Every finding on record at Savior Hospice Care Inc.

It is required that the written Patient Bill of Rights includes the right to be involved in the development of his or her plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical record reviewed with patient discharge, the agency did not ensure documentation that the patient was involved in the discharge process and development of the plan of care. CLINICAL RECORD 11: The patient elected the hospice benefit on 09/13/2024 and was discharged for extended prognosis on 01/09/2025. Clinical record review revealed the NOMNC (Medicare Notice of Non-Coverage) form was signed by the patient on the day of discharge. There was no documentation in the clinical record that the patient participated in the development/update to the plan of care when the patient was discharged from service. During a joint clinical record review and interview on 05/08/2025, the Administrator/Director of Nursing stated the "NOMNC form should have been signed 48 to 72 hours before discharge."

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current prescription and over the counter (OTC) drugs, supplements, herbal remedies, and other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following: the effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy, and drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and as appropriate, preventive measurements are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by home visit observation and interview. In 2 of 3 (67%) home visit observations, the agency did not ensure the drug profile was updated to include the patient’s current medications. Home Visit 1: The patient elected the hospice benefit on 04/22/2025 for a diagnosis of sequelae of cerebral infarction. The patient resided in a group home. During the home visit observation on 05/07/2025 with the Social Worker (SW) (Personnel Record 4), a medication review was completed by comparing the hospice medication profile (printed on 05/06/2025) to the group home medication list. The hospice medication profile included the following medications that were not documented on the Group Home medication list: Senna 8.6 mg tablet daily (dated 04/22/2025) and Gabapentin 100 mg capsule three times daily (dated 04/22/2025). The group home medication list included Tylenol 500 mg one time daily (no date). Tylenol was not included on the hospice medication profile. The hospice medication profile included an order for Mirtazapine 30 mg daily (dated 04/22/2025), and the group home medication list included Mirtazapine 15 mg daily. Home Visit 3: The patient elected the hospice benefit on 03/10/2025 for a diagnosis of Parkinson's disease. The patient resided in a skilled nursing facility (SNF). During the home visit observation on 05/07/2025 with the Registered Nurse (RN) (Personnel Record 3), a medication review was completed by comparing the hospice medication profile (printed on 05/06/2025) to the SNF medication list (printed on 05/07/2025). The hospice medication profile included the following medications that were not documented on the SNF medication list: Lorazepam 2mg/ml give 0.25 ml every four hours as needed (dated 03/10/2025) and Morphine 20 mg/ml give 0.25 ml every two hours as needed (dated 03/10/2025). The SNF medication list included the following medications that were not documented on the hospice medication profile: Mupirocin ointment to be applied to skin lesions twice daily. The hospice medication profile included an order for Tadalafil 5 mg as needed, and the SNF medication list included Tadalafil 5 mg daily. The hospice medication profile included Ropinirole 2 mg tablet three times daily, and SNF medication list included Ropinirole 1 mg tablet three times daily. During a joint clinical record review and interview on 05/07/2025, the Administrator/Director of Nursing and the Regional Executive Director/Clinical Educator stated the "medication reconciliations needed to be completed with the nursing visits, and the discrepancies didn't suggest they had been reconciled."

It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including the following measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review and interview. In 4 of 14 (29%) clinical records reviewed, the agency did not ensure the patient’s individualized written plan of care included measurable outcomes anticipated from implementing and coordinating the plan of care. CLINICAL RECORD 5: The patient elected the hospice benefit on 04/29/2025. The plan of care dated 04/29/2025 included the goals "patient's respiratory status will remain at optimal level throughout certification period" and "Patient's pain will remain at comfortable level during care." The goals on the plan of care were not measurable when they did not include a description of what the patient’s optimal level would be for respiratory status and what the patient’s pain level would be to maintain comfort. CLINICAL RECORD 8: The patient elected the hospice benefit on 10/18/2024. The plan of care dated 10/18/2024 included the goals "patient's respiratory status will remain at optimal level throughout certification period" and "Patient's pain will remain at comfortable level during care." The goals on the plan of care were not measurable when they did not include a description of what the patient’s optimal level would be for respiratory status and what the patient’s pain level would be to maintain comfort. CLINICAL RECORD 13: The patient elected the hospice benefit on 04/08/2025. The plan of care dated 04/08/2025 included the goals "Optimal hygiene during care," "Optimal level of pain control and/or symptom management on short-term basis," and "Will remain comfortable level." The goals on the plan of care were not measurable when they did not include a description of what the patient’s optimal hygiene would be and what the patient’s pain level would be to maintain comfort. CLINICAL RECORD 14: The patient elected the hospice benefit on 07/29/2024. The plan of care dated 07/29/2024 included the goal "Patient's agitation will be controlled to a manageable level." The goal on the plan of care was not measurable when it did not include a description of a manageable level of agitation would be for the patient. During a joint clinical record review and interview on 05/07/2025, the Administrator/Director of Nursing and the Regional Executive Director/Clinical Educator stated the goals "should have included measurable quantifiers."

It is required that hospice aides are assigned to a specific patient by a Registered Nurse (RN) who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 2 of 12 (17%) clinical records reviewed with hospice aide services provided, the agency did not ensure the Registered Nurse provided patient specific written instructions for the hospice aide. CLINICAL RECORD 4: The hospice aide care plans dated 09/12/2024, 10/17/2024, and 04/14/2025 assigned the aide the tasks "Assist with dressing, assist with feeding, bed bath, change linen, clean work area after care, comb/brush hair, deodorant, last BM (bowel movement), lotion, max assist with transfers, offer fluids, peri-care, position/reposition in bed, shampoo, shower and shower chair, wheelchair." The aide visit frequency was ordered twice weekly. The initial nursing assessment included documentation that the "Hoyer lift is needed to transfer." The nursing visit note dated 03/27/2025 included documentation that "compression stocking to left lower leg for 8-12 hours per day, remove at night." The nursing visit note dated 03/31/2025 included a physician's order to "cleanse lacerations to right middle finger and cover with non-adhesive dressing." The aide care plans did not include patient specific instructions to the hospice aide for the Hoyer lift, the compression stockings, or to notify the nurse if the wound dressing to the right middle finger became soiled, dislodged, or wet. CLINICAL RECORD 11: The hospice aide care plans dated 09/13/2024 and 09/30/2024 assigned the aide the tasks "assist patient with dressing, bed bath, change linens, deodorant, lotion, max assist with transfers, peri care, powder, shampoo." The frequency of these assigned tasks was listed as "as needed." The aide visit frequency was ordered three times weekly. The aide care plan did not provide the aide with specific instructions for the frequency of the tasks. During a joint clinical record review and interview on 05/07/2025, the Administrator/Director of Nursing and the Regional Executive Director/Clinical Educator agreed the items listed in Clinical Record 4 needed to be included in the instructions and that the "as needed" tasks on Clinical Record 11 were not "detailed."

It is required that a hospice aide provides services ordered by the Interdisciplinary Group, included in the plan of care, permitted to be performed under state law and regulation and consistent with the hospice aide training. This standard was not met as evidenced by clinical record review, observation, and interview. In 2 of 12 (17%) clinical records reviewed with hospice aide services provided, the agency did not ensure the aide provided services ordered by the Interdisciplinary Group and included in the plan of care. Clinical Record 2/Home Visit 2: The hospice aide care plan dated 08/22/2024 assigned the aide the tasks "assist with dressing, bed bath or shower with instructions patient/caregiver to decide whether patient gets bath or shower, change linen, comb/brush hair, deodorant, do not remove oxygen for bath, make bed, oral care, standby assist, and wheelchair." The assigned tasks were to be completed every visit. During the home visit observation on 05/07/2025 with the Hospice Aide (HA) (Personnel Record 7,) the aide was observed to take the patient into the shower without asking the patient/caregiver about the bath type. The aide was also observed to shampoo the patient's hair, apply lotion to arms, and remove the oxygen briefly before the bath. These tasks were not assigned to the aide on the aide care plan. CLINICAL RECORD 6: The hospice aide care plan dated 01/02/2025 assigned the aide the tasks for a bed bath and a shower and noted "patient/caregiver to decide whether patient gets shower or bed bath." The aide documented on the aide visit notes dated 04/14/2025 and 01/02/2025 "Patient can have shower or bed bath. Patient does not need to have both." The visit notes did not include documentation that the aide had asked the patient/caregiver regarding the bath type and the patient/caregiver had made the decision on the bed bath or shower. During a joint clinical record review and interview on 05/07/2025, the Administrator/Director of Nursing and the Regional Executive Director/Clinical Educator agreed the aides did not follow the aide care plans.

It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services and, as necessary, provides in-service training and education programs where required. The hospice has written policies and procedures describing the method(s) of assessing competency and maintains a written description of the in-service training provided during the previous 12 months. This standard was not met as evidenced by document review, personnel record review, and interview. In 2 of 7 (29%) personnel records reviewed, the agency did not ensure the skills and competencies of individuals providing care were assessed as required by agency policy. Agency policy No 3-001 Competency Program, revised May 2023, required in part: "2. The organization will establish and annually evaluate a group of specific skills related to patient care/service responsibilities and complexity of care/services provided by the personnel… 6. After completion of orientation, competency will be monitored annually thereafter as part of the annual performance evaluation." Personnel Record 2: Registered Nurse date of hire 03/20/2023. Personnel record review revealed no documented evidence that skills and competencies were assessed in 2024. Personnel Record 5: Spiritual Counselor/ Bereavement Coordinator/ Volunteer Coordinator date of hire 04/25/2023. Personnel record review revealed the employee obtained the role of Volunteer Coordinator on 02/18/2025. The personnel record did not include documentation that initial skills and competencies were assessed for the role of Volunteer Coordinator. During a joint personnel record review and interview on 05/08/2025, the Administrator/Director of Nursing and the Regional Executive Director/Clinical Educator stated, "the competencies might have been confused with the performance evaluations."

Upon patient record review, 1 of 1 applicable (Patient #4) 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 #4 The 3/18/22 aide assignment did not contain frequencies for the following assigned tasks; shower, hair/mouth/nail care, change linens.