. No evidence of psychosocial care plan with intervention and goals for funeral home planning. Patient #4, Patient has no funeral home identified. No evidence of psychosocial care plan with intervention and goals for funeral home planning. Patient #5, Initial IDG on 4/29/25 and 5/13/25 there are no care plans, intervention or goals identified. Patient is a full code and has no funeral home plans. No evidence of psychosocial care plan with interventions and goals address full code status and no funeral home plans.

Upon patient record review, 1 of 5 (Patient #2) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient #2, Physician order for MSW frequency initial evaluation then as needed. No evidence of continued frequency for MSW visits.

Upon patient record review, 3 of 5 (Patient #1,2,5) 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 equipment and supply needs. Patient #1, Commode is documented on initial nursing assessment as her own. No evidence commode was added as DME on the plan of care. Patient #2, Shower chair documented on initial nursing assessment as her own. No evidence shower chair was added as DME on the plan of care. Patient #5, Shower chair, commode, walker documented on initial nursing assessment as her own. No evidence these items were documented on the plan of care under DME.

Upon patient record review, 1 of 5 (Patient #2) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #2, Physician order states on 6/1/25, flush nephrostomy tube with 10cc normal saline every Monday, Wednesday, Friday, change nephrostomy bag every Friday. Visits completed on Monday, Wednesday, Thursday and Saturday. No evidence nephrostomy tube was flushed with 10cc normal saline. No evidence of nephrostomy bag changed Friday as no visit was made.

Upon patient record review, 3 of 14 (Patient #4,6,7) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient 4,6: On the hospice election, the area for choosing attending physician is blank. Patient 7: On the hospice election, the area for choosing attending physician has “I acknowledge my attending physician is” chosen. There is no physician name written in.

Upon patient record review, 10 of 14 (Patient #1,2,3,4,5,6,7,8,9,10) 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 Patients 1-10: Oxygen 2-5LPM via nasal cannula or mask PRN is listed as a treatment. This medication is not on the medication list. COS Patient 4: Debrox drops, 5 drops each ear X7 days each month. There is no evidence of specified dates in the instructions for administration on the medication list. COS Patient 9: Psyllium husk powder for compounding appears on the medication list without instructions. COS

Upon patient record review, 3 of 14 (Patient #6,7,10) 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 6,7,10: There is no evidence of initial bereavement assessment in the medical record.

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

Upon patient record review, 8 of 14 (Patient #1,2,3,4,5,8,9,10) 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 without evidence of problems, goals, interventions on the plan of care: bleeding prevention due to use of Eliquis. COS Patient 2: Identified needs without evidence of problems, goals, interventions on the plan of care: bleeding prevention due to use of aspirin, falls. COS Patient 3: Identified needs without evidence of problems, goals, interventions on the plan of care: high risk for skin breakdown, anxiety, confusion. COS Patient 4: Identified needs without evidence of problems, goals, interventions on the plan of care: high risk for skin breakdown, weakness. COS Patient 5: Identified needs without evidence of problems, goals, interventions on the plan of care: bleeding prevention due to use of Xarelto. COS Patient 8: Identified needs without evidence of problems, goals, interventions on the plan of care: neuro, high risk for skin breakdown. COS Patient 9: Identified needs without evidence of problems, goals, interventions on the plan of care: high risk for skin breakdown, pain, weakness. COS Patient 10: Identified needs without evidence of problems, goals, interventions on the plan of care: high risk for skin breakdown, UTI on admission, dyspnea. COS

Upon patient record review, 2 of 14 (Patient #5,8) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient 5,8: Physician’s SN visit frequency order is 1-3 times per week and PRN. There is no evidence of quantifier for PRN visits in the physician’s order. COS

Upon patient record review, 10 of 14 (Patient #1,2,3,4,5,6,7,8,9,10) 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. Patients 1-10: Oxygen 2-5LPM via nasal cannula or mask PRN is listed as a treatment, not a medication, on the plan of care. COS Patient 4: Debrox drops, 5 drops each ear X7 days each month. There is no evidence of specified dates in the instructions for administration on the plan of care. COS Patient 9: Psyllium husk powder for compounding appears on the plan of care without instructions. COS

Upon patient record review, 3 of 14 (Patient #4,8,10) 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 equipment and supply needs. Patient 4: Wheelchair is listed on plan of care as DME need, despite patient documented as bedbound. COS Patient 8: Identified DME need without evidence of DME on the plan of care: shower chair, bedside commode. COS Patient 10: Identified DME need without evidence of DME on the plan of care: shower chair. COS

Upon patient record review, 2 of 14 (Patient #3,8) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 3: SN visit frequency order is 1-3 times weekly and 4 PRN. There is evidence that patient was visited by SN 6 times during week of 4/6/25-4/12/25. COS with late entry physician’s order. Patient 8: Patient visited by SC weekly. There is no evidence of physician’s order for these visits. COS with late entry physician’s order.

Upon patient record review, 1 of 14 (Patient #1) did not have evidence that the IDG documents the sharing of information between all disciplines providing care and services in all settings, whether the care and services are provided directly or under arrangement. Patient 1: Patient seen by outside provider podiatrist. There is no evidence of podiatry visit notes in patient’s chart. COS-During survey, notes requested from podiatrist. These were received and scanned into patient’s chart.

Upon patient record review, 3 of 14 (Patient #3,8,9) 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 3, 9: Aide care plan with assigned task 'change linen.' There is no evidence of assigned frequency for this task. COS Patient 8: Aide visits increased in frequency from twice weekly to 3 times weekly after 1/31/25 SN visit noted decline in patient status. There is no evidence that aide care plan was updated to include patient’s decline in functional status. On 3/31/25, patient’s PRN oxygen was discontinued. There is no evidence that aide care plan was updated to reflect this change. COS In addition, the Aide care plan with assigned task 'change linen.' There is no evidence of assigned frequency for this task. COS

Upon patient record review 5 of 14 (Patient #1,2,3,8,9) 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 1: Patient seen by aide on 3/26/25. There is no evidence of physician’s order for this visit in the medical record. COS-Late entry physician’s order added. Patient 2: Patient seen by aide twice weekly from 12/17/24-3/27/25. There is no evidence of physician’s order for these visits in the medical record. COS-Late entry physician’s order added. Patient 3: SOC date 4/4/25 with physician’s aide visit frequency order written on this date for twice weekly. There is no evidence of documentation of any aide visits since SOC. Policy 11.6.1 states all visit reports to be submitted the next scheduled work day, not to exceed 3 business days. COS-aide synced visits back during survey. Patient 8: Physician’s aide visit frequency order is three times weekly. The most recent aide visit documented in the chart is 3/26/25. COS-aide synced visits back during survey. Patient 9: Patient’s SOC date 3/26/25. Aide visit frequency ordered twice weekly 3/26 -3/31/25 and 3 times weekly after. There are 2 aide visits documented in the medical record, on 3/28 and 3/31/25. COS-aide synced visits back during survey.

Upon patient record review, 7 of 14 (Patient #4,5,6,7,10,13,14) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient 4,6: On the hospice election, the area for choosing attending physician is blank. Patient 4,5,10,13: On hospice notice of election, responsible party signed for patient. There is no reason documented for why patients did not sign for themselves. Patient 5,14: On hospice notice of election, the hospice start date is blank. Patient 7: On the hospice election, the area for choosing attending physician has “I acknowledge my attending physician is” chosen. There is no physician name written in. In addition, on hospice notice of election, the hospice start date is blank.