Eclipse Hospice Care, Inc.

“Upon patient record review, 2 of 8 (Patient # 6,7) 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 6: The 6 month bereavement letter was not sent as outlined in the bereavement plan of care. Corrected on site. Patient 7: The 10 month bereavement letter was not sent as outlined in the bereavement plan of care. There is evidence of a returned letter dated 1-24-25 with no forwarding address. Corrected on site for 10 month letter, after agency contacted the bereaved.”

“Upon patient record review, 6 of 14 (Patients #2,3,5,6,7,10) 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: This patient has the following on medication profile-Acetaminophen 325 mg i tab Q 6 hours, Acetaminophen Suppository 650mg Q 6 hours and Norco 10/325 mg Q6 hours. The record did not indicate NTE 3000 mg of Acetaminophen in 24 hours. Corrected on site-special instructions added. Patient #3: This patient had Lantus 25 units Q morning, Humalog Kwik Pen 100units/ml per sliding scale and Polyethylene Glycol (Miralax)17 gm that were not on medication list. Additionally, Bepreve eye drops, ASA, and Alendronate were not in the home and listed on medication profile. Patient #5: Polyethylene Glycol (Miralax) order with no diluent Ordered on 4/4/25, Corrected on Site-med profile updated. Patient #6: This patient had Norco 10/325 mg Q 4 hours PRN, Acetaminophen 325 mg 2 tabs Q 4 hours. The record did not indicate NTE 3000 mg of Acetaminophen in 24 hours. ***Corrected on site-special instructions added. Patient #7: This patient had Norco 10/325 mg Q 4 hours PRN, Acetaminophen 325 mg 1 tab Q 4 hours. The record did not indicate NTE 3000 mg of Acetaminophen in 24 hours. Corrected on site-special instructions added. Patient #10: This patient has the following on medication profile-Acetaminophen 325 mg 2 tabs Q 6 hours, Acetaminophen Suppository 650mg Q 4 hours and Norco 5/325 mg Q 4 hours. The record did not indicate NTE 3000 mg of Acetaminophen in 24 hours. Corrected on site-special instructions added.”

“Upon patient record review, 2 of 14 (Patient #3, #7) 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 #3: This record indicated this patient is a diabetic and is taking oral anti-diabetic medication Jardiance 25mg and has Humolog and Lantus in the home. There was no evidence of problems, goals, or interventions related to the Endocrine system. Corrected on site Care plan updated. Patient #7: This record indicated this patient is a diabetic and is taking oral anti-diabetic medication metformin 1000mg BID and uses Diabetic Tussin 10mL. There was no evidence of problems, goals, or interventions related to the Endocrine system. Corrected on site Care plan updated.”

“Upon patient record review, 5 of 14 (Patients #2,#5, #6, #7, #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 #2: This patient has the following on Plan of Care-Acetaminophen 325 mg 1 tab Q 6 hours, Acetaminophen Suppository 650mg Q 6 hours and Norco 10/325 mg Q6 hours. The record did not indicate NTE 3000 mg of Acetaminophen in 24 hours. Corrected on site-special instructions added to supplemental order. Patient #5: Polyethylene Glycol (Miralax) order with no diluent Ordered on 4/4/25, Corrected on Site-med profile updated. Patient #6: This patient had Norco 10/325 mg Q 4 hours PRN, Acetaminophen 325 mg 2 tabs Q 4 hours. The record did not indicate NTE 3000 mg of Acetaminophen in 24 hours. Corrected on site-special instructions added. Patient #7: This patient had Norco 10/325 mg Q 4 hours PRN, Acetaminophen 325 mg 1 tab Q 4 hours. The record did not indicate NTE 3000 mg of Acetaminophen in 24 hours. Corrected on site-special instructions added. Patient #10: This patient has the following on medication profile-Acetaminophen 325 mg 2 tabs Q 6 hours, Acetaminophen Suppository 650mg Q 4 hours and Norco 5/325 mg Q 4 hours. The record did not indicate NTE 3000 mg of Acetaminophen in 24 hours. Corrected on site-special instructions added.”

“Upon patient record review, 3 of 14 (Patients #1,2,3) 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: This patient had a bedside commode. This item was not included on the Plan of Care. The Plan of Care indicated this patient had a over the bed table. This item was not in the home. Patient #2: The Plan of care indicated this patient had hospital bed, over the bed table, LAL mattress, nebulizer machine and suction machine. These items were not in the home. Patient #3: The Plan of care indicated this patient had bedside table, LAL mattress, nebulizer machine and shower chair. These items were not in the home.”

“Upon patient record review, 6 of 14 (Patients #9,10,11,12,13,14) 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. • 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 #9: The 3 month and 6 month bereavement letters were not sent per record as outlined in the bereavement plan of care. Patients #10,11,12,13,14: These patients did not have bereavement plan of care in their record to date.”

“Upon patient client record review, 8 of 14 (Patients #1,2,3,4,6,7,8,11,) 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 #1: The following SN visits did not have employee signature in space provided on the electronic record for 5/7/25, 5/14/25 and 8/5/25 (recert). Patient #2: The following RN weekly visits did not have employee signature in space provided on the electronic record from 6/28/25 through 7/29/25. Patient #3: The following RN weekly visits did not have employee signature in space provided on the electronic record from 6/24/25 through 8/8/25. Patient #4: The following SN visit did not have employee signature in space provided on the electronic record on 10/20/24. Patient #6: The following RN weekly visits did not have employee signature in space provided on the electronic record from 1/15/25 through 5/14/25. Patient #7: The following RN weekly visits did not have employee signature in space provided on the electronic record from 4/5/25 through 5/5/25. Patient #8: The following RN weekly visits did not have employee signature in space provided on the electronic record from 12/30/24 through 2/22/25. Patient #11: The following RN weekly visits did not have employee signature in space provided on the electronic record from 2/26/25 through 3/5/25.”

“Upon client record review, 5 of 14 (Patients #4,5,6,7,8) did not have evidence that the discharge summary includes all required information. as follows: Patients #4,7: The Discharge Summary did not have all CMS required elements as follows: • The patient’s current plan of care • The patient’s latest physician orders • A summary of the patient’s stay, including treatments, symptoms and pain management Patient #5,6: The Discharge Summary did not have all CMS required elements as follows: • The patient’s current plan of care Patient #8: The Discharge Summary did not have all CMS required elements as follows: • The patient’s current plan of care • The patient’s latest physician orders”