Every finding on record at Oasis Hospice & Palliative Care Inc

Based on a review of clinical records, and staff interview, the Hospice failed to ensure the Pt. care essentials/needs were identified and/or provided.  This was found in 2 of 3 (Pts. #1 and 2) clinical records reviewed. --- Findings include:1.  Pt. #1 was admitted for Hospice services on 07/01/25 with the Hospice diagnosis of Alzheimer’s Disease, Unspecified. The clinical record was reviewed on 12/15/25.  The clinical record contained the Initial Plan of Care dated 07/01/25 completed by the IDG, and IDG Update for 07/08/25 to 07/22/25, both documents required the SN to provide service 2 times a week.  The clinical record lacked documentation the skilled nurse provided a second visit during the week of 07/06/25 to 07/12/25.   2.  Pt. #2 was admitted for Hospice services on 04/05/25 with the Hospice diagnosis of Alzheimer’s Disease, Unspecified.  The clinical record was reviewed on 12/15/25.  The clinical record contained the document titled, “Hospice Physician Recertification of Terminal Illness” signed by the physician on 09/01/25 and included, “patient is at high risk of falls”.  The IDG meeting notes dated 09/30/25 included “Problem:  At risk for falls… keep bed in lowest position”.  On 10/07/25, the Pt. was transferred from routine home care to the Hospice IPU for respite care, and on 10/07/25 the RN had observed the Pt. attempting to get out of bed, and the RN redirected the Pt.  The IPU RN visit note dated 10/10/25 (8:11 AM) included documentation that at 7:05 AM, the “Bed alarm went off patient was on the floor.  Patient says ouch when tried to stand up and point to left side… Floor mats for the floor X2 are being ordered…”  The Hospice RN had identified the Pt. as being a high risk for falls, and failed to place floor mats to prevent injury, until after the fall on 10/10/25.   3.  During an interview with the Administrator, IPU Manager, and the Assistant Director of Nursing (Administrative Team) on 12/15/25 at 3:20 PM, the Administrative Team confirmed the above findings.

It is required that each patient’s individualized written plan of care reflects patient and family goals and identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 6 of 19 (32%) clinical records reviewed it was revealed that the agency did not ensure the written plan of care (POC) included patient and family goals and specific interventions based on the problems identified in the initial and updated comprehensive assessments. Clinical Record 3: The updated comprehensive nursing assessment dated 1/5/24 documented an increased use of Nitroglycerin for chest pain, dizziness, and syncope. During the Home Visit 3 interview with the patient's daughter, she confirmed the nursing assessment documentation. The POC, updated and effective 1/5/24, did not contain any problems, goals, or interventions related to chest pain, safety, and fall precautions. Clinical Record 6: The initial nursing assessment dated 5/12/23 documented the patient as a fall risk requiring the use of a walker for safety. The POC effective on 5/12/23 did not contain any problems, goals, or interventions related to fall precautions or safety. Clinical Record 7: The initial nursing assessment dated 12/31/22 documented the patient had an indwelling Foley catheter in place. The POC, effective on 12/31/22 did not contain any problems, goals, or interventions related to the indwelling catheter. Clinical Record 9: The initial nursing assessment dated 12/11/23 documented the patient had reported pain rated at six (6) out of ten (10). The POC created on 12/11/23 and updated on 12/18/23 did not contain any problems, goals, or interventions related to pain. Clinical Record 14: The initial nursing assessment dated 11/22/22 documented the patient was on a medication regime that included scheduled and as needed (PRN) morphine, scheduled senna plus and bisacodyl tablets for constipation, and lactulose PRN for constipation. The initial POC dated 11/22/22 and the updated POC dated12/12/22 did not contain any problems, goals, or interventions related to constipation. Clinical Record 15: The initial nursing assessment dated 10/2/23 documented the patient had a history of falls and increased weakness. The POC, effective 10/2/23 and updated 10/17/23 did not contain any problems, goals, or interventions related to safety and fall risk; however, they were added to the POC effective 12/19/23. Nursing documentation completed on 1/2/24 by an Licensed Practical Nurse (LPN) and 1/3/24 by the RN documented the patient tested positive for the COVID infection on 1/2/23. The POC was not updated to include this problem, or associated goals and interventions. On 1/10/24 and 1/11/24 joint record review and interviews were conducted with the Administrator and Director of Operations, who agreed that the agency did not ensure the written POC included patient and family goals and specific interventions based on the problems identified in the initial and updated comprehensive assessments.

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by an RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 3 of 17 (18%) clinical records reviewed, in which aide services were accepted, it was revealed that the agency did not ensure the RN provided specific instructions for the hospice aides to follow. Clinical Record 2: The hospice aide care plan, updated 1/5/24, documented the following tasks to be performed by the aide: Passive Range of Motion (PROM), barrier products in use: A&D ointment, and nail care. The plan did not provide specific instructions on extremity/extremities PROM was to be performed, if and where A&D ointment was to be applied, and type of nail care to be performed. Clinical Record 5: The hospice aide care plan, effective 9/17/23, documented a task for the aide to apply A&D ointment. The plan did not provide instructions on where the ointment was to be applied. Clinical Record 6: The initial nursing assessment (5/12/23) narrative and initial Plan of Care (POC) documented the patient as having an indwelling Foley catheter. The aide's care plan (5/12/23) did not provide instructions on care of or alert the aide to the indwelling catheter. On 1/10/24 and 1/11/24 joint record reviews and interviews were conducted with the Administrator and Director of Operations, who agreed that care instructions for the aides were not specific to patient needs.

It is required that a hospice aide provides services included in the plan of care. This standard was not met as evidenced by clinical record review, interview and observation. In 3 of 17 (18%) clinical records reviewed, in which aide services were provided, it was revealed that the agency did not ensure the aides provided the services included in the aide plan of care (POC). Clinical Record 3: The hospice aide care plan, effective 1/5/24, documented tasks for the aide to provide bed bath and shower. During Home Visit 3 with the aide (Staff 2) on 1/10/24, the aide reported that she provided the patient with a sponge bath each visit while the patient sat on the bedside commode (BSC) per the patient's request. Preparation by the aide to provide the patient with a sponge bath while on the BSC was observed during the home visit. The aide POC did not include instructions for the aide to provide a sponge bath. Physician order effective on 11/28/23 ordered hospice aide visit frequency as three (3) visits per week. For the week of 12/17/23, there was one (1) missed visit documented on 12/18/23 and one completed visit documented on 12/21/23. The record did not contain any documentation to support the third ordered visit for the week. Clinical Record 12: The physician order effective on 11/26/23 and updated 12/4/23 ordered the hospice aide visit frequency as three (3) visits per week. For the week of 12/3/23, there were no documented visits. The record did not contain any documentation to support the missed visits. Clinical Record 13: The physician order effective on 12/1/23 ordered hospice aide visit frequency as three (3) visits per week. For the week of 12/3/23, there were no documented visits. The record did not contain any documentation to support the missed visits. The aide visit documentation on 12/22/23 stated, "zinc applied." This task was not an ordered service on the aide POC for the aide to complete. On 1/11/24 and 1/12/24 joint record reviews and interviews were conducted with the Administrator and Director of Operations, who agreed that the agency did not ensure the aides provided services included in the aide POC.

It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse (RN) as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. This standard was not met as evidenced by clinical record review and interview. In 4 of 17 (24%) clinical records reviewed, in which aide services were accepted, it was revealed that the agency did not ensure the hospice aides reported changes in patient needs related to the plan of care (POC) to the RN. Clinical Record 5: For aide visits on 10/4/23 and 10/5/23, the task of "shower with assist 3x weekly" was ordered; however, the aide did not complete the ordered task and provided the reason as "not requested today." The record did not contain documentation that the RN was notified. Clinical Record 6: The aide documentation for the visit made on 9/29/23 stated patient refused shower and denture care. The aide documentation for the visit made on 10/2/23 stated the patient refused shower and shampoo. The aide documented bed bath or shower per the patient's request was completed on 10/5/23 and that the patient refused care except for a brief change. The record did not contain documentation that the RN was notified. Clinical Record 9: For the aide visit performed on 12/22/23, the task to complete a bed bath was ordered. The aide documented the task was not completed and provided the reason, "not requested today." The record did not contain documentation that the RN was notified. Clinical Record 16: For the aide visit performed on 12/22/23, the aide documented that the patient was "agitated and combative" therefore the aide provided a bed bath as requested by the family. The record did not contain documentation that the RN was notified of the patient's behaviors and the family's request. On 1/11/24 joint record reviews and interviews were conducted with the Director of Operations and Administrator who confirmed the records did not contain evidence that the RN was notified of changes in care needs.

It is required that hospice aides are supervised by a registered nurse who makes 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 ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. This standard was not met as evidenced by clinical record review and interview. In 5 of 17 (29%) clinical records reviewed, in which aide supervision was required, it was revealed that the agency did not ensure that the registered nurse (RN) documented the aide supervisory visit at least every 14 days. Clinical Record 1: The Plan of Care (POC) updates for the episode dated 12/12/23 - 1/9/2024 included orders for aide services three (3) times per week. The RN documented an aide supervisory visit on 12/18/23, and the next aide supervisory visit was not documented until 1/2/24 which was 15 days apart. Clinical Record 4: The POC updated 12/12/23 included orders for aide services five (5) times per week. The RN documented an aide supervisory visit on 12/15/23, and the next aide supervisory visit was not documented until 1/2/24 which was 18 days apart. Clinical Record 5: The POC updated 8/18/23, 9/5/23, 9/10/23, and 9/17/23 included orders for aide services five (5) times per week, four (4) times per week, five (5) times per week, and one (1) time per week respectively. The RN documented an aide supervisory visit on 9/1/23 and the next aide supervisory visit was not documented until 9/18/23 which was 17 days apart. Clinical Record 13: The POC effective 11/14/23 to 1/12/24 included orders for aide services three (3) times per week. The RN documented an aide supervisory visit on 11/20/23, and the next aide supervisory visit was not documented until 12/14/23 which was 24 days apart. Clinical Record 18: The POC effective 11/26/23 to 1/12/24 included orders for aide services three (3) times per week. The RN documented an aide supervisory visit on 12/18/23, and the next aide supervisory visit was not documented until 1/2/24 which was 15 days apart. On 1/12/24 joint clinical record reviews and interviews were conducted with the Director of Operations and Administrator who confirmed aide supervisory visits were not completed at least every 14 days.

It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services and, as necessary, provides in-service training and education programs where required. The hospice has written policies and procedures describing the method(s) of assessing competency and maintains a written description of the in-service training provided during the previous 12 months. This standard was not met as evidenced by document review, interview and personnel record review. In 1 of 10 (10%) personnel records reviewed it was revealed that the agency did not ensure competencies were completed as per the agency Competency Assessment policy. Document 1: Agency policy titled Competency #3-003 (Dated: 11/22) stated in part, "The competence of all organization clinical personnel (employed, contract, or volunteer) will be assessed during orientation, during the probationary period, periodically throughout the course of the year and during the annual performance evaluation." Personnel Record 7: The Hospice Medical Director was hired on 2/18/15. The personnel record lacked evidence of completed annual competencies for 2021, 2022, and 2023. On 1/11/24 joint personnel record reviews and interviews were conducted with the Administrator and the Director of Operations, who confirmed the agency did not ensure competencies were completed as per agency policy.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes physician orders. This standard was not met as evidenced by clinical record review, interview and observation. In 4 of 19 (21%) clinical records reviewed it was revealed that the agency did not ensure physician orders were obtained for all care and services provided to its patients. Clinical Record 1: The aide care plan updated on 11/30/23 included the task of washing the patient's eyes with baby shampoo. During Home Visit 1 and joint hospice binder review with RN (Staff 1), orders for the eyewash and use of artificial tears were documented as of 11/30/23. The record did not contain physician orders for the eyewash or artificial tears. Clinical Record 5: The nursing assessment documentation on 9/8/23 and 9/15/23 stated daughter was instructed to administer "4oz (four ounces) Tonic Water with Quinine BID (two times a day)" to relieve foot cramping and pain. The record did not contain physician orders for the Tonic Water and Quinine. Clinical Record 18: The nursing assessment documentation on 12/1/23 stated "Foley bag emptied... Texas catheter intact." The aide visit (12/1/23) documented the assigned task to change the Texas catheter during care was completed. The record did not contain physician orders for a Foley or Texas catheter. Clinical Record 19: The plan of care order written 12/15/23 for manual bladder irrigation as needed for sediment in the urinary bag or tubing. The record did not contain a complete physician order detailing what flush was to be used or the amount. On 1/10/24 and 1/11/24 joint clinical record reviews and interviews were conducted with the Administrator and Director of Operations, who confirmed the records did not contain physician orders for all care and services provided to the patients.