Lenity Hospice LLC

“Upon personnel record review, 2 of 15 (Personnel #4, 12 ) did not have evidence Emergency Preparedness training including: • Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles • Demonstrate staff knowledge of emergency procedures • Provide emergency preparedness training at least annually • Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others • Maintain documentation of all emergency preparedness training Personnel #4, 12: Upon review, there is no evidence of Emergency Preparedness training.”

“Upon patient record review, 4 of 14 (Patient #2, 3, 6, 8) 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 #2: Patient admitted with existing pacemaker per CTI and diagnosis of existing pacemaker, but no related problems, goals, interventions. Patient #3: Patient admitted with diagnosis of epilepsy. History of hospitalization for altered mental status and seizures. (per CTI), but no related problems, goals, interventions. Neuro problem listed, but does not address seizures. Patient has diagnosis of existing pacemaker, but no related problems, goals, interventions. Patient #6: Patient has Eliquis prescribed with no related problems, goals, interventions for bleeding precautions Patient #8: Patient admitted with diagnosis of epilepsy and Keppra prescribed 11/3/25. The F2F 3/20/26 NP documents patient has 1-2 seizures per week. There were no related problems, goals, interventions related to seizure precautions until 3/27/26. Patient on Oxygen 3 LPM continuous with dyspnea and flow rate addressed, but no problems, goals, interventions specific to related to oxygen safety precautions.”

“Upon client record review, 4 of 14 (Patient #1, 3, 4, 9) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1: Volunteer 2/month per initial and ongoing POC. No documented visits. Vol frequency remains the same 2/month and 1 /prn 4/1/26 IDG. Patient #3: 12/12/25 order for 16fr 8 cc balloon.... may change every 4 weeks and prn... and irrigate... 12/28/25 visit related to discomfort. Catheter changed. SN documented inserted 16 Fr 10 cc. No evidence order updated from 8 to 10 cc balloon at that time. Patient #4: 3/20/26 order to insert 16 Fr/5cc catheter.... may change every 4 weeks... No documented evidence catheter was inserted. GU consult suggests existing 18fr. No balloon size specified and no documentation of last change. Interview with staff confirm catheter was existing upon admission and not inserted 3/20/26. Patient #9: SC 1/month. No visit Jan 2026. No communication note of decline.”

“Upon patient record review, 2 of 14 (Patient #13, 14) did not have evidence the hospice offers bereavement counseling that includes: • Making bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. Bereavement counseling also extends to residents of a SNF/NF or ICF/IID when appropriate and identified in the bereavement plan of care • Ensuring that bereavement services reflect the needs of the bereaved • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery Patients #13, 14: There is no documented evidence of post death bereavement assessment and update. Subsequently, no update to plan of care/bereavement care plan. Bereavement services were provided in form of mailings, but no documented evidence individualized to meet the needs of bereaved.”

“Upon personnel record review, 1 of 15 (Personnel #8) 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.) ·(A) Bed bath ·(B) Sponge, tub, and shower bath ·(C) Shampoo, sink, tub, and bed; Personnel #8: Upon personnel review, there is no documented evidence of competency for sponge, tub bath, only shower and bed bath. The shampoo is listed only as general and does not specify competency for all types of sink, tub and bed.”

“Upon patient record review, 5 of 14 (Patient #2, 3, 4, 6, 8) 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: The 3/5/26 Hospice Aide assignment/care plan includes Oxygen flow rate prescribed, but does not include related safety precautions. Patient #3: Patient has Epilepsy diagnosis with no seizure precautions included in hospice aide care plan. Patient has Oxygen prescribed with no flow rate or related safety precautions include in hospice aide care plan.. Patient #4: Patient has oxygen 2 LPM continuously per order and per RN assessment. The 3/20/26 Hospice aide care plan includes flow rate as prn and no Oxygen related safety precautions. Patient has Foley catheter, but the hospice aide care plan has no reference to alert hospice aide and/or no reference to catheter care. Patient #6: Patient has Eliquis prescribed with no bleeding precautions included in the hospice aide care plan. Patient #8: Patient has Epilepsy diagnosis with Keppra prescribed with no seizure precautions in hospice aide care plan. Oxygen flow rates says 3lpm prn, but order is for continuous.”

“Upon patient client record review, 1 of 14 (Patient #3) 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 #3: 12/12/25 order for 16fr 8 cc balloon.... may change every 4 weeks and prn... and irrigate... 12/28/25 visit related to discomfort. Catheter changed. Documentation does not specify amount deflated from balloon when removed. On 2/18/26, 3/2/26, and 3/23/26, the SN visit note states catheter changed today related to discomfort. No specifics of procedure for removal or insertion of new catheter. Does not specify balloon deflation with removal and/or catheter/balloon size inserted to demonstrate compliance.”