Every finding on record at Safe Hands Hospice LLC

Based on record review and interview, the hospice failed to ensure services were provided at the frequency ordered in the plan of care for 1 (P-1) of 3 records reviewed, resulting in the patient not receiving care as ordered (See L 547). --- The cumulative effect of these systemic problems resulted in the Hospice Agency's inability to ensure the provision of quality Hospice care at the end of life, in a safe environment for the Condition of Participation: 42 CFR §418.56 Interdisciplinary Group, Care Planning, and Coordination of Services.

Based on record review and interview, the hospice failed to ensure services were provided at the frequency ordered in the plan of care for 1 (P-1) of 3 records reviewed, resulting in the patient not receiving care as ordered. Findings include: --- Patient #1 (P-1) was admitted to this hospice agency on 1/16/26 with the terminal diagnosis of severe protein-calorie malnutrition. During record review on 3/17/26, it was noted that the Frequency Profile and IDG (Inter-Disciplinary Group) Summary/Comprehensive Assessment Update ordered Skilled Nursing (SN) at frequency of 1w13 (1 time a week for 13 weeks), 10 PRN (as needed). Medical Social Worker (MSW) 1m4 (1 time a month for 4 months), 5 PRN. Spiritual Counselor 1m4, 5 PRN. Hospice Aide (HA) 2w12. The record failed to contain any documentation of completed visits or refused visits for the HA. The agency failed to provide services as ordered.  A review of the agency policy occurred on 3/18/26 titled "IDG Care Planning Process" (Revised June 2019). The policy states, "8. An individualized written plan of care is developed for each patient. The plan of care reflects patient and family goals and interventions based on the problems identified in the initial, comprehensive and updated comprehensive assessments. The plan of care includes al services necessary for the palliation and management of the terminal illness and related conditions, including: A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs...”The Director of Nursing (Staff C) reviewed and acknowledged the findings listed above in an interview on 3/18/26 at 11:50 am.

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 • Drug therapy currently associated with laboratory monitoring Patient 3: Medication profile has duplicate drug therapy without evidence of instructions on which medication to administer first. "Morphine 20mg/5ml 5mg orally Q6 PRN for pain. Patient also has an order for Tylenol 325mg 2 tabs orally PRN for pain. Stimulant Laxative 1-2tabs PRN as needed for constipation. No evidence that instructions were listed to define when to give laxative.

Upon patient record review, 1 of 5 (Patient #3) 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 3: Medication order has duplicate drug therapy without evidence of instructions on which medication to administer first. "Morphine 20mg/5ml 5mg orally Q6 PRN for pain. Patient also has an order for Tylenol 325mg 2 tabs orally PRN for pain. Stimulant Laxative 1-2tabs PRN as needed for constipation. No evidence that instructions were listed to define when to give laxative.

Upon patient client record review, 1 of 5 (Patient #5) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient 5: Start of care date left blank on election form.

Upon patient record review, 3 of 5 (Patient #2, #3, #5) 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 #2: The nurse noted on 07/25/2023 that oxygen concentrator was ordered however, there was no evidence this was included on medication profile. In addition, the nurse noted 08/04 that patient "...also uses arthritis cream" however, there was no evidence of this on medication profile. COS Patient #3: The nurse noted on 06/15 patient using Tylenol for pain however, this was not listed on med profile. COS Patient #5: The oxygen order on medication was oxygen at 2-4lpm via NC PRN without an indicator however.

Condition of Participation: Interdisciplinary Group, Care Planning, and Coordination of Services. L536

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 nurse noted on 07/25/2023 that oxygen was ordered however, there was no evidence of oxygen precautions or problems/goals/interventions on the plan of care.

Upon patient record review, 3 of 5 (Patient #3, #4, #5) 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 #3: The spiritual care visit frequency was ordered 2M and PRN without evidence of specific PRN quantity. COS Patient #4: The social work and spiritual care visit frequency was ordered 2M and PRN without evidence of specific PRN quantity. Patient #5: The social work visit frequency was ordered 1M and PRN without evidence of specific PRN quantity.

Upon patient record review, 2 of 5 (Patient #2, #3) 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 nurse noted on 07/25/2023 that oxygen was ordered however, there was no evidence of an order by the physician. In addition, the nurse noted 08/04 that patient "...also uses arthritis cream" however, there was no evidence of an order by the physician. COS Patient #3: The order for barrier cream to peri area daily PRN however, there was no indicator for PRN. In addition, the wound care orders 07/23 did not include an indicator for PRN stating "cleanse with wound cleaner, pat dry, apply hydrogel and bioblast, cover with dry dressing daily and PRN. The nurse noted on 06/21 "Dakins on heel" and on 06/15 patient using Tylenol for pain however, these was not an order for these items. COS

Upon patient record review, 1 of 5 (Patient #2) 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 #2: The nurse noted on 07/25/2023 that oxygen was ordered however, there was no evidence this was listed on plan of care. COS

Upon client record review, 1 of 5 (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: The nurse documented 07/28/2023 "wound care performed using aseptic technique. No signs/symptoms of infection noted" and there was no evidence of details of wound care performed. COS

Upon patient record review, 2 of 5 (Patient #1, #2) 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: The aide plan of care included PRN for clean and file nails, shave, reposition, comb hair, change bed linens, make bed, and perineal care. COS Patient #2: The aide plan of care included PRN for clean and file nails, change bed linens, and make bed. COS

Upon patient record review 1 of 5 (Patient #1) 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 #1: The aide plan of care for mouth care was every visit however, the visit on 07/18, 07/25, and 07/28 there was no evidence this was performed.

Upon patient client record review, 3 of 5 (Patient #1, #2, #4) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patients #1, #2, #4: There was no evidence patient or representative received notice of non-covered items after requesting upon admission.

Upon patient client record review, 5 of 5 (Patient #1, #2, #3, #4, #5) 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 #1:The initial plan of care included oxygen order that was incomplete at oxygen at 2-4lpm via NC PRN, this was complete in order and med profile. In addition, the initial physician order form that included lactulose and benadryl were incomplete with dose and frequency, there was a complete order and med profile was complete. COS Patient #2: The entries for social work visit frequency were unclear as they had been written over several time on the IDG poc updates 7/3, 7/18, and 08/01. In addition, the aide visit note had been scribbled over an incorrect entry for performing bed bath versus shower. The handwritten nursing notes dated 05/12, 05/27, 06/21, and 08/01 were not signed with name and credentials of clinician. COS Patient #3: The medication entry for morphine on the initial plan of care was incomplete missing PRN reason however, this was listed on order and medication profile. In addition, the verbal order on 05/04 for several comfort meds (morphine, ativan, atropine, etc.) was signed without credentials. COS Patient #4: The oxygen orders were inconsistent for each dated on 05/19/2023, on the initial physician order was oxygen at 2-4lpm via NC PRN, the written order read oxygen at 2-5lpm via NC continuous, and the medication profile listed oxygen at 2-4lpm via NC PRN SOB. Patient #5: The entries for medications listed on the initial physician order did not contain PRN indicator however, these were listed on order and medication profile. In addition, the discharge date on the discharge summary was written over and the actual date was not clear.

Upon observation, there was no evidence a copy is provided of the hospice written policies and procedures on the management and disposal of controlled drugs to the patient or patient representative and family. After reviewing agency admission packet, there was only evidence of drug disposal information and a small portion of the agency policy being provided to the patient/patient representative/family. COS

Upon inpatient contract review, 1 of 4 (GIP/Respite contract Orchards of Wayne ) did not have evidence that the inpatient provider has established patient care policies consistent with those of the hospice and agrees to abide by the palliative care protocols and plan of care established by the hospice for its patients. There was no evidence the inpatient provider has established patient care policies consistent with hospice. COS

Upon inpatient contract review, 1 of 4 (inpatient contract Orchards of Wayne) did not have evidence that the inpatient facility has identified an individual within the facility who is responsible for the implementation of the provisions of the agreement. There was no evidence of identified individual within the facility that is responsible for implementation of the provisions of the agreement. COS

Upon inpatient contract review, 1 of 4 (inpatient contract Orchards of Wayne) did not have evidence of a method for verifying that the requirements for ACHC standard HSP1-8B and CFR 418.108c (1)-418.108c(5)are met. There was no evidence written into contract of a method to verify requirements for ACHC standard 1-8B and CFR 418.108c(5) are met. COS