Every finding on record at The Caroline Kline Galland Home

It is required that each patient’s individualized written plan of care identified 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 5 (20%) clinical records reviewed revealed the agency did not ensure the patients individualized plan of care identified planned interventions based on problems identified in the initial and updated comprehensive assessments. CLINICAL RECORD 2: The patient elected the hospice benefit on 02/09/2026 for B cell lymphoma. The initial plan of care (POC) dated 02/09/2026 included the following: "Problem Pain. Patient has pain in right knee." A nursing visit dated 02/13/2026 included the following note: Patient see for management of symptoms. She has had a rapid decline over the last two days. She has had her pain medication increased twice in the last two days and lorazepam one in the last 24 hours. She is now receiving 15 mg of Morphine every 2 hours as needed and every 4 hours scheduled. She received 1 as needed dose at the time of my visit today. She breathes through her mouth and in a Cheyne Stokes pattern. During my visit this pattern became more pronounced with periods of 15 to 20 seconds of apnea followed by tachypnea and increased use of accessory muscles in breathing." The plan of care did not include a respiratory problem. The plan of care was not updated to reflect the medication changes, the addition of oxygen, the active dying process or education of the family or facility. An interview and joint record review was conducted with the Administrator and Quality Nurse on 06/12/2026 during which time it was agreed the "plan of care was not reflective of the interventions that were being provided by the staff."

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; other alternative treatments that could affect drug therapy. This standard was not met as evidenced by clinical record review, interview, and observation. In 1 of 4 (25%) home visit observations it was revealed that the agency did not ensure the drug profile contained the patient's current prescription and over-the-counter (OTC) drugs, supplements; herbal remedies; and other alternative treatments that could affect drug therapy. Clinical Record 1/Home Visit 1: The patient elected the hospice benefit on 02/01/2023 for a diagnosis of senile degeneration of the brain. The patient resided in an adult foster home facility. During the home visit with the Hospice Aide (Personnel Record 7) on 12/17/2024, the hospice medication profile (printed on 12/16/2024) was compared to the facility medication profile (printed on 12/17/2024). The facility medication list documented the following medications that were not documented on the hospice medication profile: Roxanol 20 mg/ml take 0.25 ml every 2 hours as needed for pain or shortness of breath, (dated 02/01/2024). The following discrepancies were also found: Hospice list had Buprenorphine 2 mg take 1 tablet two times a day (dated 11/26/2024) and facility had Buprenorphine 2 mg take 1/2 tablet two times a day (dated 10/25/2024); in addition, the hospice drug profile included Olanzapine 5 mg tablet take 1 tablet every day (dated 12/13/2024) and facility had Olanzapine 2.5 mg tablet take 1 tablet every day (dated 10/26/2024); and the hospice drug profile included hydromorphone 1 mg/ml take 1 milliliter every 3 hours as needed, while the facility list had every 4 hours as needed. An interview and joint clinical record review on 12/17/2024 with the Clinical Manager, Administrator, and Executive Director the medication lists were compared, and the discrepancies were confirmed. The Clinical Manager advised she would correct them and then confirm them with the facility.

It is required that a hospice aide provides services included in the plan of care. This standard was not met as evidenced by clinical record review, interview and observation. In 2 of 8 (25%) clinical records reviewed in which hospice aide services were accepted revealed the agency did not ensure the aide provided services included in the plan of care as ordered by the Interdisciplinary Group. Clinical Record 1/Home Visit 1: The hospice aide care plan (POC) dated 05/03/2024 included the following relevant tasks: "Bed bath, incontinent care, assistance with dressing, nail care, oral care, peri care, skin care, and report changes to the nurse." The POC was updated on 05/07/2024 to include the above tasks and added "all tasks to be performed every visit unless specified otherwise." The POC was updated on 10/22/2024 to include the above tasks and added "transfer with 2-person assist and gait belt." On 11/11/2024 the POC added "bed bath" and continued with the above tasks. The hospice aide visit frequency remained at 1 time per week. During the home visit, conducted with the Hospice Aide (Personnel Record 7) on 12/17/2024, the Aide was observed shampooing the patient's hair. This task was not included in the plan of care. Clinical Record 8: The Hospice Aide plan of care (POC) dated 11/13/2024 included the following relevant tasks: "all assigned tasks to be completed every visit, catheter care, incontinent care, assist with dressing, foot care, nail care, and peri care. Hospice Aide visits dated 11/26/2024 and 11/19/2024 documented "changing bedsheets." This task was not included in the plan of care. An interview and joint clinical record review on 12/17/2024 with the Clinical Manager, Administrator and Executive Director confirmed the tasks of shampooing and changing the bedsheets were not included in the aide plan of care.

It is required that a patient's clinical record contains correct responses to medications, symptom management, treatments, and services. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 19 (5%) clinical records reviewed revealed the agency did not ensure the correct response to treatment was included per agency policy. The Agency Policy titled, Wound Care Policy (Created 04/14/2021), stated in the relevant parts, "3. The admitting clinician will document each wound status including location and etiology, measurement of length, width and depth......5. At least every week, the wound assessment and documentation will include measurement of length, width and depth......." Clinical Record 8: The patient elected the hospice benefit on 11/12/2024 for the diagnosis of senile degeneration of the brain. A review of the complaint log indicated the patient's spouse had called in regarding getting help with "wound care". A review of the clinical record documented the patient had a Stage IV pressure ulcer to the left hip, a Stage I to the coccyx, and a pressure ulcer to the right heel, were present in the admission nurse assessment. The wounds were noted in the plan of care and education was being provided to the spouse. The record lacked evidence that the wounds had been measured upon admission to include length, width, and depth. Wound care orders were written and nursing visit frequency was 3 times weekly for wound care. The clinical record lacked documented evidence that the wounds had been measure, there were no measurements located. The patient had been on hospice services for five (5) weeks without a documented measurement of the wounds in adherence with agency policy. In an interview and joint clinical record review on 12/19/2024 with the Clinical Manager, Administrator, and Executive Director it was confirmed there was no evidence of wound measurements in the clinical record and that Agency Policy requires measurement of wounds upon admission and once weekly. .

It is required that a patient's clinical record contains correct clinical information including physician orders. This standard was not met as evidenced by clinical record review and interview. In 5 of 19 (26%) clinical records reviewed it was revealed that the agency did not ensure the clinical record contained correct clinical information including physician orders. Clinical Record 8: A physician order dated 11/13/2024 stated, "Acetaminophen 650 mg rectal suppository. Administer 1 suppository rectally every 6 hours as needed." The order did not describe the as-needed reason. Clinical Record 14: A physician order dated 11/26/2024 stated: "Acetaminophen 650 mg rectal suppository. Administer 1 suppository rectally every 6 hours as needed." The order did not describe the as-needed reason. Clinical Record 16: A physician order dated 08/31/2024 stated: "Acetaminophen 650 mg rectal suppository. Administer 1 suppository rectally every 6 hours as needed." The order did not describe the as-needed reason. Clinical Record 17: A physician order dated 05/21/2024 stated "Fluticasone Furoate-Vilanterol Aero Powder BA 200-25 MCG/ACT: Inhale 1 puff as directed once a day as needed; Ipratropium Bromide Nasal Solution 0.006% (42 MCG/Spray); Spray 2 sprays into both nostrils four times a day as needed" The order did not describe the as-needed reason. Clinical Record 18: A physician order dated 06/10/2024 stated: "Triamcinolone Acetonide Cream 0.025%. Apply 1 liberally to the affected area twice daily as needed." The order did not describe the as-needed reason. In an interview and joint clinical record review on 12/18/2024 with the Clinical Manager, Administrator, and Executive Director, it was confirmed that the orders did not contain "as needed" reasons and that they should have a reason for as needed.

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; and includes all services necessary for the palliation and management of the terminal illness, including intervention to manage pain and symptoms. This standard was not met as evidenced by clinical record review and interview. 2 of 13 (15%) clinical records reviewed revealed the hospice did not ensure the plan of care contained interventions to address all problems identified in the assessments. Record #61403 was reviewed and identified a comprehensive assessment was completed on 10/19/2021. The documentation revealed the patient had moderate pain rated as 4 out of 10 in the right lower back and left flank area, and new orders for Morphine, 15mg ER BID, and Fentanyl Patch, 12mcg. The plan of care dated 10/19/2021 did not include evidence of the patient's pain identified as a problem with interventions to address the pain. Record #95393 was reviewed and identified a comprehensive assessment was completed on 12/17/2021. The documentation revealed the patient had moderate pain rated as 4 out of 10 in lower back, with “increased pain to low back and abdomen”, and there was a new order for Tramadol, 25mg BID. The plan of care dated 12/17/2021 did not include evidence of the patient's pain identified as a problem with interventions to address the pain. The Manager of Hospice Operations was interviewed on 2/17/2022 and stated, there was no plan of care to address pain in the records identified. The Administrator confirmed these findings on 2/17/2022.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: Physician orders. This standard was not met as evidenced by clinical record review and interview. 1 of 3 (33%) clinical records reviewed of patients with wounds revealed the hospice did not ensure the clinical record included a physician order for the wound care being provided. Record #81301 was reviewed and identified a routine RN assessment was completed on 2/1/2022. The documentation stated: “left wound has more slough on it compared to last week. Wound 2.5 x 3 x 0.3 with 75% slough 25% pink. Cleansed wound and applied med honey and then covered with nonadherent dressing.” There was no evidence of a documented physician order for the application of Medihoney. The Manager of Hospice Operations was interviewed on 2/17/2022 and stated, there was no physician order documented for the identified record. The Administrator confirmed these findings on 2/17/2022.