Every finding on record at Sky Hospice Care Inc

Upon patient record review, 5 of 10 (Patient #1,3,4,5,8) 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 #1 - Admission order O2 at 2L/M nasal cannula PRN SOB may increase to 4L/M if saturation below 90% but not on medication profile. Patient #3 - SN initial assessment has patient receiving 02 at 2L/M but not on medication profile. Patient #4 - SN initial assessment has patient receiving 02 at 2L/M but not on medication profile. Patient #5 - Medication profile contained Nystatin 100,00u/g apply topically to affected areas 3 times a day and PRN - did not contain affected area or modifier for PRN. Patient #8 - SN initial assessment has patient receiving 02 at 2L/M but not on medication profile.

Upon patient record review, 1 of 10 (Patient #5) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual's attending physician, if any) • Changes that have taken place since the initial assessment • Information on the patient's progress toward desired outcomes • Reassessment of the patient's response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days Patient #5 - The comprehensive assessment was completed 05/29/25, the update was not completed until 6/16/25, greater than 15 days.

Upon patient record review, 1 of 10 (Patient #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 #5 - The MSW and Chaplain visit orders included prn visits without a frequency for those visits.

Upon patient record review, 4 of 10 (Patient #3,4,5,8) 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 - SN initial assessment has patient receiving 02 at 2L/M but not on POC. Patient #4 - SN initial assessment has patient receiving 02 at 2L/M but not on POC. Patient #5 - POC contained Nystatin 100,00u/g apply topically to affected areas 3 times a day and PRN - did not contain affected area or modifier for PRN. Patient #8 - SN initial assessment has patient receiving 02 at 2L/M but not on POC.

Upon client record review, 1 of 10 (Patient #7) did not have evidence that the IDG in collaboration with the attending physician reviewed, revised and documents the individualized plan as frequently as the patient's condition requires but no less frequently then every 15 calendar days. Patient #7 - Patient admitted on 05/11/25 patient not discussed until 05/30/25 IDG.

Upon client record review, 1 of 10 (Patient #8) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #8 - SN provided wound care on 02/15/25 and 02/17/25 but no orders for wound care.

Upon patient record review, 3 of 10 (Patient #5,6,7) 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 #5 - Aide Care Plan did not contain frequency for tasks ROM, meal preparation, feeding and set up, house keeping, make bed and change linen. Patient #6 - Aide Care Plan did not contain frequency for tasks perineal care or moisturize skin. Patient #7 - Aide Care Plan did not contain frequency for tasks ROM, meal preparation, feeding or set up, house keeping, make bed and change linen.

Upon patient record review 2 of 10 (Patient #5, 8) 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 #5 - Aide supervisor visit made 07/22/25 then again on 08/08/25. Patient #8 - Aide supervisor visit made 05/29/25 then again on 06/16/25.

Upon patient client record review, 1 of 10 (Patient #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 #5 - No credentials SN visit by Cordova Joaquin on 05/15/25 or 05/29/25,

Upon observation, the agency did not have evidence that all patient records are retained for a minimum of six years from the date of the most recent discharge or the death of the patient, unless state law stipulates a longer period of time. The agency does not have access to prior 5 patient records from previous owners.