Every finding on record at Sans Bois Hospice LLC

Upon patient record review, 1 of 19 (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) The patient's medication profile had orders for the medication Colestipol 1 gram, 2 times per day, by mouth. The patient's medication upon home visit did not contain this medication. The nurse stated Colestipol has been discontinued and the patient is no longer taking this medication.

Upon patient record review, 4 of 19 (Patients # 1, 2, 3, 4) 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 #1) During home visit, patient had an O2 concentrator in their home that she uses when saturations are low or she feels short of breath. The concentrator was not listed on the current plan of care. Patient #2) During home visit, patient had a walker, wheelchair, overbed table, and bedside commode for her use. This equipment was not listed on the current plan of care. Patient #3) During home visit, patient had a hospital bed, overbed table, wheelchair, and O2 concentrator for her use. This equipment was not listed on the current plan of care. Patient #4) During home visit, patient had a walker, shower chair, and moisture barrier pads for her use. This equipment and supply were not listed on the current plan of care.

Upon observation, 1 of 4 home visits (Patient #1) there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient #1) During home visit, the provider entered the home and sat her bag down on the patients couch with out placing a barrier. Administrator confirmed this bag is used for the iPad during patient visits. Sans Bois Hospice Policy HSP7-1A, Bag Technique-Equipment Safety, line 4a regarding equipment states, " Utilize a barrier if a clean is not available". This policy was not followed.

Upon patient record review, 1 of 19 (Patient #11) 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 # 11) The patient's aide plan of care dated 5/6/25 contained orders for the aide to assist the patient to the toilet as needed (PRN).

Upon personnel record review, 2 of 12 (Personnel #4 and 6) did not contain evidence that a Skills Competency Assessment, specific to each discipline, had been conducted for all personnel initially during orientation, specifically by a qualified clinician: Personnel #4: This PT had a documented Skills Competency conducted on 02/28/22. However, it had been signed off by a PTA clinician. Personnel #6: This ST had a documented Skills Competency conducted on 02/28/22. However, it had been signed off by a PTA clinician.

Upon patient record review, 2 of 13 (Patients #1 and 2) did not contain evidence that the Hospice had provided the following information to the applicable SNF: Physician certification and recertification of the terminal illness, specific to each patient.