Every finding on record at Renatus Care, LLC

Upon patient record review 1 of 16 (Patient #5) 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 #5: The spiritual care assessment was completed on 1-31-25 indicating greater than 5 days from admission on 01-23-25.

Upon patient record review, 6 of 16 (Patient #1,#2,#4,#5,#11,#12) 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 Patient #1: The RN assessment dated 11-22-24 and 11-25-24 documented "Abx for UTI". There was no evidence of antibiotics on the medication profile. Patient #2: Augmentin was ordered on 10-23-24 for 5 days. Augmentin remained on the medication profile until the patient's death 11-30-24. Patient #4: On the plan of care dated 12-31-25, the RN documented the patient was on 2 LPM of Oxygen via NC. Oxygen was not on the medication profile. Patient #5: On 02-25-25, an order was written for Oxycodone and Prednisone. Neither of these meds were listed on the medication profile. Patient #11: The care plan dated 04-08-25, indicated the patient was using 2LPM of O2 via NC. Oxygen was not listed on the medication profile. Patient #12: O2 2-4 LPM was ordered per the plan of care dated 04-01-25 however, oxygen was not on the medication profile.

Upon patient record review, 2 of 16 (Patient #5, #13) did not have 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 #5: The bereavement assessment was completed on 01-31-25 indicating greater than 5 days from the admission date of 01-23-25. Patient #13: There is no evidence of a bereavement assessment completed within 5 days of the admission.

Upon patient record review, 1 of 16 (Patient #9) 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 #9: On the plan of care dated 3-1-25, and through 4-1-25, the aide frequency was written as "1-3 x week". The aide was visiting the patient 3 x week.

Upon patient record review, 1 of 16 (Patient #14) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient #14: Physical therapy "eval and treat" was ordered on 04-04-25, but there was no evidence that goals and interventions were updated in the plans of care on 04-15-25 and 04-29-25.

Upon client record review, 3 of 16 (Patient #2, #4,#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 plan of care dated 10-30-25 indicated the RN frequency was 2 x week. For the week of 10-27-24 through 11-2-24, there was only 1 routine visit on 10-28-25. Patient #4: The plan of care dated 1-8-25, 1-22-25, 2-5-25, 2-18-25, 3-4-25, 3-18-25, and 4-1-25 indicate the Chaplain frequency is 1 x month. The Chaplain visited once on 01-05-25. Patient #12: Per the plan of cares dated 04-01-25, 04-15-25 and 04-29-25, the chaplain frequency was 1 x mo. but, there was no evidence of a chaplain visit in April.

Upon patient record review 2 of 16 (Patient #2, #16) 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 #2: On 10-28-24, the RN documented, "urine sample for C&S". On 10-30-24, the RN instructed the family that C&S "results were not in".There was no evidence of follow-up with caregiver about results and the nurse continued to document, "New orders due to dysuria", for bi weekly visits until 11-18-24. On 11-18-24, the RN documented the foley was changed and an additional urine sample was taken for "C&S". The caregiver requested results on 11-20-24 and through 11-30-24, there was no evidence of follow-up with caregiver about results. Additionally, the RN continued to document on 11-18, 11-20, 11-27-24, "New orders for dysuria...white milky (urine)...and signs and symptoms of UTI...", but there is no evidence of new orders since 10-23-24. Patient #16: On 04-22-25, the MSW called caregiver to schedule a monthly visit according to the plan of care. The caregiver said she was, "available on Wednesdays and Fridays". There was no follow-up to reschedule visit on the Wednesday or Friday prior to the end of the month and MSW documented a missed visit for the month of April on 04-22-25.

Upon observation, there was no evidence the organization develops, implements, and maintains an effective, on-going, organization wide Quality Assessment and Performance Improvement (QAPI) program. There were no evidence QAPI minutes, no annual review and no performance improvement activities.

Upon observation, there was no evidence the board of directors/governing body approves the frequency and detail of the data collection. There was no evidence of a QAPI plan approved by the governing body.

Upon observation, there was no evidence the hospice investigates all adverse events, incidents, accidents, variances or unusual occurrences that involve patient care and develops a plan of correction to prevent the same or similar event from occurring again. There is no evidence that plans of correction were developed to prevent patient falls.

Upon observation, there was no evidence a written plan of correction is developed in response to any QAPI activity that does not meet an acceptable threshold. There is no evidence of measurement or analyses of collected data or that a plan of correction was developed.

Upon observation, there was no evidence the number and scope of distinct QAPI projects conducted annually is based on the needs of the hospice's population and internal organizational needs and must reflect the scope, complexity, and past performance of the hospice's services and operations. There is no evidence that QAPI projects were chosen or conducted for 2024 or 2025.

Upon observation, there was no evidence the hospice documents what QAPI projects are being conducted, the reasons for conducting these projects, and the measurable progress achieved on these projects. There is no evidence of projects being conducted in 2024 or 2025.

Upon observation, there was no evidence of involvement of the governing body and organizational leaders in the Quality Assessment/Performance Improvement (QAPI) program. There is no evidence of the involvement of the governing body in the QAPI program, no QAPI minutes or annual review.

Upon observation, there was no evidence the hospice's governing body is responsible for ensuring that the hospice-wide Quality Assessment and Performance Improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness. There is no evidence of a hospice wide QAPI plan approved by the board of directors which addressed priorities, patient safety and improvement actions.

Upon observation, there was no evidence in the QAPI reports that the hospice maintains a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases. There is no evidence that the hospice maintains a coordinated infection program which identifies infections to be reported and which uses data to assess the effectiveness of the infection control program and apply corrective action plans as needed.

Upon personnel record review, 1 of 15 (Personnel #5 ) did not have evidence that all bereavement services are provided by a qualified counselor in accordance with applicable laws and regulations, professional practice standards, the hospice's policies and procedures and/or job descriptions which includes experience or education in grief or loss counseling. Personnel #5: The Bereavement Coordinator job description required "Experience in bereavement and grief counseling." There was no evidence of experience grief and bereavement in the personnel file and the personnel's application indicated she applied for the "receptionist" role.

Upon patient record review, 1 of 16 (Patient #16) did not have evidence in the patient record that hospice aide assignments and duties are: • 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 #16: The aide care plan, dated 03-10-24, indicated, "change linen" was ordered "q week and PRN". The use of “PRN” or “per patient choice”, for any task,whether personal care or non-personal care tasks, are not acceptable.

Upon observation, there was no evidence the hospice documented the cost savings achieved through the use of volunteers. Documentation must include the following: • The identification of each position that is occupied by a volunteer • The work time spent by volunteers occupying those positions • Estimates of the dollar costs that the hospice would have incurred if paid employees occupied the positions identified in paragraph (d)(1) of CFR 418.78 for the amount of time specified in paragraph (d)(2) of CFR 418.78 There was no evidence of a volunteer cost savings report.

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. There was no evidence that volunteer labor equaled 5% of all paid employee and contract labor.

Upon observation, there was no evidence the hospice is directed by a Board of Directors/governing body which assumes full legal authority and responsibility for the operation of the hospice. While there is a compliant Board of Directors Agenda, there is no evidence of meeting minutes that are dated or document attendees.

Upon patient client record review, 1 of 16 (Patient #5) did not have evidence that each patient record contains responses to medications, symptom management, treatments, and services. Patient #5: On 02-25-25, the patient developed pain and new orders for Oxycodone and Prednisone were given. There was no follow-up visit or phone call to the patient or caregiver to assess the effectiveness of the medication until 03-06-25.

Upon patient client record review, 1 of 16 (Patient #6) 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 #6: The RN completed a supervisory visit on 04-23-24, but there were no visits by the aide to the patient, and there was a missed visit documented on 04-18-25.

Upon client record review, 1 of 16 (Patient #4) did not have evidence that the discharge summary includes all required information. Patient #4: There was no evidence of a discharge summary.

Upon patient record review, 1 of 11 (Patient #2) did not have 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 #2: No evidence of Bereavement risk assessment.

Upon patient record review, 2 of 11 (Patient #1, 7) 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: Aide care plan dated 5/4/22 assigned shower q visit AND complete bed bath if pt requests or unsafe to shower. Change linens q week and prn. Patient #7: Aide care plan dated 10/7/21 assigned assist in ambulation prn and assist in transfer prn.

Upon patient record review 4 of 11 (Patient #3,4,5,11) 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 #3: Aide visits 5/27/22 and 6/2/22, Aide did not perform shower as assigned, no refusal noted nor notice to RN. Aide visits 6/4/22 and 6/11/22 aide performed partial bed bath which was not on aide assignment. Patient #4: Aide assignment dated 9/21/21 assigns shampoo hair 2 x week and shave 2x week. Visits 9/22/21, 9/23/21, and 9/24/21 indicated N (not performed) rather than complete. Patient #5: Aide performed assist with bed pan, catheter care, turn, ROM and complete bed bath on visit 10/12/21. Aide assignment does not include any of those tasks. Patient #11: Aide care plan dated 9/21/21 assigned shampoo and shave 2xwk. On 9/22 and 9/23/21 Aide visits indicate N (not performed).

Upon personnel record review, 10 of 11 (Personnel #1-4,6-12 ) did not have evidence that a skills competency assessment, specific to each discipline had been conducted for all personnel including volunteers initially during orientation. Personnel #1-4,6-12: no evidence of skills competency assessment initially per policy.