Every finding on record at Residential Hospice

Upon patient record review, 2 of 27 (Patient #8, 20) 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 8, 20 - No evidence of an initial bereavement assessment completed.

Upon patient record review, 2 of 27 (Patient #23, 27) 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 #23 - SN documented cellulitis of g-tube site 05/27/25 - there was no assessment of g-tube site following visits 06/02/25 or 06/05/25. Patient #27 - No assessment of patients wound 05/22/25 - 6/11/25

Upon patient record review, 4 of 27 (Patient #9, 19, 21, 25) 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 #9 - SN visit made visit on 05/20/25 and 05/29/25 "applied antifungal powder to wound bed" but no order on chart for antifungal powder. Patient #19 - Patient using condom catheter at night and when leaving home but no order on POC for condom catheter. Patient #21 - Patient on oxygen 2L/min per nasal cannula but visit 05/15/25 SN documented in the record that patient was on 2.5 L/min. Patient #25 - New wound care ordered on 05/09/25 with no frequency.

Upon patient record review, 1 of 27 (Patient #9) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #9 - SN visit made visit on 05/20/25 and 05/29/25 "applied antifungal powder to wound bed". The SN applied without an order.

Upon patient record review, 1 of 27 (Patient #23) 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 #23 - Aide assignment -to shave patient every visit. Patient is on Eliquis - aide care plan does not identify type of razor aide should use.

Upon patient record review 1 of 27 (Patient #19) 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 #19 - Aide documented missed visit 06/27/25 but should have been for 05/27/25.

Upon patient record review 5 of 27 (Patient #10, 15, 18, 22, 26) 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 #10 - Aide supervisory visit made 03/26/25 not again until 04/10/25 - 15 days between supervisory visits. Patient #15 - Aide supervisory visit made 05/20/25 not again until 06/06/25 - 17 days between supervisory visits. Patient #18 - Aide supervisory visit made 05/20/25 not again until 06/05/25 - 16 days between supervisory visits. Patient #22 - RN completed aide supervisory visit 05/12/25 then again on 06/02/25 - 21 days between supervisory visits. Patient #26 - Aide services started on 05/16/25 - No supervisory visit until 06/02/25.

Upon patient record review, 2 of 27 (Patient #10, 12) 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 #10 - SN documented completion of LPN supervisory visit on 03/11/25 and 04/10/25 but LPN has never made a visit. Patient #12 - SN documented completion of LPN supervisory visit on 04/11/25, 04/24/25 and 05/05/25 but LPN has never made a visit.

Upon patient record review, 1 of 27 (Patient #13) did not have evidence that the hospice provided the following information: • The most recent hospice plan of care specific to each patient • Hospice election form and any Advance Directives specific to each patient • Physician certification and recertification of the terminal illness specific to each patient • Names and contact information for hospice personnel involved in hospice care of each patient • Instructions on how to access the hospice's 24-hour oncall system • Hospice medication information specific to each patient • Hospice physician and attending physician (if any) orders specific to each patient. Patient #13 - During home visit there was no evidence that the hospice provided the following information - the most recent hospice plan of care, physician certification of the terminal illness or the names and contact information for hospice personnel involved in hospice care.

Upon patient record review, 4 of 20 (Patient #5, 6, 14, 17) 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 #5 - Patient wife called agency 05/29/2022 - patient with Oxygen sats low - placed on O2 at 2L/min nasal cannula - oxygen not added to medication profile. Patient #6 - New medications added 04/26/2022 Hydrocodone po, Morphine po and Tramadol po but all medications are to be given per g-tube. Patient #14 - Oxygen not on medication profile. SN visit 06/08/2022 possible UTI - antibiotic ordered but not added to medication profile. Patient #17 - SN visit note 04/02/2022 - SN instructed to increase oxygen to 3L/min but not changed on medication profile.

Upon patient record review, 6 of 20 (Patient #3, 5, 6, 11, 15, 16) 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 #3 - SOC date 04/14/2022, initial bereavement assessment completed 05/19/2022. Patient #5 - SOC date 05/27/2022, initial bereavement assessment completed 06/10/2022. Patient #6 - SOC date 04/19/2022, initial bereavement assessment completed 05/11/2022. Patient #11 - SOC date 05/21/2022, there was no evidence of an initial bereavement assessment. Patient #15 - SOC date 02/04/2022, initial bereavement assessment completed 02/28/2022. Patient #16 - SOC date 05/20/2022, there was no evidence of an initial bereavement assessment.

Upon patient record review, 2 of 20 (Patient #12 and 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 #12 - SC initial visit 05/31/2022 - only SC intervention and goal related to safety - no intervention or goals related to spiritual needs. Patient #14 - Infection to G-tube and suprapubic catheter but POC not revised to include interventions and goals.

Upon patient record review, 6 of 20 (Patient #5, 6, 14, 16, 17, 19) 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 #5 - POC dated 05/27/2022 - did not include Oxygen. Patient #6 - POC dated 04/19/2022 wound care does not have modifier for PRN dressing change. Hydrocodone po, Morphine po and Tramadol po but all medications are to be given per g-tube. Patient #14 - POC dated 05/19/2022 - did not include Oxygen. Patient #16 - POC dated 05/20/2022 wound care to coccyx does not include frequency. Patient #17 - POC dated 02/24/2022 - oxygen 3L/min not updated. Patient #19 - POC dated 02/18/2022 Peg tube flushing did not include cc of water, frequency of flushes and cc per mediation.

Upon patient record review, 3 of 20 (Patient #5, 13, 14) 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 #5 - POC did not include Oxygen concentrator, hospital bed or over bed table. Patient #13 - POC did not include BSC or overlay. Patient #14 - POC did not include oxygen concentrator or Trilogy machine.

Upon client record review, 6 of 12 applicable patients (Patient #1, 2, 5, 8, 14, 18) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1 - SN visit frequency effective 05/15/2022 - 3wk1, 2wk1, 1 wk11 - only 2 visits made week 1 without documentation on missed visit. Patient #2 - SC visit frequency effective 04/17/2022 1wk1, 1 qwk2 - no visit made week 3 without documentation of missed visit. Patient #5 - SN visit frequency effective 05/27/2022 - 2wk1 - only 1 visits made week 1 without documentation on missed visit. Patient #8 - SN visit frequency effective 05/31/2022 - 3wk1, 1wk12 - only 2 visits made week 1 without documentation on missed visit. Patient #14 - SN visit 06/01/2022 SN documented suprapubic catheter changed - no order for catheter change. POC dated 05/19/2022 no orders for G-tube care, flushing or feedings. Patient #18 - SN documented on 04/20/2022 dressing to biliary tube changed and visit 05/16/2022 SN tried to flush biliary tube due to clogged - no order for dressing change or flushing of biliary tube. SN documented on 04/25/2022 suprapubic catheter change but no order.

Upon patient record review, 2 of 15 applicable patients (Patient #13, 14) 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 #13 - Fall and oxygen precautions not on POC. Condom catheter not addressed on aide care plan. Patient #14 - Oxygen and aspiration precautions not on aide care plan.

Upon patient record review 5 of 15 applicable patients (Patient #2, 10, 13, 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 #2 - Aide visit frequency effective 04/17/2022, 2 wk 12, 1 wk 1, only 1 visit made week 2 without documentation of missed visit. Patient #10 - Aide visit frequency effective 04/30/2022, 1 wk 13, 0 visit made week 2 without documentation of missed visit. Patient #13 - Aide visit frequency effective 05/22/2022, 2 wk 12, 1 wk 1, only 1 missed visit documented week 1. Patient #16 - Aide visit frequency effective 05/22/2022, 2 wk 12, 1 wk 1, only 1 missed visit documented week 1. Patient #17 - Aide visit frequency effective 02/27/2022, 1 wk 1, 2 wk 11, 0 visit made week 1 without documentation of missed visit reason.

Upon patient client record review, 2 of 20 (Patient #6, 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 #6 - SN visit note dated 04/21/2022 nurse documented that patient has a #18 suprapubic catheter - patient has condom catheter. Patient #18 - SN visit note dated 05/10/2022 nurse documented patient has a nephrostomy tube - patient has a biliary drain.

Upon client record review, 2 of 8 applicable patients (Patient #19, 20) did not have evidence that a written hospice plan of care is established and maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided is in accordance with this hospice plan of care. Patient #19 - SC visit frequency dated 02/20/2022 2wk1, 1 every 2 wk 6 - 0 visit made wk 3 but no documentation of missed visit. Patient #20 - POC dated 03/15/2022 - patient has Pleurx catheter - no orders for Pleurx catheter site care, dressing change or frequency of drainage or amount. Patient also has midline catheter but no orders for care, flushing or dressing changes.

Upon client record review, 2 of 8 applicable patients (Patient #19, 20) did not have evidence that the hospice plan of care identifies the care and services that are needed and specifically identify which provider (nursing facility or hospice) is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care. Patient #19 - POC did not specifically identify which provider (nursing facility or hospice) is responsible for performing the wound care that have been agreed upon and included in the hospice plan of care. Patient #20 - POC did not specifically identify which provider (nursing facility or hospice) is responsible for performing the Plurex catheter or Midline catheter care that have been agreed upon and included in the hospice plan of care.