Every finding on record at Waterford Hospice, LLC

Upon patient record review, 2 of 14 (Patient #5,9) 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 #5 On the medication profile, order dated 1/11/25 for Nystatin powder does not contain instructions for specific location. Patient #9 On the medication profile, order dated 2/26/25 for Antifungal Cream does not contain instructions for specific location. Order dated 2/26/25 for Miralax does not contain instructions on what to mix the powder with for medication administration.

Upon patient record review, 8 of 14 (Patient #1,2,3,4,5,7,8,9) 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 #1,2,3,4,5,7,8,9 Orders for MSW frequency are PRN only, no evidence of frequency orders for routine visits. Patient #1,3,4,9 Orders for SC frequency are PRN only, no evidence of frequency orders for routine visits. Patient #9 SC visit on 2/27/25 states "monthly visits will be completed", no evidence of SC visit frequency order.

Upon patient record review, 2 of 14 (Patient #5,9) 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 #5 Order dated 1/11/25 for Nystatin powder does not contain instructions for specific location. Patient #9 Order dated 2/26/25 for Antifungal Cream does not contain instructions for specific location. Order dated 2/26/25 for Miralax does not contain instructions on what to mix the powder with for medication administration.

Upon patient record review, 2 of 14 (Patient #1,6) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1 SN visits dated 3/6/25, 3/10/25, 3/13/25, 3/17/25 there is no evidence the visit was done as it has not been started and documented by the clinician per the agency policy that visit documentation is to begin on the day of clinician visit. Patient #6 Order frequency for MSW 2x/month 12/29/24-1/31/25, no evidence of MSW visits completed.

Upon patient record review 2 of 14 (Patient #1, 10) 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 #1 Aide Supervisory visits on 3/10/25 and 3/17/25 there is no evidence the visit was done as it has not been started and documented by the clinician per the agency policy that visit documentation is to begin on the day of clinician visit. Patient #10 Aide Supervisory visit on 3/17/25 there is no evidence the visit was done as it has not been started and documented by the clinician per the agency policy that visit documentation is to begin on the day of clinician visit.

Upon patient record review, 1 of 14 (Patient #2) did not have evidence that before the recertification period for each patient, the medical director or physician designee must review the patient's clinical information and provide written documentation that it is anticipated that the patient's life expectancy is 6 months or less. Patient #2 CTI on 3/7/25 has not been signed by the medical director and should have been signed at IDG on 3/19/25.

Upon patient record review 1 of 11 (Patient #3) did not have evidence in the patient record that the comprehensive assessment identifies the 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 #3: Was admitted on 10/15/2021. The Chaplain did not complete an Initial Spiritual Assessment. On 12/26/2021, a routine visit was completed by the Chaplain.

Upon patient record review, 2 of 11 (Patients #4 and #6) did not have evidence in the patient record that the comprehensive assessment included a bereavement component. Patient #4: Patient was admitted on 11/12/2021 and the Bereavement Assessment was not completed until 1/4/2021. Patient #6: Patient was admitted on 11/10/2021 and the Bereavement Assessment had not been completed as of the survey date, 1/5/2021.

Upon client record review, 1 of 1 applicable (Patient #11) did not have evidence that the hospice forwarded a summary and a copy of the patient record, if requested, to a facility when transferring the patient to that facility. Patient #11: The patient moved out of the service area and transferred to another hospice. Although a transfer summary was completed, there was no documentation to indicate it had been sent to the receiving hospice.