Eternal Life Hospice, Inc.

“Upon patient record review, 2 of 16 (Patient #2, 6) 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: 12/8/25 GU problem for patient was not clearly documented in the plan of care with problems/goals/interventions for the management of the suprapubic catheter, only a reference to the policy D-120. Patient #6: Patient admitted with Eliquis prescribed. There were no problems/goals/interventions related to bleeding safety precautions, although interventions did address medication purpose as blood thinner.”

“Upon patient record review, 5 of 16 (Patient #2, 4, 6, 9, 10) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient’s plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient #2: 12/9/25 order states MSW monthly and as needed per patient/family request. There is no detailed scope and frequency. Patient #4: 11/4/25 order states SC will visit patient 1x/mo. plus PRN. 11/2/25 MSW each recert period and as needed per patient/ family request. There is no detailed scope and frequency. Patient #6: 4/5/24 order states MSW to evaluate and assess the patient family for needs initial eval for psychosocial counseling and support at the time of recertification and/or 1x/month. There is no detailed scope and frequency. Patient #9: 5/25/24 order states SC and MSW frequency is at time of recert and/or 1x/month or as requested per PCG/family. There is no detailed scope and frequency. Patient #10: 5/13/24 order states MSW and SC to evaluate and assess the patient family needs... at the time of recertification and/or 1x/month. There is no detailed scope and frequency.”

“Upon patient record review, 2 of 16 (Patient #1, 10) 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: 8/27/25 order for triple antibiotic ointment 1 layer topical every other day or prn soiled. No location for application specified. Patient #10: Admitted with Foley catheter 16 Fr. to gravity drainage. The 5/10/24 order to change full system every month using sterile technique does not include the catheter and balloon size.”

“Upon client record review, 5 of 16 (Patient #1, 2, 4, 6, 10) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1: Patient admitted 8/15/25. Ordered SC frequency at the time of recert and 1/month. SC documented 1/21/26 that patient/cg asked him to come another time. There was no follow up documentation of effort to reschedule, at the time of survey. Patient #2 : Patient admitted 12/8/25 with 16 Fr. suprapubic catheter in place. On 2/3/26 there is a note that states the patient suprapubic catheter 16 French changed during the visit with no physician order. In addition, on 1/12/26 SN note has no reference to injection given that had been ordered on 1/8/26. Upon interview, staff stated she had provided injection #4 that date but perhaps failed to make late entry in record. Patient #4: Patient on service 10/31/25-1/5/26. SC initial evaluation narrative included plan to revisit 1/month. Ordered SC frequency 11/4/25 says once a month plus prn. There was no documented visit after 11/4/25 initial and no documented evidence that December visit declined. Patient #6: Patient on service 4/2/24-6/28/24. The 4/5/24 order SC for spiritual assessment to identify spiritual needs support of patient family and PCG declined at this time. SC documented visit notes 4/16/24 and 5/28/24. IDG meeting notes continued to list SC frequency as declined through 6/24/25 IDG. Patient #10: Patient on service 5/10/24-7/25/24. 5/14/24 order for PT consult. Additional PT visits made in May and June, with subsequent 7/3/24 communication note that says services discontinued - highest functional level achieved. There were no documented orders for visits beyond eval and/or discharge of services.”

“Upon patient record review, 5 of 16 (Patient #11, 12, 13, 14, 15) 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 Patient #11, 12, 13, 14, 15: There was no documented evidence of bereavement services provided up to 13 months and no clearly documented evidence of declined bereavement services.”

“Upon personnel record review, 2 of 13 (Personnel #2,6) 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.) Upon observation, the hospice aide competency form utilized by agency only identifies shampoo competency and does not validate all 3 types. Patient #2: There was no documented competency of the hospice aide having completed suprapubic catheter care. This task was listed on the hospice aide assignment. Personnel #6: The hospice aide competency does not verify all 3 types of shampoo, but generally lists shampoo only.”

“Upon patient record review, 4 of 16 (Patient #1, 2, 5, 7) 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, 2, 5: Hospice Aide assignment includes oxygen flow rate, but no oxygen related safety precautions Patient #7: Hospice Aide assignment includes oxygen flow rate, but no Oxygen related safety precautions. No bleeding precautions for patient with Eliquis prescribed.”

“Upon patient record review 1 of 16 (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: Hospice Aide assignment included suprapubic care every visit. However, the task was not checked as completed Feb. 1, 4, 8, 11, 2026. (There was no documented evidence of Hospice Aide competency).”

“Upon patient client record review, 3 of 16 (Patient #2, 10, 11) 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 #2: 1/8/26 order for Ceftriaxone 2 mg IM x 5 days. SN Visit Note late evening 1/8/26 states “Ceftriaxone 2 mg IM x 5 days for UTI.” but not clear if injection provided. Note largely incomplete. 1/8/26 Upon interview with staff, agency states medication had not been delivered and nurse was unable to administer and nurse failed to document. Admin clarified that injections did not start until 1/9/26. 1/9/26 SN note, SN documented injection, but no documentation related to procedure/site. 1/10/26 SN Note says Ceftriaxone Injection #2 with no details of procedure/site. 1/11/26 SN note says SN administered Rocephin 2G IM on the left glute. Patient tolerated well...1/12/26 SN note has no reference to injection. Upon interview, staff provides text message where nurse noted she had provided injection #4 that date but perhaps failed to make late entry in record. 1/13/26 SN note documented injection provided, but site not included. In addition, on 1/12/26 the nurse visit note stated that the suprapubic catheter 16 Fr was changed on 1/1/26 but did not state who completed the task. Patient #10: Visit note 5/24/24 stated “Foley 16 Fr in place draining clear yellow urine into drainage bag hanging below the level of the bladder and off of the floor. Foley catheter was changed on 5/24/24”. No details of catheter change. 6/5/24 note stated “patient with Foley catheter 16 Fr which I exchanged today due to foley leakage. Using clean technique old foley removed by deflating 10 ml saline balloon. Tip of catheter observed intact upon removal without cause for concern. New 16 Fr Foley catheter inserted without complication using sterile technique and secured with leg strap”. No reference to balloon inflated. 6/12/24 the SN note stated “Foley 16 Fr changed and placed using sterile technique. Noted to be in place draining clear yellow urine into drainage bag hanging below the level of the bladder off of the floor”. No details to the catheter procedure performed. Patient #11: Patient transferred into this agency first benefit period.... CTI narrative inadvertently says transferred to Eternity Hospice rather than Eternal Life Hospice.”