Every finding on record at White Rose Hospice, Inc.

Upon patient record review, 1 of 14 (Patient # 14) did not have evidence in the patient record that the comprehensive assessment takes into consideration the imminence of death. Patient 14: There is no evidence of assessment of imminence of death in the RN comprehensive assessment at SOC on 04/24/25.

Upon patient record review, 3 of 14 (Patient #1, 2, 6) 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 tor Patient 1: During home visit, the medication profile on 05/07/26 contains multiple orders for acetaminophen including Oral dose of 500 mg every 4-6 hours prn, Hydrocodone/acetaminophen 5mg/325mg every 6 hours prn and rectal supp 650mg every 4 hours prn with no evidence of a limit to not exceed in 24 hour period. Patient 2: During home visit, the medication profile on 05/19/26 does not contain evidence of two medications caregiver reports client is taking including Aldactone and Ticagrelor. Caregiver reports "His daughter brought them in." The prescriptions were last refilled in 01/26. Patient 6: The medication profile on 12/11/25 contains multiple orders for acetaminophen including rectal suppository every 4 hours and oral tabs 650 mg every 6 hours prn with no evidence of a limit to not exceed in 24 hour period.

Upon patient record review, 3 of 14 (Patient # 1, 2, 6) 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 updated POC on 05/07/26 contains multiple orders for acetaminophen including Oral dose of 500 mg every 4-6 hours prn, Hydrocodone/acetaminophen 5mg/325mg every 6 hours prn and rectal supp 650mg every 4 hours prn with no evidence of a limit to not exceed in 24 hour period. Patient 2: The updated POC on 05/19/26 does not contain evidence of two medications caregiver reports client is taking including Aldactone and Ticagrelor. Patient 6: The Initial POC on 12/11/25 contains multiple orders for acetaminophen including rectal suppository every 4 hours and oral tabs 650 mg every 6 hours prn with no evidence of a limit to not exceed in 24 hour period.

Upon patient record review, 2 of 14 (Patient # 5 and 9) did not have evidence the hospice offers bereavement counseling that includes: Patient 5: There is no evidence of a Bereavement POC being developed post death 02/28/26. Patient 9: There is no evidence of a Bereavement POC being developed post death 04/25/26.

Upon patient client record review, 12 of 14 (Patient #1,2,3,4,5,6,7,8,9,10, 13 and 14) 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 1: There is no evidence of aide notes signed and dated on 5/4/26, 5/7/26, 5/11/26 and 5/14/26. Patient 2: There is evidence of Initial Spiritual care note completed by SC on 3/20/26 electronically signed and dated by LVN instead of SC. Patient 3: There is evidence of SN notes 4/27/26 and 5/4/26 not completed with electronic signature and date according to agency Policy WRH-CLN-072 submit and sign all patient-related documentation within 72 hours after actual patient visit. Patient 4: There is evidence of initial comprehensive assessments for visits completed by MSW and SC on 11/30/25 electronically signed and dated by LVN instead of MSW and SC. Patient 5: There is evidence of initial comprehensive assessments for visit completed by SC on 02/23/26 electronically signed and dated by LVN instead of SC. Patient 6: There is evidence of initial comprehensive assessments and initial bereavement assessment for visits completed by MSW and SC on 1/01/25 electronically signed and dated by LVN instead of MSW and SC. Patient 7: There is evidence of initial comprehensive assessments for visits completed by RN on 4/24/25 and SC on 4/25/25 electronically signed and dated by LVN instead of RN and SC. Patient 8: There is evidence of initial comprehensive assessments and initial bereavement assessment for visits completed by RN and MSW on 1/01/25 electronically signed and dated by LVN instead of RN and MSW. Patient 9: There is evidence of initial comprehensive assessments and initial bereavement assessment for visits completed by RN 4/23/25 and SC on 4/24/25 electronically signed and dated by LVN instead of RN and SC. Patient 10: There is evidence of initial RN comprehensive assessments completed by RN 08/18/25 is electronically signed and dated by LVN instead of RN. Patient 13: There is evidence that the initial Bereavement assessment completed by MSW on 5/4/25 is signed and dated by LVN instead of MSW. Patient 14: There is evidence that the initial Bereavement assessment completed by MSW on 4/25/25 is signed and dated by LVN instead of MSW.

Observed in Patient Home. In 1 of 1 home visits conducted, the organization failed to follow their Bag Technique Policy. The surveyor observed the LVN work with the patient and the patient's environment while wearing gloves and entered and re-entered the clinical bag several times while wearing the same gloves. The LVN did perform glove changes while working with changing the patient's wet depends and chux and performed hand hygiene at those times.

Observed in Emergency Management Session. In review of the organization's Emergency Operations Plan the surveyor noted there was no description of the patient population served by the organization and the extent to which additional populations that could be cared for during an emergency. Observed in Emergency Management Session. In review of the organization's Emergency Operations Plan the surveyor noted the plan failed to include a succession plan that identified who would replace the key leaders during an emergency if the leader was not available to carry out their duties and a delegation of authority plan that described the decisions and policies that can be implemented by authorized successors during an emergency as well as criteria that would initiate the delegation.

Observed in Emergency Management Session. In review of the organization's Emergency Operations Plan the surveyor noted the plan failed to identify a process for cooperation and collaboration with the local, state, tribal, regional, and federal emergency preparedness officials.

Observed in Emergency Management Session. In review of the organization's Emergency Operations Plan the surveyor noted the plan failed to describe how the organization would inform state and local officials of any on-duty staff they are unable to contact.

Observed in Emergency Management Session. In review of the organization's Emergency Operations Plan the surveyor noted the plan failed to describe how the organization would inform state and local emergency preparedness officials before, during, and after emergencies regarding patients the organization was unable to contact and patients in need of evacuation..

Observed in Record Review. In 1 of 11 patient records reviewed, the organization failed to conduct and document an assessment of survivor risk factors as part of the comprehensive assessment. In review of the medical record for RR 2 there was no evidence that a bereavement risk assessment had been completed as required by policy and regulation.

Observed in Record Review. In 5 of 11 patient records reviewed, the hospice organization did not provide care, treatment, or services according to the patient's individualized plan of care. In review of RR 1 the visit frequency on the plan of care included; MSW to visit for initial evaluation, once monthly, during recertification, and as needed for psychosocial support, RN to visit for initial evaluation, recertification, as needed, and for ongoing comprehensive assessment/supervisory visit every 14-days, SC to visit for initial evaluation, every recertification and as needed for spiritual support, and spiritual counseling, however there was no evidence of documented visits as planned for RN, MSW, and SC. This also occurred in review of RR 2, RR 3, RR 4 and RR 5. Observed in Record Review. In 2 of 3 patient records reviewed, for bereavement services, the surveyor noted that care was not provided in accordance with the organization's policy no. 2-010.1 Bereavement Services which states that within 3 to 5 weeks after the patient's death, a bereavement assessment will be completed by the bereavement counselor following the family/caregiver. For BR 1 and BR 2 the post death bereavement assessment was conducted by the bereavement coordinator the day following the death documenting that no bereavement care was desired at the moment. Additionally, for BR 2 records the organization failed to document a bereavement plan of care. This was discussed with the Bereavement Coordinator and DPCS. Observed in Patient Home. In 1 of 3 home visits conducted, with the Hospice Aide the surveyor noted that care was not provided according to the care plan. For HOS 3 the Hospice Aide was showering the patient however the Aide Care Plan included a bed bath be given each visit. Additionally, the Hospice Aide was shaving the patient and performing range of motion exercises and vital signs including blood pressure, pulse oximeter and temperature which were not on the care plan. This was validated with the DPCS and Owner.

Observed in Leadership Session. The Hospice QAPI program did not reflect the complexity of the organization and its services. In review of the QAPI program and in discussion with the DPCS the surveyor noted that the organization's QAPI plan failed to include DME, pharmacy or bereavement services or address palliative outcomes.

Observed in Patient Home. In 3 of 3 home visits conducted, the organization failed to follow their Bag Technique Policy No. 9-014.1 which states, prior to administering care, alcohol-based hand rub or soap and paper towels will be removed, and hands will be washed. For HOS 1 the surveyor observed the RN remove equipment and administer care prior to washing her hands and subsequently enter and re-enter the clinical bag several times throughout the home visit without performing hand hygiene. This was also observed for the care provided to HOS 2 by the RN and for care provided to HOS 3 by the Hospice Aide. This was discussed with and validated by the DPCS. Observed in Patient Home. In 3 of 3 home visits conducted, staff failed to perform hand hygiene consistent with the organization's Hand Hygiene Policy No. 9-009.1 which requires Hand decontamination using an alcohol based hand rub before; having direct contact with patients, before donning gloves and after removing gloves. For HOS 1 the RN was observed donning gloves without first washing her hands or using an alcohol based hand rub to assist the patient go to the bathroom. The RN then washed her hands with soap and water but throughout the visit was in and out of the clinical bag without performing hand hygiene and had several glove changes without hand hygiene. Additionally, for HOS 2 and HOS 3 staff changed gloves without performing hand hygiene. This was discussed with the DPCS and Owner.

Observed in Infection Control System Tracer. In review of the organization's Infection Control Plan which stated that the hospice will perform a risk analysis, the surveyor noted and it was confirmed by leadership that the organization had not identified infection risks based on the following: the care, treatment, or services it provided.

Observed in Patient Home. In 1 of 1 home visits conducted, with the Hospice Aide, the organization had not provided accurate written patient care instructions. For HOS 3 the patient's condition had improved and the Hospice Aide was showering the patient however the Aide Care Plan had not been updated and included a bed bath be given each visit. Additionally, the Hospice Aide was shaving the patient and performing range of motion exercises and vital signs including blood pressure, pulse oximeter and temperature which were not on the care plan. This was validated with the DPCS and Owner.

Observed in Tracer Activities. In discussion with the Volunteer Coordinator and in review of the Volunteer Program the surveyor noted that hospice had not documented its efforts to recruit and retain volunteers. There was a Volunteer Recruitment Plan for 2020, however not for 2021 or 2022 and there was no documentation on the Volunteer Recruitment Activities Logs. This was validated by the Volunteer Coordinator/Owner.

Observed in Leadership Session. The governing body/leadership did not ensure that the following Conditions of Participation were met as determined through observations, documentation and staff interviews: 418.58, 418.108 and 418.60. This was discussed with the organization's Owner and DPCS.

Observed in Patient Home. In 2 of 3 home visits conducted, the surveyor noted that the organization failed to provide education and training to the patient and caregiver. For HOS 1 the RN reported that she was reinforcing education to the caregivers at the board and care facility regarding the patient's low salt, lo fat diet however there was no evidence in the medical record or home chart that education had been provided for the patient who had been admitted to hospice care more than six weeks ago. Additionally, for HOS 2 who had been admitted to hospice care six months ago there was no evidence that the organization had provided education to the patient or caregiver on procedures to follow if care, treatment, or services are disrupted by a natural disaster or an emergency. The Evacuation Plan in the patient's home folder indicated that the patient would evacuate to the home of a family member or friend however that information had no been completed and the information regarding medical equipment was blank even though the patient used a walker and oxygen. This was discussed with and validated with the DPCS.

Observed in Document Review. In review of the organization's contracts the surveyor noted that the contract with the Skilled Nursing Facility was an individual contract for a hospice patient that needed general inpatient care and that the organization was not prepared to provide short-term inpatient care for pain control, symptom management, and respite care in the event that their hospice patients would need those services. This was verified with the DPCS who reported that if a patient desires treatment for pain management then hospice care is revoked and the patient is sent to the emergency room or if the patient is DNR then the organization will provide continuous care at home.