Every finding on record at Regency Hospice of Northwest Florida, Inc.

Upon patient record review 1 of 23 (Patient #1) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient #1: The patient was admitted on 3/18/24. There is not evidence the spiritual assessment was completed until 3/25/24 which is greater that the 5 day requirement.

Upon patient record review, 5 of 23 (Patient #2, #3, #4, #5, #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. Patient #2: The record indicated an order on 10/18/23, Aspercreme 4% topical apply daily as needed for pain. The order did not identify a specific location. In addition, an order on 10/18/23, Ketoconazole 2% as needed per instruction. The record did not include a frequency. In addition, there were a duplicate medications, on 10/18/23 Imodium AD 2mg., one daily as needed for diarrhea and on 4/16/24 Imodium AD 2mg. one q 4 hours as needed for diarrhea. Also, an order Monistat 7% vaginal cream 2 times daily for 7 days. The medication remains on the medication list. In addition, 5/29/24 the nurse documented the PCP prescribed Nystatin powder. There was no evidence that Nystatin was on the medication profile. (All corrected on site.) Patient #3: The record indicated multiple medications listed the medication route as "cheek of mouth". These medications included, but were not limited to, Aleve, Amlodipine, Century vitamin, etc. Corrected on site. Patient #4: The record indicated multiple medications listed the medication route as "cheek of mouth". These medications included, but were not limited to, Senna, Spironolactone and Acetaminophen. Corrected on site. Patient #5: The record indicated an order on 3/24/24, ASA 81mg., chew and swallow 4 tablets daily for 60 days. The medication remains on the medication record. Corrected on site. Patient #9, the agency medication record did not list lactulose that was on the facility medication profile. In addition, the facility medication record did not list benzonatate and bisacodyl which were listed on the agency medication record.

Upon patient record review, 8 of 23 (Patient #1, #3, #6, #7, #8, #9, #10, #18) there was no 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. Patient #1: The record indicated the patient was admitted on 3/18/24. The Bereavement assessment was completed on 3/25/24, which is greater than the five day requirement. In addition, the bereavement assessment was completed on the daughter only. The patient lives with her spouse who is involved in her care. There was not evidence there was a bereavement assessment completed on the spouse. Corrected on site. Patient #3: The bereavement assessment was completed for the daughter only. The patient lives with his spouse. There was not evidence there was a bereavement assessment completed for the spouse. Corrected on site. Patient #6: The record indicated the patient was admitted on 3/21/24. The Bereavement assessment was completed on 3/27/24, which is greater than the five day requirement. Patient #7: The record indicated the patient was admitted on 4/21/24. The Bereavement assessment was completed on 4/28/24, which is greater than the five day requirement. Patient #8: The record indicated the patient was admitted on 1/29/24. The Bereavement assessment was completed on 2/5/24, which is greater than the five day requirement. Patient #9: The record indicated the patient was admitted on 4/3/24. There was no evidence in the record that the Bereavement assessment was completed. Patient #10: The record indicated the patient was admitted on 2/11/23. The Bereavement assessment was completed on 2/221/23, which is greater than the 5 day requirement. Patient #18: The record indicated the patient was admitted on 8/22/23. The Bereavement assessment was completed on 9/1/23 which is greater than the 5 day requirement.

Upon patient record review, 1 of 23 (Patient #13) 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 #13: The medication record indicated the patient was on Plavix 75 mg daily and ASA 81 mg daily. There was no evidence of bleeding precautions on the plan of care.

Upon patient record review, 2 of 23 (Patient #13, #17) 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 #13: The record indicated, the initial plan of care included MS and SC prn visits, this is not a detailed frequency specific to meet patient/family needs. Patient #17: The record indicated, the initial plan of care included MS and SC prn visits, this is not a detailed frequency specific to meet patient/family needs.

Upon patient record review, 4 of 23 (Patient #2, #3, #4, #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 #2: The record indicates an order on 10/18/23, Asper creme 4% topical apply daily as needed for pain. The order did not identify a specific location. In addition, an order on 10/18/23, Ketoconazole 2% as needed per instruction. In addition, 5/29/24 the nurse documented the PCP prescribed Nystatin powder. There was no order for Nystatin. (All corrected on site.) Patient #3: The record indicates multiple medications listed the medication route as "cheek of mouth". These medications included, but were not limited to, Aleve, Amlodipine, Century vitamin, etc. Corrected on site. Patient #4: The record indicates multiple medications listed the medication route as "cheek of mouth". These medications included, but were not limited to, Senna, Spironolactone and Acetaminophen. Corrected on site Patient #9: Lactulose that was on the facility medication profile there was not evidence of a lactulose order in the hospice record.

Upon client record review, 2 of 23 (Patient #2,#12) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #2: The record indicated on the Initial Plan of Care a request for Volunteer evaluation. There is no evidence a Volunteer evaluation was completed. In addition, the medical record indicates O2 at 2L via NC continuously. The nursing document indicated the patient was on room air during most visits. There was no evidence in the chart that the order was revised or discontinued. Patient #12: The record indicates skilled nurse frequency 2 times a week. For the week of 5/19 to 5/25/24 there was only one visit on 5/22/24. Patient #13: The record indicated on 5/10/24 an order for O2 1-2 L as needed. The medical record indicates the patient was on O2 at 2.5 L via NC . There was not an order for O2 2.5 L. In addition, the record indicates skilled nurse frequency 2 times a week. For the week of 5/12 to 5/18/24 there was only one visit on 5/12/24.

Upon patient record review, 4 of 23 (Patient #2, #13, #14, #16) 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 #2: The record indicated the HHA plan of care identified nail care "as needed" and shampoo "as needed". In addition, the patient's CTI indicated that the patient was a high fall risk and there was no evidence of fall precautions. The medication record indicates the patient was on Eliquis with no evidence of bleeding precautions and the patient was on O2 with no evidence of O2 precautions. Precautions corrected on site. Patient #13: The medication record indicated the patient was on Plavix and ASA with no evidence of bleeding precautions and the patient was on O2 with no evidence of O2 precautions. Corrected on site. Patient #14: The record indicated the patient had a fall on 4/8/24. There was no evidence of fall precautions. Corrected on site. Patient #16: The medication record indicated, the patient was on O2 2-4 L continuously. The HHA plan of care did not include O2 precautions. Corrected on site.

Upon patient record review 7 of 23 (Patient #7, #8, #10, #11, #15, #16, #17) 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 #7: The HHA plan of care indicated linen change each visit. On 5/16/24, the HHA documented, , "per frequency not needed this visit". In addition, the HHA plan of care indicated nail care: weekly. On 5/14/24 and 5/16/24 the HHA completed nail care each visit. Patient #8: On 5/14/24, the HHA documented for Service: Bathing (shower): completed: Y. Note: bed bath. There was no evidence found in the record to indicate the HHA contacted the nurse. Patient#11: The HHA plan of care indicated linen change and hair care weekly. On 4/9 and 4/12/24, the HHA documented, linen change and hair care each visit. In addition, skin care was to be each visit. On 5/31/24, the HHA documented "completed: no, note: per frequency not needed this visit". Patient #13: The HHA plan of care indicated linen change and hair care each visit. On 5/6/24, the HHA documented "completed: no, note: per frequency not needed this visit". Patient #15: The HHA plan of care indicated shampoo each visit. On 5/16/24, the HHA documented, shampoo completed: no "per frequency not needed this visit". Patient #16: The HHA plan of care indicated shampoo each visit. On 5/15/24, the HHA documented, shampoo completed: no "per frequency not needed this visit". Patient #17: The HHA plan of care indicated shampoo each visit. On 6/5/24, the HHA documented, shampoo completed: no "per frequency not needed this visit".

Upon patient record review 1 of 23 (Patient #13) did not have evidence documentation in the patient record that a Registered Nurse made 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 to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs. Patient #13: The record indicated the HHA visited on 4/25/24. There was not a supervisory visit by the RN until 5/15/24 outside the 14 day frequency.

Upon observation, there was no evidence the annual report documents the use of volunteers providing day to day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract personnel. The annual report of volunteer usage for the year 2023 was documented as 3.4%.

Upon personnel record review, 1 of 14 (Personnel #8 ) did not have evidence the hospice employees and contract employees have received orientation on the hospice philosophy. Personnel #8: There was not evidence in the record of orientation to the hospice philosophy. Hospice confirmed recent use of the physical therapist.

Upon patient client record review, 1 of 23 (Patient #13) did not have evidence that each patient record contains Advance Directives. Patient #13: The record indicated the patient had a DNR document. There was not a copy of the DNR in the chart.

Upon patient client record review, 1 of 23 (Patient #18) 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 #18: The record indicated an EOB signed electronically identified the patient wished to receive the Patient notification of hospice non-covered items, services and drugs. The paper copy of the EOB signed on the same day, indicated he did not wish to receive the patient notification of hospice non-covered items, services and drugs. It could not be determined if the patient wished to receive or did not wish to receive this document.