Haven Hospice

“Upon patient record review, 1 of 19 (Patient #1) 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) Patient’s current medication profile and POC for certification period 6/26/25-08/24/25 had medication order for Loperamide HCL 2 mg tab PRN daily for diarrhea. Upon home visit, the patient’s medications did not contain Loperamide HCL 2 mg.”

“Upon patient record review, 19 of 19 (Patients # 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19) 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 #1) Upon review of the patient’s POC, there was no evidence that the POC contained the medical supplies related to the management of the terminal illness needed for the palliation and management of the patient’s end of life care. Patient #2) Upon review of the patient’s POC, there was no evidence that the POC contained the medical supplies related to the management of the terminal illness needed for the palliation and management of the patient’s end of life care. Patient #3) Upon review of the patient’s POC, there was no evidence that the POC contained the medical supplies related to the management of the terminal illness needed for the palliation and management of the patient’s end of life care. Patient #4) Upon review of the patient’s POC, there was no evidence that the POC contained the medical supplies related to the management of the terminal illness needed for the palliation and management of the patient’s end of life care. Patient #5) Upon review of the patient’s POC, there was no evidence that the POC contained the medical supplies related to the management of the terminal illness needed for the palliation and management of the patient’s end of life care. Patient #6) Upon review of the patient’s POC, there was no evidence that the POC contained the medical supplies related to the management of the terminal illness needed for the palliation and management of the patient’s end of life care. Patient #7) Upon review of the patient’s POC, there was no evidence that the POC contained the medical supplies related to the management of the terminal illness needed for the palliation and management of the patient’s end of life care. Patient #8) Upon review of the patient’s POC, there was no evidence that the POC contained the medical supplies related to the management of the terminal illness needed for the palliation and management of the patient’s end of life care. Patient #9) Upon review of the patient’s POC, there was no evidence that the POC contained the medical supplies related to the management of the terminal illness needed for the palliation and management of the patient’s end of life care. Patient #10) Upon review of the patient’s POC, there was no evidence that the POC contained the medical supplies related to the management of the terminal illness needed for the palliation and management of the patient’s end of life care. Patient #11) Upon review of the patient’s POC, there was no evidence that the POC contained the medical supplies related to the management of the terminal illness needed for the palliation and management of the patient’s end of life care. Patient #12) Upon review of the patient’s POC, there was no evidence that the POC contained the medical supplies related to the management of the terminal illness needed for the palliation and management of the patient’s end of life care. Patient #13) Upon review of the patient’s POC, there was no evidence that the POC contained the medical supplies related to the management of the terminal illness needed for the palliation and management of the patient’s end of life care. Patient #14) Upon review of the patient’s POC, there was no evidence that the POC contained the medical supplies related to the management of the terminal illness needed for the palliation and management of the patient’s end of life care. Patient #15) Upon review of the patient’s POC, there was no evidence that the POC contained the medical supplies related to the management of the terminal illness needed for the palliation and management of the patient’s end of life care. Patient #16) Upon review of the patient’s POC, there was no evidence that the POC contained the”

“Upon personnel record review, 1 of 19 (Personnel # 7) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) ·Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff. ·Reading and recording temperature, pulse, and respiration ·Safe transfer techniques and ambulation. ·Normal range of motion and positioning ·Appropriate and safe techniques in personal hygiene and grooming that include-- ·(A) Bed bath ·(B) Sponge, tub, and shower bath ·(C) Shampoo, sink, tub, and bed ·(D) Nail and skin care ·(E) Oral hygiene ·(F) Toileting and elimination The other subject areas in this section may be evaluated through written examination, oral examination or after observation of a Hospice Aide with a patient. Personnel #7) Upon review of employee file, there was no evidence that the competency for appropriate and safe techniques in personal hygiene and grooming included shampooing in the sink, tub and bed.”

“Upon patient record review, 1 of 19 (Patient #2) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • 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 # 2) Upon review of hospice aide POC the task of shower was ordered every visit. The documentation in the aide’s notes on 5/23, 5/29. 6/5, 6/9, 6/12, 6/19 states patient refused shower. The one note on 5/23 states the daughter told the aide that the patient should only be getting a bed bath. The aide documented that she notified the RN however, no evidence the RN updated the aide POC.”

“Upon patient record review 1 of 19 (Patient # 2) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #2) Aide POC ordered patient shave, shower, assist with ambulation and transfers. These tasks were documented as not done on review of patient’s Aide notes on the following days 5/23, 5/29. 6/5, 6/9, 6/12, 6/19. The aide note on 6/23 stated the tasks of shower, assist with ambulation and transfers as not completed. The aide note for 6/25 and 7/1/25 documented shave was not done.”