Every finding on record at Trio Hospice Inc

Upon patient record review, 1 of 14 (Patient #1) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient 1: Election of benefits signed on 3/25/25 by responsible party AB did not indicate wishes under area of right to choose attending Physician. There is no evidence that the right to choose an attending Physician was honored.

Upon patient record review 3 of 14 (Patient #6,7,8) 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 6: Patient declined spiritual services as indicated in progress note dated 11/21/24. There is no evidence that a comprehensive spiritual assessment was completed within 5 days of admission. Patient 7: Patient declined spiritual care visits as indicated in documentation dated 2/27/25. There is no evidence that a comprehensive spiritual assessment was completed within 5 days of admission. Patient 8: Patient declined spiritual services as indicated in progress note dated 06/17/25. There is no evidence that a comprehensive spiritual assessment was completed within 5 days of admission.

Upon patient record review, 10 of 14 (Patient #1,2,3,4,5,6,7,8,9,10) did not have evidence in the patient record that the comprehensive assessment takes into consideration the imminence of death. Patient 1: The patient was admitted on 3/25/25. The comprehensive assessment does not assess for imminence of death. Patient 2: The patient was admitted on 8/19/25. The comprehensive assessment does not assess for imminence of death. Patient 3: The patient was admitted on 9/16/25. The comprehensive assessment does not assess for imminence of death. Patient 4: The patient was admitted on 11/18/24. The comprehensive assessment does not assess for imminence of death. Patient 5: The patient was admitted on 9/13/24. The comprehensive assessment does not assess for imminence of death. Patient 6: The patient was admitted on 11/02/24. The comprehensive assessment does not assess for imminence of death. Patient 7: The patient was admitted on 2/27/25. The comprehensive assessment does not assess for imminence of death. Patient 8: The patient was admitted on 06/12/25. The comprehensive assessment does not assess for imminence of death. Patient 9: The patient was admitted on 06/30/25. The comprehensive assessment does not assess for imminence of death. Patient 10: The patient was admitted on 10/21/25. The comprehensive assessment does not assess for imminence of death.

Upon patient record review, 3 of 14 (Patient# 1,2,9) 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: Current medication record contains an order dated 8/29/25 for Miralax Powder for solution 17g orally without diluent. Corrected onsite, medication record updated. Patient 2: The medication record contains an order dated 9/5/25 for Miralax Powder for solution 17g orally without diluent. Corrected onsite, medication record updated. Patient 9: Medication record contains an order dated 6/30/25 for Lidocaine 2% gel without indication of site of application.

Upon patient record review, 1 of 14 (Patient #3) 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 3: 9/17/25 visit note entered by RN documents a new wound to left buttocks without measurements per agency policy.

Upon patient record review, 1 of 14 (Patient #7) 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 7: The current POC dated 03/12/25 has a medication order for Eliquis (anticoagulant) without a risk for bleeding care plan with appropriate goals and interventions.

Upon patient record review, 3 of 14 (Patient #1,2,9) 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 medications and treatments. Patient 1: Current POC dated 9/10/25 contains an order for Miralax Powder for solution 17g orally without diluent. Corrected on site, POC updated. Patient 2: Current POC dated 9/10/25 contains an order for Miralax Powder for solution 17g orally without diluent. Corrected onsite, POC updated. Patient 9: Most current POC dated 7/30/25 has an order for Lidocaine 2% patch without indication of site for application.

Upon patient record review, 4 of 11 records (Patients #1,#3,#9,#11) 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. Patient 1: The medication profile contained lidoderm patch with no defined area for administration. Corrected on site. Patient 3: The medication profile contained contradicting morphine frequency and instructions. The frequency stated every 3-4 hours PRN, and instructions stated every 3-4 hours PRN, may repeat in 15 minutes if no relief. There was no evidence of parameters on how many times the dose could be repeated at 15 minute intervals. Corrected on site. Patient 9: The medication profile contained nitro-bid transdermal ointment with no defined area for administration. The profile also contained nitroglycerin with a frequency stating take times 3. There was no evidence of whether this was a one time order, a prn order, or any defined time interval between doses. Patient 11: The plan of care and nursing documentation upon admission identified patient use of oxygen equipment. There was no evidence of oxygen listed on the medication profile.

Upon patient record review, 3 of 11 records (Patients #3,#4,#11) 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 3: The medical record contained nursing documentation upon admission identifying that the patient was a high fall risk. There was no evidence of problems, goals, and interventions related to fall prevention and safety. Corrected on site. Patient 4: The medical record contained nursing documentation upon admission identifying that the patient was discharged from the hospital prior to hospice, for a cardiac event requiring a cardizem bolus and drip for stabilization. There was no evidence of problems, goals, and interventions related to cardiac dysfunction. Corrected on site. Patient 11: The medical record contained nursing documentation upon admission identifying patient use of oxygen and primary hospice diagnosis of COPD. There was no evidence of problems, goals, and interventions related to respiratory disfunction.

Upon patient record review, 4 of 11 records (Patients #1,#3,#9,#11) 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 medical record contained an order for a lidoderm patch with no defined area for administration. Corrected on site. Patient 3: The medical record contained an order for morphine frequency stating take every 3-4 hours PRN, and instructions stating every 3-4 hours PRN, may repeat in 15 minutes if no relief. There was no evidence of parameters on how many times the dose could be repeated at 15 minute intervals. The medical record also contained an order 8/17/22 for a foley catheter and irrigation instructions. There was no evidence of a defined foley size and frequency for change of foley or irrigation frequency. Corrected on site. Patient 9: The medical record contained an order for nitro-bid transdermal ointment with no defined area for administration. The profile also contained an order for nitroglycerin with a frequency stating take times 3. There was no evidence of whether this was a one time order, a prn order, or any defined time interval between doses. Patient 11: The plan of care and nursing documentation upon admission identified patient use of oxygen equipment. There was no evidence of an order for oxygen.

Upon client record review, 3 of 11 records (Patient #3, 4, 7) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 3: The medical record contained nursing documentation upon admission identifying nurse completion of wound care. There was no evidence of an order for wound care. Patient 4: The medical record contained documentation error on the plan of care that omitted the spiritual care frequency of twice monthly. Spiritual care visited twice a month. Corrected on site. Patient 7: The medical record contained documentation error on the plan of care stating nursing visit frequency was one to two times monthly instead of one to two times weekly. Nursing went weekly. Corrected on site.

Upon patient client record review, 1 of 11 records (Patient #8) did not have evidence that each patient record contains Physician certification and recertification of terminal illness. Patient 8: The medical record contained a CTI signed 11/22/21 with the recertification narrative composed without consideration of a face to face encounter which did not occur until 11/24/21.