Every finding on record at Priority Hospice Care, Inc.

Observed in Patient Home. In 2 of 3 home visits conducted, it was noted the organization did not ensure that a thorough and ongoing medication reconciliation process was conducted. It was observed during home visits (HOSRRHV#1, HOSRRHV#2) wherein the nurse had failed to conduct effective medication reconciliation as evidenced by not verifying the medications currently in use by reviewing each medication bottle or prescription container during the visit.This finding was discussed and validated by the hospice Administrator who was present during the visit.

Observed in Record Review. In 10 of 10 active patient records reviewed, it was noted the organization failed to ensure that the written hospice plan of care was based on the patient's goals and the timeframes required to meet those goals.. For example the following goals were not measurable:HOSRRHV#1: Pt will achieve and maintain optimal skin integrity daily for the next 90 days. HOSRRHV#2: Patient will have agitation and anxiety under control for the next 6 months. HOSRRHV#3: Safe and comfortable dying over these 6 months. HOSRRNHV#1: Patient will maintain adequate cardiac/circulatory function and fluid volume for the following 90 days. HOSRRNHV#2: Self-determined life closure in the next 6 months. HOSRRNHV#3: Pt will experience no discomfort as PO intake declines in the next 90 days. HOSRRNHV#4: Promote optimal patient safety and prevention of injury over the next 6 months. HOSRRNHV#5: Patient will achieve and maintain optimal physical comfort within the next 7 days. HOSRRNHV#6: Promote optimal patient safety and prevention of injury over the next 6 months. HOSRRNHV#7 Safe and comfortable dying within the 90 days. This finding was discussed and validated by the hospice leadership team.

Observed in Record Review. In 5 of 10 active patient records reviewed, it was noted the organization failed to ensure that the hospice plan of care plan includes all services needed for the palliation and management of the terminal illness and related conditions, including medications necessary to meet the patient’s needs. Upon review of the records, multiple PRN pain medications ordered to be given for pain without specifying which medication should be administered based on specific guidance. For example: HOSRRNHV#2: Tylenol 325 mg 2 tablets every 6 hours as needed and Morphine Sulfate (concentrate) 100 mg/5ml as needed for pain/sob HOSRRNHV#3: Tylenol 650 mg 1 tablets PO as needed for pain; Tramadol HCl 50 mg 1 tablet every 6 hours for pain; and Morphine Sulfate Concentrate 100 mg/5 ml to take 0.25 ml every 2 hours as needed for pain. HOSRRNHV#4: Tylenol 160 mg/5 ml 20 ml every 8 hours as needed for pain; Tramadol HCL 50 mg. 1 tablet as needed for pain, Morphine Sulfate 20 mg/ml 5 ml every hours as needed for pain. HOSRRNHV#5: Lidocaine 5% 1 patch 1 x a day as needed for pain; Morphine Sulfate 100 mg/5ml 0.25 ml every 2 hours as needed for pain HOSRRNHV#6 Tylenol Arthritis Strength 650 mg 1 tablet PO as needed for pain; Norco 5:325 mg 1 tablet PO every 6 hours as needed for pain; Morphine Sulfate 20 mg/ml 5 mg PO every 2 hours as needed for pain. This finding was discussed and validated by the hospice leadership team.

Observed in Record Review. In 3 of 6 active patient records with hospice aide services, it was noted the organization had failed to ensure that the 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. For example,HOSRRHV#2. Based on documentation, the patient was at risk to aspiration related to impaired ability to swallow, however, the hospice aide care plan did not include a written instruction related to aspiration. HOSRRNHV#5, the patient was on continuous oxygen at 4 LPM via nasal cannula, however, the hospice aide care plan did not address whether the oxygen could be removed for the bath and for how long. Lastly, HOSRRNHV#6 a review of hospice aide assignments revealed missing written instructions regarding patient precautions related to prescribed blood thinner medication (Eliquis). This finding was discussed and validated by the hospice leadership team.

Observed in Record Review. In 2 of 6 active patient records with hospice aide services, it was noted the organization failed to ensure that hospice aide supervision was conducted at the patient's home no less than every 14 days as required. During review of record HOSRRHV#2 documentation showed a gap of 15 days between the 01/28/26-02/12. Also noted in HOSRRNHV#5, has gap of 16 days from 01/20 - 02/05/26. This finding was discussed and validated by the Hospice leadership team.

Observed in Leadership Session. The organization informs the patient of the patient's rights prior to beginning care, treatment, or services or during the initial evaluation visit before beginning care, treatment, or services. The patient was not provided in writing an approximate dollar amount they will be responsible for, even if that amount is zero . This was confirmed by the Executive Director.

Observed in Record Review. In 7 of 13 patient records reviewed, The written plan of care was not based on the patient’s goals and the time frames, settings, and services required to meet those goals. During review of patient records 1, 5, 6, 8, 9, 10, and 11 it was noted that the goal for wound care did not have any time frames. This was confirmed by the Executive Director.

Observed in Record Review. In 3 of 13 patient records reviewed, The organization did not plan the patient’s care. During review of records 3, 4, and 11 it was noted that there were not care plan interventions documented from problems identified in the comprehensive assessment such as pain or dysphagia. This was verified by the Executive Director.

Observed in Individual Tracer. The organization did not implement the infection prevention and control activities it has planned. During home visit 2 the LVN cleaned equipment after use with Wet Ones brand hand wipes which were not 70% isopropyl alcohol as required by policy. The label on the container said to wet hands and allow to dry. The nurse was not aware of dry time for the equipment after cleansing. This was confirmed by the Executive Director.

Observed in HR File Review. Staff did not participate in ongoing education and training. During review of HR record 6 it was noted that the employee did not have documentation of ongoing training. This was confirmed by the operations Director.

Observed in Record Review. In 13 of 13 patient records reviewed, Staff were not supervised effectively. During review of records 1-13 it was noted that supervisory visits for aides were not documented. This was confirmed by the Executive Director.

Observed in HR File Review. Staff competence was not assessed and documented once every three years, or more frequently as required by organization policy or in accordance with law and regulation. During review of HR records 1,and 2 it was noted that competency had not been documented since 2018. This was confirmed by the Operations Director.