Eos Hospice & Palliative Care Inc.

“Upon patient record review, 10 of 14 (Patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 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 #1-10: There was no evidence in the record of an ongoing process to monitor effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate therapy and or drug therapy currently associated with laboratory monitoring when there are medication changes. The place for documentation of this in the EMR was in the IDG meetings and was left blank on every IDG meeting.”

“Upon patient record review, 10 of 14 (Patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10) 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 #1,3,5,9: The patient has a nebulizer and suction machine with no interventions for nebulizer or suction machine on the plan of care. The patient has a comfort kit for use for symptom issues. There was no evidence of interventions or goals related to the comfort kit in the plan of care. Patient #2,7: The patient has a nebulizer and suction machine with no interventions for nebulizer or suction machine on the plan of care. The patient is taking Eliquis, there are no interventions or goals for use of anticoagulants and bleeding in the plan of care. The patient has a comfort kit for symptom issues. There was no evidence of interventions or goals related to the comfort kit in the plan of care. Patient #4: The patient has a nebulizer and suction machine with no evidence of interventions for nebulizer or suction machine on the plan of care. The patient is taking aspirin daily. There is no evidence of interventions or goals for use of anti coagulants and bleeding in the plan of care. The patient had been prescribed a comfort kit for symptom issues. There was no evidence of interventions or goals related to the comfort kit in the plan of care. Patient #6: The patient had substance abuse concerns, history of emotional illness, strained family relationships and was assessed as moderate psychosocial distress. There is no evidence of interventions or goals for these items in the POC. The patient has a nebulizer and suction machine with no interventions for nebulizer or suction machine on the plan of care. The patient had a comfort kit for symptom issues. There was no evidence of interventions or goals related to the comfort kit in the plan of care. Patient #8: The patient had a comfort kit for symptom issues. There was no evidence of interventions or goals related to the comfort kit in the plan of care. Patient #10: The patient has a nebulizer and suction machine with no interventions for nebulizer or suction machine on the plan of care. The patient is a full code with no evidence of interventions or goals for advanced directives or code status in the plan of care. The patient had a comfort kit for symptom issues with no evidence of interventions or goals”

“Upon patient record review, 2 of 14 (Patient #1,8) did not have evidence that the hospice plan of care identifies the care and services that are needed and specifically identify which provider (nursing facility or hospice) is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care. Patient #1: The wound order for a coccyx wound does not state when hospice RN will perform dressing change versus the facility staff. It does not state a reason for prn dressing changes such as for soilage. Patient #8: The wound order for a coccyx wound does not state when hospice RN will perform dressing change versus the facility staff. It does not state a reason for prn dressing changes such as for soilage.”

“Upon patient record review, 3 of 14 (Patient #1,2,3) 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: Patient 1: There is a medication order on the POC for “Diclofenac Sodium Arthritis Pain Reliever 1% topical Gel 2grams topical twice daily ordered on 2/14/25”. This order is not included on the SNF medication profile, corrected on site. The POC 4/15/25 includes an order for “Tylenol 650mg every 4 hours as needed on 10/28/24”. This order is not included on the SNF medication profile, corrected on site. The hospice POC contains a medication order ,”Ativan 2mg/ml 0.5-1mg, 0.25-0.5ml sublingual every 2 hours prn on 9/23/24”,corrected on site. Patient 2: The HSP medication profile contains Calmoseptine 1 application topically BID and prn without a frequency for the PRN or site to apply. Corrected on site. The HSP POC 4/15/25 “Ativan 2mg/ml 0.5-1mg 0.25-0.5ml sublingual every 2 hours as needed for anxiety” This medication order is not included on the SNF medication profile, corrected on site. The HSP POC 4/15/25 contains an order for “oxygen 2L/min via NC for shortness of breath/wheezing PRN” This medication order is not included on the SNF medication profile, corrected on site. Patient 3: On the SNF MAR contains orders for the following meds that were not included on the HSP medication profile: Acetaminophen Oral Tablet 325mg give 2 tablets via G-tube every 8 hours as needed ordered 2/21/25, Aspirin Oral Tablet Chewable 81mg ordered 2/21/25 ordered, Atorvastatin Calcium Oral Tablet 20mg ordered 3/15/25, Calcium Carbonate Oral Tablet ordered 2/21/25, Hydrocodone-Acetaminophen oral Tablet 5-325 on 2/21/25, Melatonin Oral Tablet 3mg ordered on 2/21/25, Multivitamin-Minerals Oral Tablet ordered on 2/21/25, Psyllium Oral Capsule ordered on 2/21/25. Corrected on site.”

“Upon patient record review, 4 of 14 (Patient #3,6,10,12) 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 3: The POC 4/16/25 contains an order for wound care being completed by facility nursing 3 times per week and to collaborate with hospice. There is no evidence the SN from hospice assessed and collaborated with the facility nurse performing the wound care or assessed the wound since 4/1/25. The patient has a G tube per Comprehensive assessment 3/15/25 there is no evidence the SN assessed the site for signs and symptoms of infection at any of the visits performed since admission. Patient 6: The SN documented in the comprehensive assessment 3/18/25, the patient is on peritoneal dialysis 3 times per week and family assists patient with this. The SN did not document any assessment of the peritoneal dialysis port or assess for signs and symptoms of infection on the following visits: 3/21/25,3/25/25,4/1/25. Patient 10: The SN documented in the comprehensive assessment on 1/16/25 that the patient had a colostomy, there was no assessment of the colostomy in any of the the SN assessments. Patient 12: Pt in SNF and on routine level of care. On 2/16/25 the FSN documented at 23:19 “Resident was noted O2 sat 85% immediately notified hospice nurse, recommended breathing treatment and Ativan”. Hospice SN documented speaking with SNF “condition improved with Duoneb and Ativan and O2 sat up to 94% and breathing is less labored”. There was no visit made by hospice nurse, the next hospice nurse visit was 2/18/25. The FSN documented on 2/18/25 “Called hospice at 10am to report change in condition temp 101.1, HR 115, resp 24, 95% 3 liters, bp 125/69 patient not eating and has labored breathing, gave Duoneb and Ativan for tachypnea. The hospice nurse made a visit at 18:31 that evening.”

“Upon patient record review, 1 of 14 (Patient #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 6: On the nursing comprehensive assessment the SN documented a risk of aspiration. There is no evidence that a risk of aspiration care plan exists with goals and interventions. Corrected on site.”

“Upon patient record review, 3 of 14 (Patient #7,#8,9) 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: Patient 7: The POC 3/13/24 Change patient to routine level of care, SN frequency 2 times per week and 5x weekly prn for change in condition. This would allow the patient to be seen daily with no order frequency change. Patient 8: The POC 9/17/24 contains an order for SN twice a week with 5 PRN weekly for change in condition. This would allow for the SN to see the patient 7 days a week, if patient needs visits 7 days per week, the SN frequency would need to be increased with an order. Patient 9: The POC 7/29/24 contains an order to place patient back on routine level of care and for SN 2 times per week and 5 prn for change in condition. This would allow the patient to be seed daily with no order frequency change. The POC 7/31/24 contains an order for SN twice a week with 5 PRN weekly for change in condition. This would allow for the SN to see the patient 7 days a week, if patient needs visits 7 days per week, the SN frequency would need to be increased with an order.”

“Upon patient record review, 4 of 14 (Patient #1,2,3,6) 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 1: On 9/23/24 the POC states “wound care per facility protocol, wound care to be performed by nursing staff at facility, to coordinate treatment with hospice”, there is no specific orders for wound care or assessment needs found on the POC. On the SNF medication profile “Ensure one can daily ordered, as tolerated on 9/24/24”, this order is not on the hospice POC, corrected on site. Patient 2: On the current POC there is an order for “Calmoseptine cream one application” There are no directions for application, dose or where to apply. Corrected on site. Patient 3: The SN documented on the comprehensive assessment patient has new G tube. There are no orders on the POC for G tube site care or flushing. Corrected on site. On the SNF POC there is an order for “Acetaminophen Oral Tablet 325mg give 2 tablets via G-tube every 8 hours as needed 2/21/25” There is no order on the hospice POC, corrected on site. On the SNF POC there is an order for “Aspirin Oral Tablet Chewable 81mg ordered 2/21/25” There is no order on the hospice POC, corrected on site. On the SNF POC there is an order for Atorvastatin Calcium Oral Tablet 20mg ordered 3/15/25” There is no order on the hospice POC, corrected on site. The SNF POC contains an order for “Calcium Carbonate Oral Tablet ordered 2/21/25” There is no order on the hospice POC, corrected on site. On the SNF POC there is an order for “Hydrocodone-Acetaminophen oral Tablet 5-325 on 2/21/25” There is no order on the hospice POC, corrected on site. On the SNF POC there is an order for “Melatonin Oral Tablet 3mg ordered on 2/21/25” There is no order on the hospice POC, corrected on site. The SNF POC contains an order for Multivitamin-Minerals Oral Tablet ordered on 2/21/25” There is no order on the hospice POC, corrected on site. The SNF POC contains an order for “Psyllium Oral Capsule ordered on 2/21/25” There is no order on the hospice POC, corrected on site. Patient 6: On the POC 3/27/25 there is an order for “stool for C-diff” there is no frequency or who is to complete this order. On POC 3/18/25 there is an order for “Gentamicin 0.1% topical ointment to prevent infection”, there is no dose or route for this medication listed on the POC. On POC 3/18/25 there is an order for Vancomycin Hydrochloride 280mg/5ml powder for solution, there is no diluent listed for this order. The SN documented in the comprehensive assessment 3/18/25 “pt is on peritoneal dialysis 3 days per week for comfort it is not related to the hospice diagnosis”. There were no orders on the POC for assessment or care of the peritoneal dialysis port. Corrected on site.”

“Upon patient record review 1 of 14 (Patient #12) did not have evidence that the IDG ensures that the care and services provided are based on all assessments of the patient and family needs. Patient 12: The medical record contains a POLST with comfort care and full code for respiratory and cardiac arrest. Upon admission, the MSW did their comprehensive assessment and documented “explained the differences with DNR and full code with family”. There was no further documentation on DNR vs full code. Pt was in GIP level of care for respiratory distress from 2/12/25-2/15/25 there was no evidence of discussion to change patient to DNR or how to care for a patient in GIP level of care for respiratory distress that is a full code. The MSW did not make visits to assist with this care need. MSW was ordered for 1 initial comprehensive assessment and 2 monthly prn for psychosocial needs. Pt back on routine level of care 2/16/25. On 2/18/25 began to again have respiratory distress the SN visited “due to respiratory distress and possible aspiration offered to transfer patient to hospital but family declined”. There was again no discussion about the full code status. The MSW was not called in to assess the situation and assist with the full code status. The patient did revoke that night and went to the hospital and passed away.”

“Upon patient record review, 9 of 14 (Patient 1,2,3,5,6,7,8,9,10) did not have evidence in the patient record that hospice aide assignments and duties are: Patient 1:The Aide plan of care 9/23/24 includes orders for the following: turn and reposition the patient, change linens, but does not include a frequency. Corrected on site. Patient 2: The Aide POC 5/3/24 includes orders to turn and reposition the patient, but does not include a frequency. Corrected on site. Patient 3: The Aide POC 3/15/25 includes orders to turn and reposition patient, empty collection bag and record bowel movements but does not contain a frequency. Corrected on site. Patient 5: The Aide POC 11/5/24 includes orders to turn and reposition patient and record bowel movements but does not contain a frequency. Corrected on site. Patient 6: The Aide POC 3/18/25 includes orders to turn and reposition patient and record bowel movements but does not contain a frequency. Corrected on site. Patient 7: The Aide POC 3/11/25 includes orders to record bowel movements and change linens but does not contain a frequency. Patient 8: The Aide POC on 9/17/25 includes orders for the following: turn and reposition patient, empty colostomy bag, change patient linens but does not contain a frequency. Patient 9: The Aide POC 7/29/25 includes orders for the following: turn and reposition, record bowel movements but does not contain a frequency. Patient 10: The Aide POC 1/16/25 includes orders for the following: turn and reposition, empty colostomy bag, record bowel movement, mechanical lift, change linens, these orders do not contain a frequency.”

“Upon patient record review 5 of 14 (Patient# 2,3,7,9,12) did not have evidence documentation in the patient record that a hospice aide provides services that are: Patient 2: The POC 4/15/25 contains an order for aide visits three times weekly. There was one aide visits made the week on 4/10/25 during the week of 4/6/25 - 4/12/25 and there was no missed visit documentation, no evidence of refusal. Patient 3: The POC 4/16/25 contains an order for aide visits two times weekly. There was one aide visits made on 4/10/25 during the week of 4/4/25 - 4/10/25, there was no missed visit documentation, no evidence of refusal . Patient 7: The POC 4/16/25 contains an order for aide visits two times weekly. There was one visit made during the week of 3/9/25 - 3/15/25 and no missed visit documentation, no evidence of refusal. Patient 9: The Aide was ordered on 7/29/24 POC for 3 times a week the aide saw 8/1/24 and 8/3/24 the week of 7/28/24-8/3/24., there was no missed visit documentation or evidence of refusal. Patient 12: The Aide was ordered on 2/12/25 for 3 times a week the aide saw 2/13/25 and 2/18/245 there was no 3rd visit made and no missed visit documented or evidence of refusal.”

“Upon patient client record review 2 of 14 (Patient #3,6) 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: On the comprehensive nursing assessment there was documentation “dysphagia with new GT” GT is not an approved abbreviations in the hospice policy for approved abbreviations. Patient 6: On the comprehensive nursing assessment there was the following documentation: “PD and MASD” on 3/18/25 by the RN. On SN visit 4/10/25 the SN documented “ the pt is AAOx2” These are not approved abbreviations in the hospice policy for approved abbreviations. On 3/27/25 POC there is a medication “Regan 5mg 1 tab 3xs daily”, upon clarification with RN, the medication was misspelled should have been Reglan. Corrected on site. The SN documented on 4/3/25, 4/8/25, 3/27/25 performing wound care by restating the MD order and it was not in past tense to indicate the wound care was completed. The skilled nurse documented on 3/27/25, 4/3/25, 4/8/25, 4/10/25, “wound care is done by hospice RN” the wound care is documented by restating the order not in past tense to indicate that the wound care was completed.”

“Upon client record review, 3 of 14 (Patient #1,2,3) did not have evidence that a written hospice plan of care is established and maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided is in accordance with this hospice plan of care. Patient 1: The POC contains an order for the SN to visit two times weekly, on the week of 3/30/25 - 4/5 there was one visit made. There was no missed visit documentation. The POC 9/23/24 states “wound care per facility protocol, wound care to be performed by nursing staff at facility, to coordinate treatment with hospice”, there is no specific orders for wound care or assessment of wound found on the POC, corrected on site. Patient 3: The SN documented on 3/29/25, 4/4/25,4/8/25,4/11/25 “Patient gastrostomy tube placement checked, feeding is tolerated, no residual noted, flushed with 50ml of water”. There is no order on the POC for checking placement or flushing of the G tube, corrected onsite.”

“Upon patient record review, 1 of 14 (Patient #12), there was no evidence there is a designated member of the IDG responsible for any patient who is a resident of the SNF/NF or ICF/IID. The designated IDG member is responsible for communicating with the a SNF/NF or ICF/IID facility’s medical director, the patient’s attending physician, and other physicians participating in the provision of care as needed to coordinate the hospice care of the patient with the medical care provided by other physicians. Patient 12: Pt under routine LOC 2/16/25-2/18/25. Pt having respiratory distress documented by FSN 2/16/25 and HSP nurse on 2/18/25. There was no evidence of any communication done with the hospice medical director other than an order to increase oxygen on the POC.”