Fellowship Hospice Services Inc.

“Upon patient record review, 6 of 14 (Patient #2,5,6,7,11,12) 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. 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 #2 orders written on 8/23/24 for A&D Ointment and Calmoseptine do not indicate place of application on medication profile. Patient #5 orders written on 10/14/24 for A&D Ointment and Calmoseptine do not indicate place of application on medication profile. Patient #6 Oxygen was noted by SN on 1/8/24, however no evidence of oxygen on medication profile. Patient #7 orders written on 2/26/24 for Hydrocortisone cream do not indicate place of application and orders written on 5/28/24 for Levaquin for 7 days does not indicate a stop date on medication profile. Patient #11 orders written on 9/14/24 for A&D Ointment does not indicate place of application on medication profile. Patient #12 orders written on 9/15/24 for Voltaren Gel does not indicate place of application on medication profile.”

“Upon patient record review, 1 of 14 (Patient #3) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual’s attending physician, if any) • Changes that have taken place since the initial assessment • Information on the patient’s progress toward desired outcomes • Reassessment of the patient’s response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days Patient #3 Comprehensive assessment not updated every 15 days as it was completed on 4/16/24 and was not updated on 4/30/24”

“Upon patient record review, 6 of 14 (Patient #2,5,6,7,11,12) 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 #2 plan of care orders written on 8/23/24 for A&D Ointment and Calmoseptine do not indicate place of application. Patient #5 plan of care orders written on 10/14/24 for A&D Ointment and Calmoseptine do not indicate place of application. Patient #6 oxygen was noted by SN on 1/8/24, however no evidence of oxygen on the plan of care. Patient #7 plan of care orders written on 2/26/24 for Hydrocortisone cream do not indicate place of application. Patient #11 plan of care orders written on 9/14/24 for A&D Ointment does not indicate place of application. Patient #12 plan of care orders written on 9/15/24 for Voltaren Gel does not indicate place of application.”

“Upon patient record review, 8 of 14 (Patient #1,2,5,6,7,9,12,14) 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 #1, Walker ordered on admit, but no orders on the plan of care Patient #2 Oxygen, wheelchair and hospital bed ordered on admit, no orders on the plan of care Patient #5 Shower chair, walker and wheelchair ordered on admit, no orders on the plan of care Patient #6 Oxygen, walker and wheelchair ordered on admission , no orders on the plan of care Patient #7 Walker and wheelchair ordered on admit, no orders on the plan of care Patient #9 Walker and wheelchair ordered on admit, no orders on the plan of care Patient #12 Walker and wheelchair ordered on admit, no orders on the plan of care Patient #14 Oxygen, hospital bed ordered on admit, no orders on the plan of care”

“Upon patient record review, 6 of 14 (Patient #2,5,6,7,10,14) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #2 Upon review orders written 8/23/24 for LVN frequency are 2x/week, no visits made the week of 8/23/24 and only 1 visit made the week of 8/25/24. Orders written on 8/23/24 for RN visit frequency are 2x/month and the only visit made that month was on 8/23/24. Orders written on 8/23/24 for Chaplain visit frequency is for 1x eval, no evidence of visit completed. Patient #5 Orders written on 10/14/24 for MSW eval, no evidence of visit completed. In addition, PT visits were completed on 10/18/24, 10/23/24 and 10/29/24 however no orders in place for PT. Patient #6 Orders written on 1/23/24 for LVN visit frequency for 2x/week, however only 1 LVN visit per week completed. Patient #7 Orders written 9/30/23 for MSW eval to be completed, no evidence of visit completed. Patient #10 SN documents foley catheter in place during SN visits on 10/14/24, 10/21/24 and 10/28/24 however there are no orders for foley catheter. Patient #14 SN note on 7/16/24 and 7/23 state patient with wound to coccyx and “Wound care completed as ordered”, however no wound care order present.”

“Upon patient record review 8 of 14 (Patient #2,5,6,7,9,10,11,14) 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 Orders dated 8/23/24 for aide visits 3x/week, visits made 2x/week on 8/26/24 and 8/28/24 that do not meet visit frequency. Patient #5 Orders dated 10/14/24 for aide visits 1 every 2 weeks. Visits made on 10/16/24 and 10/23/24 that do not meet visit frequency. Patient #6 Orders written on 1/8/24 for Aide visit frequency is 3x/week, no evidence of Aide visits completed. Patient #7 Orders dated 9/30/23 for aide visits 3x/week. Visits made 10/28/24, 10/30/24, 11/3/24 and 11/5/24 that do not meet visit frequency. Patient #9 Orders written on 10/4/24 for Aide visit frequency of 1x/week, no evidence of Aide visits completed. Patient #10 Orders written on 9/18/24 for Aide visit frequency of 3x/week, no evidence of Aide visits completed. Patient #11 Orders dated 9/14/24 for aide visits 2x/week. No visits made week of 9/15/24, visit made 9/27/24 and no visits made week of 11/1/24. Patient #14 Orders dated 7/20/24 for aide visits 3x/week, visits made only 2x/week for benefit periods 1 and 2 that do not meet visit frequency.”

“Upon patient record review 2 of 14 (Patient #11,14) 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 #11 Aide supervisory visits last completed on 9/30/24 by RN due 10/14/24 and 10/28/24 were not completed. Patient #14 Aide supervisory visits last completed on 09/20/24 by RN due 10/6/24 and 10/20/24 were not completed.”

“Upon observation, there was no evidence the hospice documented the cost savings achieved through the use of volunteers. Documentation must include the following: • The identification of each position that is occupied by a volunteer • The work time spent by volunteers occupying those positions • Estimates of the dollar costs that the hospice would have incurred if paid employees occupied the positions identified in paragraph (d)(1) of CFR 418.78 for the amount of time specified in paragraph (d)(2) of CFR 418.78 There was no cost savings report for the agency.”