Every finding on record at Niagara Hospice, Inc.

Upon patient record review, 2 of 26 (Patients #2,3) 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: This patient had a bed rail. This item was not included on the Plan of Care. Patient #3: This patient had a lift chair and blood glucose machine. These were not included on the Plan of Care.

Upon patient client record review, 1 of 26 (Patient #17) 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 #17: This patent had a Certificate of Terminal Illness (CTI) for Benefit Period 1 that was not dated by the Medical Director (signed only). The CTI print date was 2/10/26 (SOC 1/10/26). Patient Verbal CTI was received timely. However, as noted above the CTI print date was greater than 30 days of SOC.

Upon observation, there was no evidence the hospice inpatient facility tests their power systems in accordance with NFPA 99 and NFPA 110 including the maintenance and testing of alternate power sources and transfer inspection and testing and maintenance and testing of circuitry. The agency had not completed emergency power generators triennial 4 hour load test per NFPA 110 (2010) 8.4.0 guidelines.

Upon observation, there is no evidence the interior finish of a facility is provided consistent with the 2012 editions of the LSC of the National Fire Protection Association and NFPA 99. Hospices are exempt from chapter 19.3.6.3.5 "exception number 1 and 2" and 19.3.6.3.6 number 2. If recommended by state survey agency, CMS may waive for periods deemed appropriate, specific provisions of the LSC which, if rigidly applied, would result in unreasonable hardship to the hospice, but only if the waiver would not adversely affect the health and safety of patients. The provisions of the adopted edition of the Life Safety Code do not apply in a State if CMS finds that a fire and safety code imposed by State law adequately protects patients in hospices. Existing Construction During building tour it was observed three ceiling tiles in laundry area were discolored/stained. These tiles remained in place and had not been replaced, indicating deferred maintenance. (NFPA 101-4.6.12.1).

Upon patient record review, 2 of 16 (Patient #10, 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 Patient 10: The medication list indicates furosemide 40mg take 1mg po daily; this is an inaccurate drug order as it provides unclear instructions related to the drug dosage, which were clarified with the SN and MD's order to be furosemide 40mg take 1 tablet po daily. Additionally the medication list indicates the patient is to utilize Miralax 17g for constipation, but did not provide instructions for reconstitution of this powdered medication. (corrected onsite) Patient 13: The medication list indicates the patient is to utilize Benefiber for constipation, but did not provide instructions for reconstitution of this powdered medication. (corrected onsite)

Upon patient record review, 1 of 16 (Patient #4) 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 4: Prior to hospice admission, on 08.30.2022, the patient was determined to have insufficient mental capacity to make healthcare decisions and his healthcare proxy was activated. The hospice obtained appropriate paperwork related to this on admission for hospice services and these became a part of the patient's medical record. The initial comprehensive nursing assessment noted the acceptance of these documents, and also noted the patient's diminished cognitive capacity. However, no care plan was developed, or has been developed since, related to the patient's lack of decision making capacity or requirement to communicate with the healthcare proxy related to medical care. (corrected onsite)

Upon patient record review, 1 of 16 (Patient #3) 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 3: The patient requires a hospital bed and wheelchair for management of the terminal illness; however, this DME does not appear on the patient's plan of care. (corrected onsite)

Upon patient client record review, 1 of 16 (Patient #3) 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 3: On the hospice election form, the patient's daughter's name (who is designated as the healthcare proxy per the patient's cognitive decline) was entered into the heading for Patient Name, rather than the patient's own name. (corrected onsite)