Uni Care Hospice Inc.

“Upon patient record review, 1 of 19 (Patient #6) 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 #6: 5/25/25 note regarding call from facility reporting hypotension of 76/39. PRN visit made shows bp 72/40. Next day, LVN noted call to facility with no answer and no follow up noted. 5/28/25 call from facility reported unable to give meds related to deep sleep. LVN made call to provide education. 5/29/25 RN visit made. BP 91/45. Per RN patient appears weak and tired, decreased energy and decreased ability to participate in activities, unable to bear weight at times. SpO2 recorded as 85% on room air. Respiratory system assessment documented - assessed no issue specified. Patient has order in place for Oxygen prn and order to notify MD SpO2<85%. Although there is previous documentation of patient’s refusal of Oxygen, there is no re-education/reoffering related to current symptoms. Not seen again by nursing until 6/5/25.”

“Upon patient record review, 2 of 19 (Patient #1, 2) 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 #1: Eliquis prescribed with no bleeding precautions identified in problems, goals, interventions. patient #2: Oxygen prescribed with no Oxygen related problems, goals, interventions including no safety precautions.”

“Upon patient record review, 2 of 19 (Patient #3, 7) 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: 9/26/25 Treatment order as needed for any new skin tears: Cleanse with wound cleanser. Pat dry. Cover with border gauze. Notify hospice. Patient #7: 5/9/25 Order to apply Bacitracin topical antibiotic ointment to open wounds daily, (without specifying wound locations). 4/24/25 order for Foley catheter, change monthly, without specifying catheter/balloon size and or circumstance for change. corrected on site”

“Upon personnel record review, 1 of 15 (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: Competency form utilized by agency for hospice aide lists shampoo only not specifically sink, tub, and bed.”

“Upon patient record review, 6 of 19 (Patient #1, 2, 3, 7, 8, 10) 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 #1: Patient on Eliquis since admission, but bleeding precautions is not marked for Hospice Aide assignment. Aspiration precautions are marked. Encourage fluids as tolerated if not contraindicated is marked. There is an order for Nectar Thickened Liquids not noted on aide assignment. Patient #2, 3, 7: Oxygen section is blank, although patient has order for prn Oxygen. Patient #8: Oxygen flow rate addressed, but not Oxygen related safety precautions. Patient #10: Colostomy care assigned every visit as needed. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable”

“Upon patient client record review, 2 of 19 (Patient #6, 7) 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 #6: Per CTI: (Patient name) is an 89 year old female with a hospice eligible dx of bladder carcinoma. She had been on hospice services but revoked upon transport to the ER following a fall. Interview with RN identifies that physician was mistaken. Patient did not revoke hospice but was discharged upon transport to ER by facility without hospice contact/authorization. Patient #7: Foley catheter changes 5/5 and 5/20/25. 5/5/25 visit: 16 Fr Foley discontinued and new one placed. 5/20/25 SN visit: A 16 Fr Foley was replaced today. Neither note included specifics of procedure including balloon size and or deflating prior to removal. Documentation was updated with details, during survey.”