Every finding on record at St. Vincent Hospice, LLC

The documented comprehensive assessment must include a drug profile that includes the patient's current prescription and over-the-counter (OTC) drugs, supplements, and herbal remedies. This standard was not met as evidenced by clinical record review, interview, and observation. In 1 of 4 (25%) home visits observed revealed that the agency did not ensure that the drug profile included all of the patient's current prescription and over-the-counter medications. CLINICAL RECORD 2/HOME VISIT2: The patient was admitted on 06/18/2025. During the home visit (Home Visit 2) at a facility on 07/29/2025 with a Registered Nurse [Personnel Record 3], it was revealed during medication reconciliation that the patient was ordered a sliding scale for insulin on 06/18/2025, which is based on her blood glucose levels: 0-149 = 0 units, 150-199= 2 units, 250-299= 3 units, 300-349= 4 units, 350-399= 5 units, 400-449= 6 units, greater than 449 contact MD. The agency's current medication list was not specific, and the insulin order read: Insulin Aspar PRT-Insulin Aspart 100units/ml (70-30) 10 units with meals plus a sliding scale as directed. The agency's medication list also did not include an MVI daily and Juven 7-7-1.5 gms 2 times daily, which is currently on the facility's medication list. The Director of Nursing confirmed in an interview on 7/29/2025 that the medication list did not include specific insulin instructions related to the sliding scale, an MVI, and the supplement Juven.

It is required that each patient’s individualized written plan of care identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%), of clinical records reviewed revealed that the agency did not ensure that the plan of care included necessary interventions identified in the initial and updated assessments. CLINICAL RECORD 3: The patient’s election of benefit (EOB)was dated 03/18/2025 with diagnoses of heart failure, a pulmonary embolism, and pulmonary hypertension. The skilled nurse initial comprehensive assessment dated 03/18/2025 revealed that the patient was short of breath and that Oxygen would be initiated. The plan of care dated 03/18/2025 did not include any interventions to assess or manage respiratory status. The skilled nurse (SN) visit note dated 03/19/2025 included documentation that oxygen was in the home and safely stored. In an interview on 07/29/2025, the Director of Clinical Services confirmed that the clinical record did not include required interventions and then stated, " I have already educated staff to make sure they are including everything."

It is required that each patient’s individualized written plan of care included drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. In 2 of 19(5%) clinical records reviewed revealed that the agency did not ensure that all medication and treatments were included on plan of care. CLINICAL RECORD 3: The patient was admitted on 03/18/2025 with a diagnosis of heart failure, pulmonary embolism, and pulmonary hypertension. The skilled nursing assessment on 03/18/2025 revealed that oxygen would be initiated due to patient shortness of breath. The plan of care did not include treatment orders for oxygen including frequency, route, and dose. The skilled nursing note on 03/19/2025 confirmed that the oxygen was safely stored. CLINICAL RECORD 10: The patient’s election of benefit was dated 05/02/2025, with a diagnosis of Malignant neoplasm of the colon. The skilled nurse initial comprehensive assessment dated 05/02/2025 included documentation that the patient had a Foley catheter 16fr. The plan of care effective 05/02/2025 did not include treatment orders for a Foley catheter or state the size of the catheter, balloon size, how and when to irrigate or how and when to change the catheter if necessary. In an interview on 07/29/2025 the Director of Nursing confirmed that oxygen was not included on the initial plan of care and that the clinical record did not include order for the foley catheter and stated, "because he was admitted with it, we don't have anywhere to put orders" and reported that she would obtain orders to update the clinical record.”

It is required that each patient’s individualized written plan of care include medical supplies and appliances necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed the agency did not ensure that the plan of care included all medical supplies necessary to meet the patient's needs. CLINICAL RECORD 3: The patient elected hospice on 03/18/2025 with a diagnosis of heart failure, pulmonary embolism and pulmonary hypertension. The initial skilled nursing assessment on 03/18/2025 revealed that the patient was short of breath and oxygen was initiated. The plan of care dated 03/18/2025 read "NONE" under DME and supplies. CLINICAL RECORD 10: Patient admitted on 05/02/2025 with a Foley catheter in place as documented on the initial skilled nursing assessment on 05/02/2025. The plan of care dated 05/02/2025 read, "NONE" under DME and supplies. In an interview on 07/29/2025, the Director of Clinical Services confirmed the findings and stated that staff have already been educated to add supplies.

It is required that hospice aides are assigned to a specific patient by a registered nurse 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 1 of 13 (8%) clinical records reviewed with home health aide services revealed that the agency did not ensure that the aide's care plan provided specific instructions. CLINICAL RECORD 5: The patient was admitted on 03/24/2025. The Skilled nurse's initial assessment on 03/24/2025 revealed abnormal breath sounds and shortness of breath. Oxygen was ordered at 1-3 liters PRN. The aide care plan created on 03/24/2025 did not include oxygen or instructions if it can be removed during bathing. The Director of Nursing confirmed in an interview on 7/29/2025 that the home health aide plan of care did not include oxygen and instructions if it can be removed for care.

It is required that each patient’s individualized written plan of care: Identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 2 (50%) clinical records reviewed the agency did not ensure that the plan of care was updated with all interventions and goals when the nurse updated the comprehensive assessment. Clinical Record 2: The patient was admitted for Hospice services with a primary diagnosis of Liver Cancer on 08/16/2022. On initial assessment, he was using a condom catheter. On 08/20/2022 a Foley catheter was inserted. The plan of care was not updated with goals or interventions for this as of death 08/24/2022. An interview with the Regional Director revealed that the plan of care was not updated after the comprehensive visit for the Foley insertion.

It is required that hospice aides are assigned to a specific patient by a Registered Nurse 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 a review of clinical records and interviews. 1 of 2 (50%) clinical records in which hospice aide services were accepted did not document complete instructions on the plan. Clinical Record 2: The patient was admitted for Hospice services on 08/16/2022 with aide care accepted. On 08/20/2022 a Foley catheter was placed and remained in use until death on 08/24/2022. The aide's plan of care was not updated to include Foley catheter care. The aide provided daily services each day until death. An interview with the Regional Director revealed that the aide's plan of care should have included the Foley catheter care but did not.

It is required that each patient room in the hospice facility always has an adequate supply of hot water and has plumbing fixtures with control valves that automatically regulate the temperature of the hot water used by patients. This standard was not met as evidenced by observation and interviews. The Inpatient unit was toured on 11/2/2022 and 11/18/2022. The hot water temperature at the faucet in the patient room was over the high range of acceptable hot water temperatures with the risk of scalding a patient. IPU TOUR - Patient room 51 hot water temperature at the patient faucet was 121.8 degrees on 11/18/2022. Patient room 52 hot water temperature at the faucet was 122.2 on 11/18/2022. Facilities manager was notified on 11/18/2022 with a planned visit to correct the water temperature. IPU TOUR - Patient room 51 hot water temperature at the patient faucet was 121.8 degrees on 11/18/2022. Patient room 52 hot water temperature at the faucet was 122.2 on 11/18/2022. Facilities manager was notified on 11/18/2022 with a planned visit to correct the water temperature. An interview with the Administrator on 11/02/2022 revealed the water temperatures in 2021 and 2022 had not been documented by the contracted maintenance team as per CFR 418.110(i) to ensure "an adequate supply of hot water at all times". A phone call was placed to the Maintenance Director by the Administrator and it was revealed that the water temperature at the control valve to the hospice was conducted weekly but the Maintenance Director confirmed the actual temperature reading was not documented. The maintenance director stated that adjustments to the temperature are made automatically when the temperatures approach 120 degrees. An interview with the Facilities Manager on 11/18/2022 revealed the hot water range should not exceed 120 degrees. The plan verbalized by the Facilities Manager and Administrator is that the hot water room temperatures would be monitored weekly.

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. 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 a review of clinical records. 1 of 13 (8%) clinical records reviewed, the agency did not ensure the drug profile included all current prescription medications. Clinical Record 2: The patient was admitted on 9/24/2021. The benefit period reviewed was 3/23/22-5/11/2022. The Face to Face completed by the physician dated 3/22/2022 documented that the patient was oxygen dependent. The physician orders included oxygen 2-4 liters per nasal cannula as needed. The patient was receiving oxygen at 3 liters per nasal cannula. Oxygen was not documented on the drug profile. During the interview and joint review of the clinical record on 9/29/2022, the Director of Quality was not able to locate an additional drug profile that included oxygen.