Every finding on record at Sentara Home Care Services

Upon patient record review 1 of 19 (Patient #14) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient 14: The spiritual care provider did not perform a SC assessment with in 5 days and there is no evidence the MSW or SN performed the assessment.

Upon patient record review, 6 of 19 (Patient #2,3,4,6,9,14) 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: Patient 2: Upon home visit finding, the facility MAR contains Vit D2, Deep sea nasal spray, Flonase, Lidocaine, MiraLAX, Sodium Bicarbonate. These medications were not on the medication profile. Patient 3: The medication profile contains orders for Acetaminophen 500mg 2 tabs twice daily prn and Tylenol 650mg every 6 hours prn there is not a directive for maximum daily limit for acetaminophen. Patient 4: Upon home visit finding, the patient is not taking Sertraline and has not taken it for over a year per the caregiver. This medication remains on the medication profile Patient 6: The medication profile contains orders for Acetaminophen 500mg 2 tabs twice daily prn and Tylenol 650mg every 6 hours prn there is not a directive for maximum daily limit for acetaminophen. Patient 9: The medication profile contains an order for Depakote "take 1 tab by mouth Radiology and PVL freq" PVL and Freq are not approved abbreviations and is unclear. Patient 14: The medication profile contains Acetaminophen 325mg Q4 hours prn and Acetaminophen 500mg every 4 hours prn with no directive for maximum daily limit for acetaminophen.

Upon patient record review, 2 of 19 (Patient #7,11) 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 7: The agency policy "wound care at home" includes measuring a wound at each dressing change. The SN performed wound care on 4/14/26 and did not measure the wound. Patient 11: The current POC contains an order for site care to the biliary drains and JP drain for dressing changes weekly and prn if soiled. There is no evidence the JP or bilateral biliary drain sites were assessed during the visits or if the dressing change was completed by the SN or the family the weeks of 3/23/26, 3/24/26, 3/26/26. On 4/6/26 SN documented biliary drains flushed without resistance. There is no documentation regarding wound care to site or assessment of site. The last documentation regarding the JP drain was 3/26/26, the order for JP tube care remains active though there is not documentation since 3/26/26 of JP care being completed.

Upon patient record review, 2 of 19 (Patient #13,14) 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: Patient 13: The week of 12/1/25-2/22/26 there is an order for SN 1 visit a week which overlaps the order for SN 1 visit every week for 13 weeks 2/23/26-5/23/26 in the same Medicare week, there was a visit made on 2/23/26. The orders were not written correctly for the Medicare weeks. Patient 14: The SN visit schedules are overlapping the first order string is 2/12/26-4/12/26 for 1 visit every week for 10 weeks and then starting 3/2/26-4/12/26 2 visits every week for 7 weeks and then 1 visit every week for 4 weeks starting 3/26/26-4/18/26 this is causing the EMR to make it look like visits are missed though the visits were made. The orders were not written correctly for the Medicare weeks.

Upon patient record review, 11 of 19 (Patient #1,2,3,4,6,9,10,11,12,14,15) 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 1: The current POC contains a care plan for foley catheter. There are no orders for size, frequency of change. Patient 2: Upon home visit finding, the facility MAR contains Vit D2, Deep sea nasal spray, Flonase, Lidocaine, MiraLAX,Sodium Bicarbonate. These medications were not on the POC. Patient 3: The current POC contains an order for a coude catheter with no balloon size. The POC contains orders for Acetaminophen 500mg 2 tabs twice daily prn and Tylenol 650mg every 6 hours prn there is not a directive for maximum daily limit for acetaminophen. Patient 4: Upon home visit finding, the patient is not taking Sertraline and has not taken it for over a year per the caregiver. This medication remains on the POC. Patient 6: The POC contains orders for Acetaminophen 500mg 2 tabs twice daily prn and Tylenol 650mg every 6 hours prn there is not a directive for maximum daily limit for acetaminophen. Patient 9: The POC 2/27/26 contains an order for Depakote "take 1 tab by mouth Radiology and PVL freq" PVL and Freq are not approved abbreviations and order is unclear. Patient 10: The current POC contains an order for Acetaminophen 650mg every 6 hours prn and 650mg 2 tabs daily prn with no directive for maximum daily limit for acetaminophen. Patient 11: The POC 4/7/26 contains an order for a coude foley catheter with no order for balloon size or order for frequency to change. The POC 3/20/26 contains an order for care of JP drains and biliary drains though does not state who is to perform the cares. Patient 12: The POC 3/7/26 contains duplicate orders for MSW from 3/7/26-3/11/26 for 1 visit every 5 days for 5 days. Patient 14: The POC 4/7/26 contains Acetaminophen 325mg Q4 hours prn and Acetaminophen 500mg every 4 hours prn with no directive for maximum daily limit for acetaminophen. Patient 15: The POC 8/12/25 contains Acetaminophen 650mg every 4 hours prn and Norco 5/325 1 tab every 4 hours prn with no directive for maximum daily limit for acetaminophen.

Upon patient record review, 1 of 19 (Patient #10) 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 10: The POC 12/18/25 contains an SBAR by the volunteer that patient requested a volunteer and that volunteer placement is pending until they find a volunteer to assign. There is no order frequency written on the POC for the volunteer. This SBAR continues on each POC update until current and no volunteer was ever scheduled.

Upon client record review, 11 of 19 (Patient #2,3,4,6,8,9,10,11,12,13,18) 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 POC 12/23/25-3/11/26 contains an order for chaplain 4 visits every 30 days for 79 days. The Chaplain had missed 1 visit from 12/23/25-1/21/26, 2 Missed visits 1/22/26-2/20/26 and 2 missed visits 2/21/26-3/11/26. There was no missed visit documentation or evidence of refusal. Patient 3: The POC contains orders for the MSW has to assess community resource needs every visit and on 12/15/25,1/24/26, 2/24/26 this was not completed. Patient 4: The POC 6/12/25 contains an order for SN visit ordered once weekly, from 7/6/25-7/12/25 there is no SN visit completed. The SN is ordered once weekly and no visit made the week of 2/22/26-2/28/26. There was no missed visit documentation or evidence of refusal. Patient 6: The current POC contains an order for MSW 1 visit every week, the week of 4/12/26-4/18/26 there was no visit made and no missed visit documentation or evidence of refusal. The POC 3/5/26 contains an order for the SN to measure MAC every visit, the MAC was not measured on 3/10/26 by the SN. Patient 8: The POC 5/4/25 contains orders for SN twice weekly, the week of 5/4/25-5/10/25 there was no second visit made. The week of 5/25/25-5/31/25 there was no second visit made. There is no missed visit documentation or evidence of refusal. The current POC contains an order to measure MAC every other visit by the SN. The SN measured MAC 3/26/26 and no further MAC measurements have been completed through current. The MSW documented on 3/31/26 "arrived with Licensed Massage Therapist", there was no order for massage on the POC. Patient 9: The POC 2/27/26 contains an order for SN once weekly. The week of 3/22/26-3/28/26 there was no visit made with and no missed visit documentation and no evidence of refusal. The POC current has orders to assess skin integrity, wound, patient ID, every visit this was not completed on 3/17/26 and 3/30/26. On 4/8/26 the SN did not document against care plan intervention patient ID which is ordered every visit. Patient 10: The 3/15/26 POC contains an order for SN twice weekly, the week of 3/15-3/21/26 there was no second visit made with no missed visit documentation or evidence of refusal. Patient 11: The SN documented on 3/22/26 flushing the biliary drains with 5ml of NS, the order is to flush with 10ml NS. Patient 12: The SN documented on 3/26/26 patient had a fall and an abrasion to the right elbow. The SN educated patient to cover with a dry dressing or band aid. There was no order for this wound care. Patient 13: The POC contains orders on 4/2/26-5/23/26 for 7 SN visits every week for 8 weeks. There were 4 missed visits the week of 3/29/26-4/4/26. The week of 12/1/25-2/22/26 there is an order for 1 visit a week, there was no visit made the week of 2/22/26. There was no missed visit documentation or evidence of refusal. The POC contains orders for chaplain 11/30/25-2/22/26 for 4 visits every 30 days. There was no visit completed the week of 2/22/26-2/28/26 with no missed visit documentation or evidence of refusal. Patient 18: The POC 1/9/25 contains orders for SN 2 times a week for 13 weeks. There was only 1 visit made the week of 1/5/25-1/11/25. The POC contains an order for SN beginning 4/9/25-7/5/25 for SN 1 visit every week for 13 weeks, the week of 4/6/25-4/12/25 there was no visit made. There was no missed visit documentation or evidence of refusal.

Upon patient record review 2 of 19 (Patient #10,14) 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 10: The POC 12/18/25 contains an SBAR by the volunteer that patient requested a volunteer and that volunteer placement is pending until they find a volunteer to assign. This SBAR continues on each POC update until current and no volunteer was ever scheduled. Patient 14: The SN documented on 3/30/26 that a volunteer was requested. There have been no volunteers sent.

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. Patient 5: The medical record has evidence of a patient fall documented by the SN on 3/3/26. There was no incident report completed. Patient 12: The medical record has evidence of a patient near miss fall documented by the MSW on 3/26/26. There was no incident report completed.

Upon home visit observation 1 of 4 visits, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient 3: The RN performed wound care, cleansed wound and did not change gloves or wash hands prior to applying new clean dressing.

Upon patient record review, 1 of 19 (Patient #17) did not have evidence the hospice offers bereavement counseling that includes: Patient 17: The patient expired 5/2/25 and there has been no bereavement counseling documented.

Upon personnel record review, 1 of 15 (Personnel #7) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) ·Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff. ·Reading and recording temperature, pulse, and respiration ·Safe transfer techniques and ambulation. ·Normal range of motion and positioning ·Appropriate and safe techniques in personal hygiene and grooming that include-- ·(A) Bed bath ·(B) Sponge, tub, and shower bath ·(C) Shampoo, sink, tub, and bed ·(D) Nail and skin care ·(E) Oral hygiene ·(F) Toileting and elimination The other subject areas in this section may be evaluated through written examination, oral examination or after observation of a Hospice Aide with a patient. Personnel 7: The aide has not had a competency on reading and recording temperature, pulse and respirations.

Upon patient record review 7 of 19 (Patient #5,6,10,11,13,15,18) did not have evidence documentation in the patient record that a hospice aide provides services that are: Patient 5: The aide POC contains an order for aide twice weekly. The week of 2/22/26-2/28/26 there was no second visit made that week. No evidence of refusal or missed visit documentation. Patient 6:The current aide POC contains orders for aide twice weekly the week of 2/22/26-2/28/26, The aide make only 1 visit. There is no missed visit documentation or evidence of refusal. Patient 10: There is a POC order 12/21/25 for aide visits 3 times weekly. The week of 12/28/25-1/3/26 there were no aide visits made with no missed visit documentation or evidence of refusal. The week of 1/11/16-1/17/26 there was only 2 visits made by the aide and is ordered 3 times a week. The week of 3/8/26-3/13/26 there was no third visit made, 3/22-3/28/26 there was no third visit made. There were no missed visit documentations or evidence of refusals. Patient 11: The aide POC 3/20/26 contains an order for 2 visits every week. The week of 3/20/26-3/21/26 there were no visits made. The week of 4/5/26-4/11/26 there was no third visit made, the week of 4/12/26-4/18/26 there was no third visit made. There was no missed visit documentations or evidence of refusals. Patient 13: The POC contains an order for aide visits twice weekly from 11/25/25-2/21/26. The week of 11/25-11/29/25 there was only 1 visit made. There was no missed visit documentation or evidence of refusal. Patient 15: The aide POC 9/9/25 contains an order for aide visits twice weekly. The aide did not make a second visit the week of 9/7-9/13/25. There was no missed visit documentation or evidence of refusal. Patient 18: The POC 1/9/25 contains an order for Aide care 2 visits every week for 13 weeks beginning 1/15/25-4/8/25, the weeks of 3/16-3/22/25 there were 2 visits missed, the week of 3/23/-3/29/25 there was 1 visit missed. There is an new order beginning 4/9/25-7/5/25 for 2 aide visits every week for 13 weeks. There was no visit completed the week of 4/9-4/12/25. There was no missed visit documentations completed at any of these missed visits or evidence of refusal.

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. Upon observation, The hospice 2025 volunteer hours were 3.85%.

Upon personnel record review, 1 of 15 (Personnel #9) 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 9: The OT had an initial OT competency evaluated and signed off by an RN.

Upon patient client record review, 1 of 19 (Patient #3) did not have evidence that each patient record contains responses to medications, symptom management, treatments, and services. Patient 3: The SN performed wound care 3/6/26 through current, though did not document how the patient tolerated the wound care.

Upon patient client record review, 6 of 19 (Patient #1,3,7,9,11,14) 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 SN documented on 4/20/26 cleansing wound but did not document what it was cleansed with. It is unclear if the POC was followed. Patient 3: SN documenting 3/6/26 through current, performing wound care and cleansing wound, the nurse did not document what type of dressing was applied to the wound or what the wound was cleansed with. It is unclear if the POC was followed. Patient 7: The SN documented on 4/21/26 performing wound care as ordered. It is unclear if the SN followed the POC. Patient 9: The SN documented performing "wound care per orders" on 3/12/26, 3/30/26, 4/8/26 it is unclear if the POC was followed. The medical record contains active wounds on the nursing documentation notes with a start date of 1/12/26, patient was admitted to hospice 2/27/26. This should have been resolved when patient was admitted to hospice as this is a wound from the patient's hospitalization record. Patient 11: The POC 4/7/26 has documentation by the SN performing a procedure on the biliary drains and the patient tolerated the procedure well. It is unclear the SN followed the POC for the biliary drain care ordered. The SN documented 3/23/26 "flushed drains with NS and patient tolerated without diff" It is unclear how much NS was used in the flushes and "Diff" is not an approved abbreviation. The SN documented 3/24/26, 3/26/26 "flushed drains" though did not state which drains were flushed or what the drains were flushed with. It is unclear the POC was followed. Patient 14: The MSW documented on 8/18/26 that patient's religious background is Pescatarian. This is not a religious affiliation.

Upon observation, there was no evidence the organizational chart matches the hospice's information submitted to CMS and/or State licensing agencies for ownership and management personnel. The agency had a change in Administrator effective 9/21/25 and the State of Virginia was not contacted until 4/14/26 and CMS was notified 4/4/26. This is greater than the 30 days required compliance. There is no evidence ACHC was notified.

Upon patient record review, 2 of 5 (Patient #1, #4) 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 #1: Chaplain visits were ordered "3 PRN" without a defined frequency. In addition, the Chaplain evaluation indicates the planned frequency would be "1x q 30 days" These orders were not included on the Plan of Care. Patient #4: The Social Worker evaluation dated 6/6/23 indicated the MSW goals "family will verbalize understanding of hospice benefit, services, and philosophy within 2 weeks". There were no orders written for subsequent visits included on the Plan of Care.

Upon client record review, 1 of 5 (Patient #1) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1 The POC included order for only "3 PRN" for chaplain. There is documentation of Chaplain visits dated 5/15/23, 5/19/23, 5/26/23, 6/1/23. There was no evidence that any of these visits were PRN visits.

Upon patient record review, 1 of 23 (Patient #10) did not have evidence that the patient has received effective pain management and symptom control from the hospice for conditions related to the terminal illness. Patient 10: Patients should not have to experience long waits for pain and symptom management, medications, or interventions to address the patient’s condition. Hospices should have methods in place to assure that the patient’s pain, and all other distressing symptoms, are controlled effectively 24 hours a day/7days per week, in all settings and wherever the patient resides. There is evidence the patient was initially ordered Dilaudid 1mg PO Q3 hours prn. The RN documented on 3-22-23 "Pt went to ED last night due to pain, complains of Dilaudid not working". The patient did not call hospice first. Pt has documented pain to legs, hip, back. The RN did call and received orders to increase Dilaudid to 1.5mg Q3 hours prn. The MSW completed a phone call on 3-22-23 and is informed of above complaints as well. There is no evidence of a call to follow up on pt pain. The next nursing visit was completed on 3-29-23, pt continues to have documented pain to legs, hip, back. RN calls NP face to face during visit and Dilaudid is increased to 2mg po Q3 hours prn. NP documents the patient has been in the ED 3 times since admission to hospice once in December and twice in March for pain with no significant findings other than pain. There is no follow up completed by visit or phone call. The next nursing visit is 4-14-23 pt complaining of leg, hip, back and shoulder pain. Pain with transfers/movement. Caregiver reports giving Dilaudid every 3 hours prn. Nurse completed a phone call to NP and Norco 5-325mg Q12 hours prn added to regime. No follow up phone call completed or visit. Pt next seen 4-20-23 nurse documents "Pt receiving lorazepam and hydromorphone around the clock for pain to abdomen and buttocks and anxiety." There is no evidence of increasing frequency of visits, phone calls to assess pain after increasing pain medication or changes in level of care for symptom management. Surveyor went to home today for visit. Pt continues to be having pain as evidenced by facial grimacing and moaning noted with first the pulse oximeter check and applying the blood pressure cuff. Pt had been medicated at 6am and 10am, visit was at 10am.

Upon patient record review, 4 of 23 (Patient #3,#12,#15,#16,#23) 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: Patient 3: The Medication profile contains Miralax 17gm with no diluent. Corrected on site. Patient 12: The Medication profile contains Guaifenesin 100mg/5ml give 200mg. No frequency or amount in ml. The POC contains orders for oxygen that are not on the medication profile. Corrected on site. Patient 15: The Medication profile cetirizine TK 1 T PO QD, T is not approved and no dose noted, Magnesium Oxide take by mouth, no dose or frequency, Simethicone 125mg take 125mg by mouth, no frequency. Corrected on site. Patient 16: RN documents on 3-24-23 "Pt on 3 liters oxygen via nasal cannula" and RN documents on 4-3-23 "Pt was administered Fleets then Milk of Magnesia, then Kaopectate. There is no evidence of an oxygen, Milk of magnesia, Kaopectate or fleets order on the medication profile. Corrected on site. Patient 23: The medication profile contains Keppra 100mg/ml give 250mg into G tube Q12 hours. No evidence of amount in ml's to give. Ferrous Sulfate 220mg/5ml give 220mg daily. No evidence on amount in ml's to give.

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

Upon patient record review, 1 of 23 (Patient #10) 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 10 documentation from 3-22-23 to current of uncontrolled pain. No evidence of an increase in nursing visits or nursing assessments, no follow up phone calls to assess effectiveness of pain in order to better manage pain.

Upon patient record review, 6 of 23 (Patient #1,#2,#12,#16,#19,#23) 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 1: The medical record contains evidence the pt has a Foley catheter, there is no care plan for a Foley. There is evidence pt has a trach, there is no care plan for a trach. Pt has a colostomy, there is no care plan for a colostomy. Hospice is supplying DME and supplies for both trach and colostomy. Corrected on site. Patient 2: The medical record contains evidence the pt has a Foley catheter. There is no evidence of a Foley catheter care plan. There is evidence the pt has a single lumen picc line and pt having a PCA pump. There is no care plan for a Picc line or PCA pump. Patient 12: The POC contains diagnosis of Problems swallowing and mastication. The medical record contains a note by RN 3-20-23 "CNA feeds pt due to hx of dysphagia and aspiration". There is no evidence of a risk for aspiration care plan. Corrected on site. Patient 16: The POC contains a Dx of CHF and documentation includes pt having dependent edema, there is no evidence of a cardiac care plan. Corrected on site. Patient 19: RN documented on 3-6-23 "Pt in ED prior to admission for fall with laceration to the head." There is no evidence of a fall care plan. Patient 23: RN documented on 5-10-22 "pt is a high aspiration risk". There is no evidence of a risk for aspiration care plan. The medical record contains evidence pt has a G tube and there is no evidence of a g tube care plan.

Upon patient record review, 8 of 23 (Patient #1,#2,#3,#10,#12,#15,#16,#20,#23) 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 1: POC Foley catheter orders do not contain size, frequency of changes, flushes. There is evidence pt has a trach there are no orders for trach care, no. Pt has a colostomy, there are no orders. Hospice is supplying DME and supplies for both trach and colostomy. Corrected on site. Patient 2: POC Foley orders do not include size, frequency, flushes. Corrected on site. There is evidence of a single lumen picc line and pt having a PCA pump. There are no orders for a Picc line. Patient 3: The POC contains Miralax 17gm with no diluent. Corrected on site. Patient 10: RN documents on 3-15-23 "foam dressing and zinc ointment". There is no evidence of an order for Zinc ointment. Patient 12: The POC contains Guaifenesin 100mg/5ml give 200mg. No frequency or amount in ml. Corrected on site. Patient 15: The POC contains Apple Cider 500mg by mouth, no dose or frequency, cetirizine TK 1 T PO QD, T is not approved and no dose noted, Magnesium Oxide take by mouth, no dose or frequency, Miralax 17gm daily no diluent, Simethicone 125mg take 125mg by mouth, no frequency. Corrected on site. Patient 16: RN documents on 3-24-23 "Pt on 3 liters oxygen via nasal cannula" and RN documents on 4-3-23 "Pt was administered Fleets then Milk of Magnesia, then Kaopectate. There is no evidence of an oxygen, Milk of magnesia, Kaopectate or fleets order on the POC. Corrected on site. Patient 20: The RN documents pt has a Foley on 4-19-23 there is no evidence of an order for a Foley. Patient 23: The POC contains Keppra 100mg/ml give 250mg into G tube Q12 hours. No evidence of amount in ml's to give. Ferrous Sulfate 220mg/5ml give 220mg daily. No evidence on amount in ml's to give. Pt has evidence of a G tube there is no evidence of an order for G tube care on the plan of care.

Upon patient record review, 3 of 23 (Patient #2,#3,#9) 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 RN initial assessment contains evidence of pt having a Hoyer lift. The Hoyer lift is not on the POC. Corrected on site. Patient 3: The MSW documents on 9-12-22 pt has a wheelchair. The wheelchair is not on the POC. Corrected on site. Patient 9: The RN initial assessment notes "pt uses walker or cane to get around". Walker and cane are not listed on POC. Corrected on site.

Upon client record review, 5 of 23 (Patient #8,#10,#14,#15,#18,) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 8: RN documents 4-11-23 "Wound care provided by NP" and on 4-19-23 "wound care provided". There is no evidence the nurse followed the plan of care to complete the wound care. Patient 10: RN documents on 3-15-23 "foam dressing and zinc ointment" There is no evidence the nurse followed the plan of care to complete the wound care. Patient 14: There is evidence of a missed nursing visit 2-26-23--3-4-23 with no missed visit documentation. The POC contains orders for wound care clean with wound cleanser, pack with gauze saturated in wound gel and cover with optifoam change every 3 days. The nurse documents on 4/14 in the wound documentation "site care, barrier cream, wound care provided per order", 4/17 "coccyx hydrogel plan", 3-17-23 "foam plain, care per order". There is no evidence the nurse followed the plan of care for the wound care. The nurse documents pt had a fall and did not assess pain. Pain is to be assessed every visit according to the POC. Patient 15: The medical record contains evidence of an RN missed visit on 3-5-23--3-11-23 with no evidence of missed visit documentation. Patient 18: The Plan of care contains visit orders for 2 times a week for 4 weeks starting 4-15-23 the patient was seen 1 time this week. The POC contains an order for SN visits two times a week for 4 weeks starting 4-23-23--4-29-23 there is evidence the patient was seen 3 times this week with no evidence of the visit being PRN.

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. Patient 14: The medical record contains documentation by the nurse of pt having falls on 3-8-23,3-23-23,4-13-23. There is no evidence an incident report was completed. Nursing completed incident report on 4-26-23 during survey. Patient 15: The medical record contains documentation by the nurse of pt having falls on 1-27-23 and 3-21-23 with no evidence of an incident report being completed. Patient 19: The nurse documents pt had a fall on 4-6-23 there is no evidence of an incident report completed.

Upon patient record review, 1 of 23 (Patient #14) did not have evidence in the patient record that hospice aide assignments and duties are: Patient 14: The aide documents on 4-11-23, 4-13-23, 4-14-23 and each visit up through 4-25-23 that she informed the nurse that pt does not have hair so she cannot wash her hair. There is no evidence of the nurse removing this intervention from the aide care plan. Removed from care plan during survey.

Upon patient record review 2 of 23 (Patient #10, #14) did not have evidence documentation in the patient record that a hospice aide provides services that are: Patient 10: The medical record contains evidence of missed visits by the aide for the following weeks: 1-29-23--2-4-23, 3-19-23--3-25-23, 4-16-23--4-22-23. There is no evidence of missed visit documentation. Patient 14: The medical record contains evidence of a missed visit by the aide 3-12-23--3-18-23 with no evidence of missed visit documentation. The aide documents on 4-11-23 shampoo and hair care "not needed". On visits 4-13-23,4-14-23, 4-25-23 document change bed linens not needed.

Upon patient client record review, 1 of 23 (Patient #18) 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 18: The Election of benefits date is 4-14-23, the Election of benefits was signed on 4-15-23.

Upon patient client record review, 1 of 23 (Patient #21) did not have evidence that each patient record contains Advance Directives Patient 21: The medical record did not contain a copy of the patient's DNR. The CTI indicated pt is a DNR.

Upon patient client record review, 4 of 23 (Patient #7,#8,#9,#14) 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 7: RN notes 2-22-23 "GOC". This is not an approved abbreviation. Patient 8: RN notes 4-11-23 "wound care provided by NP". There is no evidence an NP made a visit. Patient 9,10,13: The POC contains orders for PT, OT, SLP. These were entered in error per the nurse. Removed from all care plans while on site. Patient 14: The RN documents on 4-4-23 "dressing changed by aide this morning at 10am" Nursing manager called nurse to confirm and nurse reports the aide did not do a dressing change, she meant to chart the dressing was changed while aide was present. Nurse added an addendum to her documentation to support this. The POC DME list contains Oxygen it was entered in error. Corrected on site.

Upon client record review, 1 of 23 (Patient #2) did not have evidence that the hospice forwarded a summary and a copy of the patient record, if requested, to a facility when transferring the patient to that facility. Patient 2: The medical record contains evidence pt was admitted at a SNF 4-14-23. He was transferred to the hospital 4-15-23 for GIP care and then sent back to the SNF for routine home care. There is no evidence a transfer summary was completed for either transfer.

Upon client record review, 2 of 23 (Patient #19,#20) did not have evidence that the discharge summary includes all required information. Patients 19 And 20: The discharge summary does not include the patient's current plan of care.

Upon client record review, 2 of 23 (Patient #1,#3) 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 1: The POC contains an order for Senna S the facility MAR does not contain that order. Corrected on site. Patient 3: The POC contains an order for Phenytoin Sodium 100mg 2 capsules BID, the facility MAR contains order of Phenytoin Sodium 100mg 1 capsule BID. Corrected on site.

Upon client record review, 1 of 23 (Patient #15) 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 15: The POC contains an order "skin tear to left wrist, cleanse with DWC apply protective dressing, secure with coflex. The order does not state who will perform the wound care. Corrected on site.