Every finding on record at Vistacare USA, LLC

Upon patient record review, 5 of 19 (Patients #5,#6,#7,#12,#13) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications. Patient 5: Upon home visit medication review, the facility and hospice medication profiles did not match. The facility had an albuterol inhaler and lidocaine patch daily as needed that were not on the hospice profile, the facility had gabapentin 400mg three times daily listed with hospice dose at 100mg twice daily, the facility listed lorazepam every 2 hours as needed with hospice every 8 hours as needed, the facility listed melatonin scheduled with hospice listed as needed, and facility listed ondansetron every 6 hours as needed with hospice every 8 hours as needed. Corrected on site. Patient 6: The medical record contained nursing documentation since admission identifying patient use of oxygen. There was no evidence of oxygen included in the medication profile. Corrected on site. Patient 7: Upon home visit medication review, the facility and hospice medication profiles did not match. The facility had an albuterol inhaler and guaifenesin that were not on the hospice medication profile. Corrected on site. Patient 12: Upon home visit medication review, the patient did not have citalopram that was listed on the medication profile, and had divalproex as needed that was not on the profile. Corrected on site. Patient 13: The medical record contained nursing documentation since admission identifying patient use of oxygen. There was no evidence of oxygen included in the medication profile. Upon home visit medication review, the facility medication profile did not contain ondansetron as needed. Corrected on site.

Upon patient record review, 2 of 19 (Patients #5,#9) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient 5: The initial bereavement assessment was completed 2/25/25 with start of care 2/19/25, not meeting the five day timeline. Patient 9: The initial bereavement assessment was completed 2/7/25 with start of care 2/1/25, not meeting the five day timeline.

Upon patient record review, 2 of 19 (Patients #5,#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 5: The medical record contained nursing documentation 2/19/25 upon admission, identifying the patient had a coccyx wound that was unable to be examined during the initial assessment. There was no evidence of a skin assessment completed until 3/4/25. Patient 11: The medical record contained wound care orders 1/30/25 for right and left buttocks. There was no evidence of measurements of the left buttock wound from 1/30/25 to 2/24/25, and no assessments of the left buttock wound from 2/3/25 to 2/24/25.

Upon patient record review, 3 of 19 (Patients #9,#11,#14) 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 9: The medical record contained documentation of the patient's primary diagnosis of Alzheimer's disease. There was no evidence of problems, goals, and interventions related to neurological dysfunction included in the plan of care. Corrected on site. Patient 11: The medical record contained nursing documentation upon admission identifying the patient as a high risk for falls. There was no evidence of problems, goals, and interventions related to fall safety. Corrected on site. Patient 14: The medical record contained nursing documentation upon admission identifying patient is a high risk for falls and has pitting edema. There was no evidence of problems, goals, and interventions related to fall safety and edema included in the plan of care. Corrected on site.

Upon patient record review, 3 of 19 (Patients #3,#6,#13) 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: The medical record contained nursing documentation since admission identifying patient use of a Bipap at night. There was no evidence of an order for Bipap parameters. Corrected on site. Patient 6,13: The medical record contained nursing documentation since admission identifying patient use of oxygen. There was no evidence of an order for oxygen rate, frequency and delivery method. Corrected on site.

Upon patient record review, 6 of 19 (Patients #3,#5,#7,#9,#12,#14) 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 3: The medical record contained nursing documentation since admission identifying patient use of a Bipap at night. There was no evidence of an order for the equipment. Corrected on site. Patient 5: The medical record contained nursing documentation upon admission identifying patient use of a nebulizer. There was no evidence of an order for the equipment. Corrected on site. Patient 7: The medical record contained nursing documentation upon admission identifying patient use of half rails, and 12/20/24 identifying use of an over the bed table and low air loss mattress. There was no evidence of an order for the equipment. Corrected on site. Patient 9: The medical record contained nursing documentation upon admission identifying patient use of a hospital bed, over the bed table, wheelchair, and oxygen. There was no evidence of an order for the equipment. Corrected on site. Patient 12: The medical record contained nursing documentation upon recertification 1/13/25 identifying patient use of a fall mat. There was no evidence of an order for the equipment. Corrected on site. Patient 14: The medical record contained nursing documentation upon admission identifying patient use of a hospital bed, low air loss mattress, and over the bed table; and 2/24/24 identifying use of a wheelchair. There was no evidence of an order for the equipment. Corrected on site.

Upon patient record review, 4 of 19 (Patients #5,#7,#8,#13) 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 5: The plan of care contained active wound care orders. The wound was documented as healed 3/4/25. Corrected on site. Patient 7: The medical record contained nursing documentation 11/4/24 identifying patient relocation to a facility. The plan of care contained active problems, goals, and interventions identifying caregiver strain with the patient's need for long-term placement. Corrected on site. Patient 8: The plan of care was not updated with DNR code status, signed 2/4/25. Patient admitted as full code that was still the identified code status on the plan of care. Corrected on site. Patient 13: The medical record contained nursing documentation upon admission identifying patient was receiving fluids via an IV. There was no evidence of current IV fluid administration and the plan of care contained active problems, goals, and interventions for IV use. Corrected on site.

Upon patient record review, 2 of 19 (Patients #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 4: The medical record contained an order 1/29/25 indicating one nursing visit ordered for that week. There was no evidence of a visit completed. Patient 7: The medical record contained an order for social work visits twice monthly. There was no evidence of a second visit completed in February 2025.

Upon patient record review, 1 of 19 (Patient #5) did not have evidence in the patient record that hospice aide assignments and duties are: • 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: The aide care plan contained tasks to turn and reposition per patient request as needed; and transfer as needed. Corrected on site.

Upon patient record review, 1 of 19 (Patient #12) 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 12: The election form identified the patient's responsible party elected to receive the Notification of Hospice Non-covered Items upon admission 10/27/24. The addendum was not furnished until 11/22/24, outside of the five day requirement.

Upon patient record review, 1 of 19 (Patient #18) did not evidence that each patient record contains physician orders. Patient 18: There was no evidence of a physician order to discharge the patient due to extended prognosis.

Upon patient record review, 1 of 19 (Patient #3) 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 3: The medical record contained a missed visit documented for 12/6/24 in error for the week of 1/5/25. After agency investigation of missed frequency, the error in documentation was discovered.

Upon patient record review, 1 of 19 (Patient #10) 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 10: The medical record contained an order 2/2/25 that does not specify facility or hospice responsibility for barrier ointment to perirectal area, stating hospice nurse/facility nurse/caregiver to complete treatment. Corrected on site.

Upon patient record review, 4 of 13 (Patient #6, #7, #8, #12) 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 #6-The medication profile contains duplicative/unclear dosing of Ondansetron. The profile includes 07/23/21 Ondansetron 4 mg 1 tab qd at noon; 08/18/21 Ondansetron 4 mg 1 tab two times a day administer at 10 am and 4 pm. 09/22/21 Ondansetron 8 mg tab 1 tab three times daily. Each are listed as current medications. Patient #7-The medication profile contains duplicative/unclear dosing of Sertraline. The profile includes 1/21/22 Sertraline 100 mg tablet 1 tab daily for depression and 1/21/22 Sertraline 25 mg 1 tab daily for depression. The profile also includes Miralax 17 gm powder oral packet 1 daily. The profile does not include a diluent for Miralax. Patient #8- On 09/24/21 the nurse documents an order was written to DC all routine meds. The routine medications were not discontinued from the medication profile. Patient #12-The medication profile includes Tylenol 325 mg 2 tabs q4h prn mild to moderate pain. The profile also includes Tylenol 325 2 tabs four times daily and Acetaminophen 650 mg rectal suppository q6h prn for fever greater than 100.4. The profile does not include the maximal allowable dosage.

Upon patient record review, 5 of 13 (Patient #3, #6, #7, #8, #12) did not have evidence the plan of care must included all services necessary for the palliation and management of the terminal illness and related conditions, including specific/accurate orders for medications and treatments. Patient #3- The 1/12/22 plan of care includes orders for music therapy. Upon interview with leadership this is an error as the agency does not currently provide music therapy. Patient #6-The 02/01/22 plan of care contains duplicative/unclear dosing of Ondansetron. The orders include 07/23/21 Ondansetron 4 mg 1 tab qd at noon; 08/18/21 Ondansetron 4 mg 1 tab two times a day administer at 10 am and 4 pm. 09/22/21 Ondansetron 8 mg tab 1 tab three times daily. The plan of care also includes orders for Music therapy dated 12/29/21. Upon interview with leadership the order for music therapy is an error as the agency does not currently provide music therapy. Patient #7-The 02/10/22 plan of care contains duplicative/unclear dosing of Sertraline. The orders include Sertraline 100 mg tablet 1 tab daily for depression and Sertraline 25 mg 1 tab daily for depression. The plan of care also includes Miralax 17 gm powder oral packet 1 daily. The order does not include a diluent for Miralax. Patient #8- On 09/24/21 the nurse documents an order was written to DC all routine meds as the patient was imminent. The plan of care was not updated with orders to discontinue the routine medications. Patient #12-The 1/31/22 plan of care includes Tylenol 325 mg 2 tabs q4h prn mild to moderate pain. The plan of care also includes Tylenol 325 2 tabs four times daily and Acetaminophen 650 mg rectal suppository q6h prn for fever greater than 100.4. The plan of care does not include the maximal allowable dosage.

Upon patient record review, 1 of 11 applicable (Patient # 2) did not have evidence in the patient record that hospice aide assignments and duties include the tasks to be provided and the frequency of those tasks. Patient #2- The Aide Care plan has an assignment of bed bath every visit and shower every visit leaving the discretion of bath type up to the Aide.

Upon patient record review, 2 of 13 (Patient #2, #12) did not have evidence that all entries are accurate. Patient #2-On 02/16/22 the nurse documented the patients pain was an 8 on a 10 point pain scale upon admission. The nurse reported it to the attending physician and documented the physician stated the patients Fentanyl patch dosage had been increased from 25mcg/hr to 50 mcg/hr and the physician wanted to wait before routinely scheduling Oxycodone. Surveyor noted medication profile contained Fentanyl Patch 25 mcg/hr. Upon investigation and interview with leadership the Fentanyl 50 mcg/hr was a documentation error as the patients Fentanyl patch had been increased from 12.5 mcg/hr to 25 mcg/hr. (late entry corrected on site). Patient #12-The patient was admitted on 01/31/22 and the BP on admission is documented as 203/89. Upon investigation and interview with leadership, this was a typographical error as the patients BP was 103/89. The patient does not have a medical history of hypertension.

Upon patient record review, 2 of 2 applicable (Patient #7, #9) did not have evidence that the discharge summary includes all required information. Patient #7- On 02/22/22 the patient revoked the hospice election. The discharge summary only states the patient revoked the election to seek aggressive treatment. The discharge summary does not include a summary of the patient's stay, including treatments, symptoms and pain management. Patient #9- On 03/08/22 the patient was discharged for cause. The discharge summary only states the patient was discharged to home/self care for noncompliance. The discharge summary does not include a summary of the patient's stay, including treatments, symptoms and pain management.

Upon patient record review, 1 of 8 applicable (Patient # 6) 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 #6-The patient resides in an SNF. On 1/20/22 orders were obtained for wound care as follows: Abdominal wound: Cleanse with NS, apply crushed Metronidazole to wound and cover with bordered foam dressing. Dressing to be changed every three days. Hospice nurse to perform once weekly on visits and facility nurse to perform other days. On the weekly visits 2/3/22 and 3/3/22 the hospice nurse documented wound care was not performed and not ordered.

Upon patient record review, 1 of 8 applicable (Patient # 13) 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 #13- The patient resides in a SNF. The 02/24/22 plan of care orders include wound care to right upper back abscess bid. Cleanse with NS, pack with Iodoform, skin care to peri wound. Cover with ABD and secure with tape. Wound care to be performed by SN. The order does not specify whether the hospice nurse or facility nurse is responsible for the wound care.