Every finding on record at Reliable Hospice, Inc.

Observed in Record Review. In 7 of 10 patient records reviewed, the Surveyor noted the initial bereavement assessment (BR) had not been completed. For example, in RRHV#1, the patient had not had an initial BR documented since coming onto service 12 days prior. RRHV#3 the patient had no documented initial BR and had been on service for 29 days. RRNHV#4, the patient has been on service since December 2024 (162 days), and there has been no documented initial BR. RRNHV#6 had been on service since December and no initial BR had been documented. RRNHV#7 had been on service since 2023, and no initial BR had been documented. RRNHV#8 the patient had been on service since 2022 and there had been no initial BR present in the record. RRNHV#9, no initial BR had been documented and pt on service of over 1 year and in RRNHV#10 there had been no initial BR documented and patient had been on service since December 2024. This was validated with the DOPCS.

Observed in Record Review. In 3 of 10 patient records reviewed, the Surveyor had been unable to validated that volunteer services had been offered to a patient. In RRHV#2, RRHV#3, and RRNHV#8 there had been no documentation that a volunteer had been offered to the patient and family. This was validated with the DOPCS.

Observed in Record Review. In 2 of 10 patient records reviewed, the Surveyor noted plan of care goals that had been generic, without a time frame for achievement or not measurable. For example, in RRHV#3 the patient had for Incontinent of urine- Family/PCG will verbalize having urinary elimination needs met at an acceptable level throughout benefit period. For Integumentary (Pt had 2 stage 2 pressure injuries)- Altered skin will resolve without complications by... (blank), and for pain- Pain will remain at comfortable level during care throughout benefit period. In RRNHV#4, the patient had the time frame for achievement of goals as during the level of care and other goals that had not been clear. For example, Patient will remain safe and free of any injury related to anxiety during the level of care, and for respiratory Patient will no develop respiratory infection that prevention of respiratory distress. This was validated with the DOPCS

Observed in Record Review. In 2 of 10 patient records reviewed, the surveyor noted a patient care order that had been incomplete. For example, in RRHV#2, the patient had an indwelling catheter with orders to change monthly and PRN without clinical indications for what constitutes a PRN change. In RRNHV#4, the patient had an indwelling cath with orders to Change drainage bag per protocol and Change Foley Catheter monthly and PRN This was validated with the DOPCS.

Observed in HR File Review. In 1 of 8 HR files reviewed, the Surveyor noted an incomplete competency of a volunteer who started with the HCO within the past year. For example, in HR#8, the volunteer competency had been blank, except for signatures of the employee and the volunteer coordinator. This was validated with the Operations Director and Administrator.

Observed in Record Review. In 2 of 10 patient records reviewed, the Surveyor noted the active medication list had not been accurate to what the patient was currently being administered. For example, in RRNHV#6, the medication list still had an antibiotic (Azithromycin) that was prescribed in early April for a 5 day course. The patient in RRNHV#7 had a time limited medication ordered (Mupirocin twice a day for 10 days) written in February 2025 that was still on the active patient medication list. This was validated with the DOPCS. Observed in Patient Home. In 1 of 3 home visits conducted, the Surveyor noted the medication list in the electronic medical record had not reflected all the medications the patient had been currently taking. For example, in RRHV#1, the patient had been taking AREDS 2, Cranberry tabs, Vitamin C, Diclofenac 1% and a small HHN Albuterol since admission and these had not been recorded in the patient medication profile. This was validated with the DOPCS.

Observed in HR File Review. In 6 of 6 HR files reviewed, the organization had not provided emergency preparedness training to staff, volunteers, and individuals providing on-site services under arrangement at the following intervals: at least every 2 years. This documentation was missing in all employee files as confirmed with the Office Manager.

Observed in Record Review. In 2 of 11 patient records reviewed, the hospice had not conducted and documented a patient-specific comprehensive assessment and reassessment that identified the patient’s need for hospice care and services. The assessment did not include the patient’s need for physical, psychosocial, emotional, and spiritual care, including the following: Survivor risk factors, such as the nature of the relationship with the patient, circumstances surrounding the death, behaviors before and after the death, availability of coping mechanisms, and potential for pathological grief reactions; Cultural factors that may impact the patient’s and family’s ability to cope with the patient’s death. In the charts for RR#7 and RR#8, there was no initial bereavement risk assessment. The initial SN assessment included only a bereavement screen with no detail. This was discussed with the DPCS.

Observed in Record Review. In 2 of 11 patient records reviewed, the hospice’s interdisciplinary group had not updated the comprehensive assessment in collaboration with the patient’s attending physician, if any, as frequently as the patient’s condition requires, but no less than every 15 days. The hospice had not updated the comprehensive assessment no less frequently than at least every 21 days (per CMS 1135 waiver as implemented by the organization). In the chart for HV#2, the last RN visit note was dated more than 25 days prior to the date of the home visit by the Hospice Surveyor as confirmed with the DPCS, though SN services were being provided by the hospice. In the chart for RR#5, the last RN visit was more than 30 days prior to the survey as well, though SN services were being provided routinely

Observed in Record Review. In 3 of 11 patient records reviewed, the written plan of care (POC) was not based on the patient’s goals and the time frames, settings, and services required to meet those goals. In the chart for HV#1, all of the goals on the POC had the last day of the benefit period as they anticipated achievement date, including Family/PCG will verbalize understanding of non-verbal signs of pain, and pain will remain in comfortable level during care. for this patient with chronic pain. Additionally, this patient was at moderate risk for falls, yet there were no goals related to fall prevention. In the chart for HV#2, the patient with a constipation problem, yet the goal was not individualized to the patient and the target date was the end of the BP. The goals read Optimal bowel elimination and comfort and facilitate optimum bowel movement In the chart for RR#2, goals were not individualized/appropriate/measurable for the hospice patient. Example was Increase strength/energy for optimal functional activities MB medication compliance and eating meals. The anticipated achievement date was the last day of the benefit period. This was discussed with the DPCS.

Observed in Record Review. In 4 of 11 patient records reviewed, the plan of care (POC) did not include all services needed for the palliation and management of the terminal illness and related conditions, including the following: Medications and treatment necessary to meet the patient’s needs. In the chart for HV#1, the patient had been assessed to be at moderate risk for falls, yet the POC did not include any interventions related to falls prevention. Observed during the visit were a walker, bed rails in use. In the chart for HV#3, the patient's caregiver is confused about medications, so the SN is filling the medi-planner for the patient. This important safety intervention is not on the POC. In the chart for RR#1, the POC did not include any interventions related to oxygen safety. In the chart for RR#5, the LVN documented that wound care was provided, however there were no orders found for wound care on the hospice POC. This was discussed with the DPCS.

Observed in Record Review. In 4 of 11 patient records reviewed, the plan of care revisions were not based on information from updates to the patient’s comprehensive assessment and did not address the patient’s progress toward goals and outcomes. In the chart for HV#2, the patient's Fentanyl patch was discontinued more than a month ago, yet this remained as an active intervention under the problem of ROM loss R/T pain.... In the chart for HV#3, the care plan had not been updated. The patient had an eye infection in 11/21. This remains on the current POC as a current problem, though the patient is no longer receiving treatment for this infection. Additionally, the aide assignment indicated that the patient is continent of bowel/bladder and able to transfer to a wheelchair. The wheelchair had been removed from the home per primary caregiver request due to falls. For more than one month the RN had documented that the patient was bed bound and incontinent of bowel. The Aide care plan was not updated with these changes. In the chart for RR#2, the POC was not updated. PCG and family will verbalize signs and symptoms of hypertension including restlessness, anxiety, blurred vision, ringing in ears, headache, and signs of symptoms of stroke. The goal was added 11/2020 with a target date of 1/1/21. This goal remained active on the POC at discharge in November 2021. In the chart for RR#7, while seeing the patient at the SNF, the physician note indicated that the POC contained conflicting orders for the patient’s tube feedings and he clarified the order. This information was not updated on the hospice POC. In addition, the patient’s current POC included an order for G-tube site care for 21 days only which began more than 9 months ago. This was discussed with the DPCS.

Observed in Record Review. In 4 of 11 patient records reviewed, the organization had not provided the patient with care, treatment, or services according to the patient's individualized plan of care. In the chart for HV#2, SN was ordered 1-3/week, yet SN visits were being provided 5-7x/week over the past 3 weeks as discussed with the DPCS. In the chart for RR#1, SN visits were ordered weekly. During week 2, three routine SN visits were made. In the chart for RR#2, SN services were ordered 1-3/week +prn. No SN visits were made from 10/8-10/21/21. CHHA visits were ordered 3/week. During two weeks of the last benefit period, the aide saw the patient 2/week rather than 3. In the chart for RR#7 aide visit frequency was not followed. This was discussed with the DPCS. Observed in Patient Home. In 1 of 3 home visits conducted, the organization had not provided the patient with care, treatment, or services according to the patient's individualized plan of care. During HV#2, the patient had a dry dressing on her wound upon arrival. Upon questioning about the dressing, which was not the ordered dressing, the LVN confirmed with the caregiver that the hospice aide had placed a dry dressing on the patient’s wound during her visit the previous day. This was not included on the aide plan of care. This was discussed with the DPCS.

Observed in Record Review. In 1 of 11 patient records reviewed, all disciplines that provide care, treatment or services to the patient did not collaborate in the care of the patient and coordinate their efforts to support the goals outlined in the plan of care. In the chart for RR#4, the RN noted a new wound and provided care, however, there was no documentation to support the physician was made aware, nor was an order for care obtained until one week later. This was discussed with the DPCS.

Observed in Patient Home. In 2 of 3 home visits conducted, the organization had not implemented infection prevention and control activities it had planned. During HV#1, the clinician washed his hands under running water for 10 seconds, as confirmed with the clinician. The organization follows CDC guidelines which required 20 second minimum hand hygiene. During HV#2, the LVN missed 3 hand hygiene opportunities between glove changes during the wound care as confirmed with the clinician during the visit. Organizational policy for hand hygiene required hand hygiene between glove changes, following CDC recommendations. Also during HV#2, the LVN cleaned his equipment with Cavicide wipes. He wiped the equipment and immediately returned it to his clinical bag. Upon review of the manufacturer's recommendations, a three minute wet time is required for this product to be a disinfectant. Upon discussion, this is not the product supplied by the organization, rather one that the clinician had supplied himself. He indicated that the organization had supplied Alcohol wipes for cleaning equipment. This was discussed with the DPCS.

Observed in Record Review. In 1 of 11 patient records reviewed, a registered nurse who is a member of the interdisciplinary group and is responsible for hospice aide supervision had not prepared written patient care instructions for the hospice aide. In the chart for HV#2, the aide assignment sheet did not include the presence of a Foley catheter. It also indicated that the oxygen was continuous. The oxygen was ordered prn.

Observed in Record Review. In 4 of 11 patient records reviewed, the registered nurse had not supervised the hospice aide no less frequently than every 14 days. In the chart for HV#1, despite the RN having seen the patient during an in-person visit at least weekly, there was no documented supervision of the hospice aide for greater than 30 days at the time of the survey. In the chart for HV#2, it had been more than 6 weeks since a documented aide supervisory visit despite the SN seeing the patient multiple times weekly. In the chart for RR#2, there were no supervisory visits documented in the final two months prior to discharge, though the RN saw the patient at least every 12 days. In the chart for RR#5, it had been more than 30 days since the last aide supervisory visit. This was discussed with the DPCS.

Observed in HR File Review. In 1 of 7 HR files reviewed, the organization had not oriented staff on the following: Relevant policies and procedures; Their specific job duties, including those related to infection prevention and control and assessing and managing pain. Completion of this orientation was not documented in the file for the Medical Director as confirmed with the Office Manager.

Observed in Record Review. In 5 of 11 patient records reviewed, the patient record did not contain the following clinical information: Any specific notes on care, treatment, or services. In the chart for HV#2, the past three RN visits notes were blank. These visits were made three, four and five weeks prior to the date of this survey. Additionally, wound care is not fully documented each visit, rather included documentation Wound care to R buttock as per order with no signs of infection noted.. In the chart for HV#3, documentation was incomplete. The RN documented Pt repositioned and Tramadol administered without dosage or route included. In the chart for RR#3, the Initial MSW assessment was blank, yet indicated that an in-person visit was made. Additionally, in at least one SN note, the RN documented G-tube flushed and patent., missing solution and volume. In the chart for RR#4, when a wound was first noted during a visit, the RN documented “Wound care is provided and dressed.” without indication of what care was provided. Additional incomplete documentation included Prior to exit SN performed treatment as ordered and Tylenol suppository administered. On 4/19/22, a MSW telephone visit, there was no documentation. In the chart for RR#5, the most recent RN note, more than one month prior to the survey, was blank. Additionally, the LVN documented that wound care was provided, however did not indicate any detail. This was confirmed with the DPCS.

Observed in Record Review. In 2 of 11 patient records reviewed, in which a live discharge occurred, the hospice discharge summary did not includes the following: Any other documentation that will assist in post-discharge continuity of care or that is requested by the attending physician or receiving physician. In the chart for RR#1, the discharge summary indicated only the reason for the patient's revocation of the hospice benefit. In the chart for RR#3, the discharge summary did not include the required elements. This was discussed with the DPCS.

Observed in Record Review. In 1 of 2 patient records reviewed, for hospice care provided to a resident of a Skilled Nursing Facility (SNF), the hospice plan of care (POC) did not identify which provider was responsible for performing the functions that have been agreed upon and included in the plan of care. In the chart for RR#7, the POC did not specify which provider was to perform wound care and G-tube site care as confirmed with the DPCS.

Observed in HR File Review. In 1 of 7 HR files reviewed, the organization had not obtained a criminal background check on the applicant. In the absence of state requirements, criminal background checks are obtained within three months of the date of employment for the states that the individual has lived in or worked in during the past three years. In the file for the RN, there was no criminal background check for this employee hired more than 6 months ago as confirmed with the Office Manager.