Zirra Hospice Care, Inc.

“Upon patient record review, 1 of 14 (Patient #11) did not have evidence that the patient has received effective pain management and symptom control from the hospice for conditions related to the terminal illness. Patient #11: Patient was admitted on 04/19/25 with a diagnosis of Prostate Cancer. On admission, patient stated his self identified threshold for pain was a level 2. He complained of pain at a level 7. The admit nurse documented he would follow the medications from admission. No follow up visit or phone call for 4 days. Nursing visit on 04/23/25, patient complained of pain level of 5 and the nurse documented increased respirations and heart rate. The nurse documented that they would continue to monitor. No call to MD no change in plan. No follow up visit or phone call for 5 days. On nursing visit 4/28 the RN completed a supervisory visit and pain was described as level 4, with no change to plan of care. The last nurse contact was 04/29/25, and then patient revoked services for aggressive treatment on 05/08/25.”

“Upon patient record review, 3 of 14 (Patient #6, 7, 8) 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 #6: Medication profile has order written for Haldol 1mg/0.5ml the directions stated to inject 5ml IM q 4 hours as needed. Order was supposed to say inject 0.5ml IM q 4 hours as needed. Patient #7: The medication profile has Bentyl 10mg ordered as needed for IBS. There is also Dicyclomine 10mg ordered as needed for IBS. Bentyl and Dicyclomine are the same medication, duplicative medication. Patient #8: The patient is diabetic, taking Metformin. There is an entry on the medication profile for Glucagon injection to be given daily. Glucagon is indicated for an emergency injection for hypoglycemic crisis and not a daily medication.”

“Upon patient record review, 2 of 14 (Patient #5,6) 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 #5: The LVN is ordered for weekly visits. The RN is ordered to visit q 14 days. The LVN is only visiting q 14 days. Patient #6: The RN is ordered to see the patient every 14 days. There has been no documented RN visit since 05/19/25.”

“Upon patient record review, 3 of 14 (Patient #2, 6, 11) 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 #2: The patient record indicates that Medi honey and gauze was ordered for the patient on 05/23/25. There is no nursing documentation in any visits or in communication notes of why this was ordered. There are no wound assessments that show a wound requiring Medi honey. Patient #6: Patient admitted 04/24/25. There was documentation of a “pressure ulcer on coccyx”. There is no further assessment of the stage of wound, measurements, if there is exudate, odor, signs or symptoms of infection, tunneling or maceration of the wound on any further nurse visits. Patient #11: Patient was admitted on 04/19/25 with a diagnosis of Prostate Cancer. On admission, patient stated his self identified threshold for pain was a level 2. He complained of a pain of level 7. The admit nurse did not address pain and documented for patient to follow current medications. No follow up visit or phone call for 4 days. Nursing visit on 04/23/25, patient complained of pain level of 5 and the nurse documented increased respirations and heart rate. The nurse documented that they would continue to monitor. No call to MD and no change in plan of care. No follow up visit or phone call for 5 days. Nursing visit on 4/28 by RN for supervisory visit. Pain described as level 4, no change to plan of care. The last nurse contact was 04/29/25. There was no evidence that the RN performed continuous assessment and follow-up of the patient’s needs.”

“Upon patient record review, 3 of 14 (Patients #1, 2, 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 #1: The patient is admitted to Hospice with a primary diagnosis of cancer of the pancreatic duct. There is no evidence in the record of interventions or goals related to cancer diagnosis. The patient complains of frequent nausea. There are no interventions or goals related to nausea on the POC. Patient #2: The patient was reportedly ordered to have Medi honey and gauze added however, there are no interventions or goals related to this on the POC. In addition, during a visit to this patient, they were noted to have what appeared to be severe circulation concerns on his Left foot AEB extremely black toes. There was no documentation or interventions or goals regarding this. Patient #7: The patient is ambulatory with a cane and currently needs no assistance, however, the plan of care includes interventions for teaching on a turning schedule to prevent skin breakdown. The patient was reportedly ordered to have a foley catheter insertion on 04/25/25, though there are no interventions or goals for foley catheter or for the care of the catheter.”

“Upon patient record review, 1 of 14 (Patient #2) 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: The frequency orders include the order that stated visits could be completed using telehealth. Telehealth is not an acceptable means of visit frequency. Telehealth may not take the place of in person aide visits.”

“Upon patient record review, 2 of 14 (Patient #2, 6) 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: There is an order for Medi honey and Gauze on 05/23/25. The order does not include the type of wound, location, frequency, or who will change it. Patient #6: The patient record includes an order for “Antibiotic apply to affected area (buttock) once daily for wound care”. There is no evidence of a full wound care order that included exact location with type of wound, cleansing directions, and when the nurse would do the dressing changes on which visits each week.”

“Upon patient record review, 7 of 14 (Patient #1,3,5,6,7,8,9) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1: The patient is ordered to have SC and MSW visits monthly. There was no evidence of a visit in May. Patient #3: This patient was admitted 06/02/25. The agency has 5 days to develop the comprehensive assessment, however, the LVN saw the patient on 06/03/25 and 06/05/25. There are no physician orders for any visits after initial assessment. Patient #5: The patient is ordered to have SC and MSW visits monthly. There was no evidence of a visit in May. The LVN is ordered for weekly visits. The RN is ordered to visit q 14 days. The LVN is only visiting q 14 days. Patient #6: The patient is ordered to have SC visits monthly. There was no evidence of a visit in May. The RN is ordered to see the patient every 14 days. There has been no documented RN visit since 05/19/25. Patient #7: The patient is ordered to have SC and MSW visits monthly. There was no evidence of a visit in May. In addition, on 04/25/25, there is a physician order for insertion of a foley catheter (18fr/10cc). Order reads to change monthly and as needed for leaking. States the insertion was 04/25/25 in the order. There is no evidence of a nursing visit being completed on 04/25/25. There is no evidence in the record that this was documented in a communication note, visit, IDG, or added onto the POC. All subsequent nursing visits state under GU system that patient is continent. Patient #8: The patient is ordered to have SC and MSW visits monthly. There was no evidence of a visit in May. The LVN is ordered to see the patient weekly. There is no evidence of LVN visits from 04/23/25 until 06/03/25. Patient #9: The patient is ordered to have SC visits monthly. There was no evidence of a visit in April or May.”

“Upon personnel record review, 1 of 12 (Personnel #10) 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 #10: The personnel record did not have proof that the following were performed with a patient or pseudo patient: Tub bath, shower, use of bedpan, transfers from chair to stand, and use of a cane. The record listed that the method of orientation was verbal.”

“Upon patient record review, 2 of 14 (Patients #2, 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 #2,7: The aide assignment includes mechanical lift. The patient does not have a mechanical lift. The patient has oxygen. Oxygen precautions are not marked on aide assignment. The aide assignment orders for aide to “assist patient with oral medications” this is outside the aide scope of practice.”

“Upon patient record review 1 of 14 (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: The aide visited patient 05/17/25. The following tasks on the aide assignment were not marked completed: Patient non ambulatory, stool incontinence care, brush teeth, aspiration precautions, ROM, mental status, assist with feeding. In addition, on admission, the aide visits were ordered for twice weekly. The first aide visit was not for 19 days.”