Every finding on record at Quiet Waters Hospice, LLC

Upon patient client record review, 1 of 5 (Patient #2) 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 #2: The admission assessment of A1110 indicated the patient's preferred language was "English" and the patient declined an interpreter. However, the admission assessment narrative indicated the patient could speak English, "but her main language is Vietnamese. Interpreter available upon patient request."

Upon patient record review, 3 of 14 (Patient #1,#2,#9) 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 1: The medication profile contained MiraLAX with no instructions for a diluent. Patient has a peg tube, but the medication profile did not contain instructions for peg tube administration for any of the medications. Also, oxygen on medication profile is O2 at 2L/min as needed, but patient currently using O2 at 3.5L/min continuously via nasal cannula. Medication profile contains Lorazepam 1mg Q6H as needed; however, the bottle in the home is labeled with instructions as 0.5mg Q4H as needed. Instructions for Promethazine on medication profile is Q8H as needed, but bottle in home is labeled Q6H as needed. Patient 2: The medication profile contains triple antibiotic ointment to be applied to scabbed skin tear, but there was no instructions for the location of application. Patient 9: Triple antibiotic ointment remained on medication profile for cut on hand; however, care plan for wound was closed as resolved on 7/18/25.

Upon patient record review, 1 of 14 (Patient #3) did not have evidence in the patient record that the written plan of care is developed by the IDG, in consultation with the patient's attending physician, which specifies the services necessary to meet the patient and family-specific needs identified in the comprehensive assessment as it relates to the terminal illness and related conditions. Patient 3: There was no evidence in the patient record that the written plan of care is developed by the IDG, in consultation with the patient's attending physician.

Upon patient record review, 1 of 14 (Patient #13) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient 13: RN visit documentation on 2/9/26 indicates patient is imminent of death with symptoms of dyspnea on oxygen at 2L/min and mild grimacing. There was no evidence of follow up by nurse. Patient passed on 2/11/26.

Upon patient record review, 9 of 14 (Patient #1,#2,#4,#8,#9,#10,#11,#13,#14) 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: Admission documentation identifies patient as a high risk for falls and infections; however, there was no evidence of problems, goals and interventions for either of these risks. Patient 2: Patient taking anticoagulants Eliquis and Clopidogrel but there was no evidence of care plan for bleeding precautions. Patient 4: Patient taking anticoagulants Clopidogrel and aspirin but there was no evidence of problems, interventions and goals for risk for bleeding. Patient 8,9,11,13: Medication profile contains aspirin; however, there was no care plan for bleeding precautions. Patient 10: Patient taking Clopidogrel with no evidence of problems, interventions and goals for risk for bleeding. Patient 14: Patient taking Eliquis with no evidence of problems, interventions and goals for risk for bleeding.

Upon patient record review, 3 of 14 (Patient #4,#5,#7) 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 4,5: Social Worker order frequency is no visits with 1 PRN, as the patient declined the service following the initial comprehensive assessment. Patient 7: Social Worker and Chaplain order frequency is no visits with 1 PRN, as the patient declined the services of both disciplines following their initial assessments.

Upon patient record review, 3 of 14 (Patient #1,#2,#9) 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. Patient 1: The medical record contained an order for MiraLAX with no instructions for a diluent. Patient has a peg tube, but medication orders did not contain instructions for peg tube administration for any of the medications in the medical record. Patient currently using O2 at 3.5L/min continuously via NC; however, the medical record contains order for O2 at 2L/min PRN. Order for Lorazepam 1mg Q6H as needed in medical record, but the bottle in the home is labeled with instructions as 0.5mg Q4H as needed. Promethazine order in medical record is Q8H as needed but bottle in home is labeled Q6H as needed. Patient 2: Triple antibiotic ointment ordered to be applied to scabbed skin tear, but the order was missing instructions for the location of application. Patient 9: Order for triple antibiotic ointment for cut to hand remained current, but care plan for wound was closed as resolved/fully healed on 7/18/25.

Upon patient record review, 1 of 14 (Patient #1) 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: Patient has full bedrails and was identified as risk for falls on admission. There was no evidence of orders for the DME included in the plan of care.

Upon client record review, 2 of 14 (Patient #3,#11) did not have evidence that the IDG in collaboration with the attending physician reviewed, revised and documents the individualized plan as frequently as the patient's condition requires but no less frequently then every 15 calendar days. Patient 3: There was no evidence that the IDG in collaboration with the attending physician reviewed, revised and documents the individualized plan as frequently as the patient's condition requires but no less frequently then every 15 calendar days. Patient 11: There was no evidence of patient being reviewed/discussed during IDG meeting on 2/10/26 and previous meeting was 1/27/26.

Upon client record review, 1 of 14 (Patient #3) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 3: POC order on 12/2/25 and 12/30/25 for MSW visit frequency of 1x/monthly. There was no evidence of MSW visit in December or January.

Upon patient record review 2 of 14 (Patient #3,5) did not have evidence that the IDG ensures that the care and services provided are based on all assessments of the patient and family needs. Patient 3: Patient was offered and accepted volunteer visits upon admission, but there was no evidence of volunteer contact or visit made.Patient 5: Patient was offered and accepted volunteer visits upon admission, but there was no evidence of volunteer contact or visit made.

Upon patient record review, 4 of 14 (Patient #1,#4,#11,#13) 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 1: No evidence of instructions for full bedrails, as patient was identified as risk for fall upon admission. Patient 4,11,13: Patient taking anticoagulants, but there was no instructions for risk for bleeding.

Upon patient client record review, 1 of 14 (Patient #3) did not have evidence that each patient record contains Physician certification and recertification of terminal illness. Patient 3: There was no evidence of a CTI from the attending physician elected by the patient/responsible party.

Upon patient record review, 1 of 5 (Patient #3) 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 3: The patient's oxygen was not included on the medication list. (corrected onsite)

Upon patient record review, 1 of 5 (Patient #2) 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 patient is admitted for hospice services with a primary terminal diagnosis of Alzheimer's disease. The physician's certification of terminal illness and SN initial comprehensive assessment indicate the patient is confused, has a FAST score of 7D, has a PPS of 30%, requires ATC supervision and full assistance with all ADLs, and sleeps more than 12 hours daily. Subsequent comprehensive nursing assessments and recertification documentation indicates similar cognitive status/function, period of anxiety and restlessness, and continued reliance on others for care and ADLs. However, no care plan was developed on hospice admission, at the time of recertification, or at any subsequent time since related to the patient's cognitive status or the interventional needs related to her ATC care. (corrected onsite)

Upon patient record review, 1 of 5 (Patient #3) 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: • 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 3: Orders for both the social worker and chaplain are entered as 0 visits monthly/2 PRN, as the patient declined the services of both disciplines after the initial comprehensive assessment. (corrected onsite)

Upon patient record review, 1 of 5 (Patient #1) 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. Patient 1: Orders for the patient included the following 1) colostomy to left abdomen for intestinal obstruction, change every week and PRN and 2) 16 Fr/5mL Foley catheter for urinary retention; change every 30 days and PRN. Neither of these orders included an indicator for the PRN instructions. (corrected onsite)

Upon client 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: Chaplain visits are ordered at a frequency of 1 x monthly, with 2 PRN visits for spiritual distress needs; however, there was no evidence of a chaplain visit being made during the month of October 2022.