Haven Hospice

“It is required that the hospice Interdisciplinary Group, in consultation with the individual’s attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review and interview. In 2 of 42 (5%) clinical records reviewed, the agency did not ensure that the comprehensive assessment was completed within 5 days after the election of hospice. CLINICAL RECORD 1: The patient elected hospice care on 05/01/2026. The patient resided in a private home. The spiritual assessment was completed by the Chaplain (SC) on 05/08/2026 (7 days outstanding) and the Social Worker completed the psychosocial assessment on 05/07/2026 (6 days outstanding). A review of the clinical record revealed no evidence of missed visit notes or care coordination notes to explain the delay in the spiritual or psychosocial assessments. Clinical record 37: The patient elected hospice care on 02/17/2026. The patient resided in a private home. The Social Worker completed the psychosocial assessment on 02/23/2026 (6 days outstanding). A review of the clinical record revealed no evidence of missed visit notes or care coordination notes to explain the delay in the psychosocial assessment.”

“It is required that the documented comprehensive assessment includes a drug profile that contains the patient’s current: prescription and over-the-counter (OTC) drugs; supplements; herbal remedies; [and} other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following: the effectiveness of drug therapy; drug side effects; actual or potential drug interactions; duplicate drug therapy; [and] drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and, as appropriate, preventive measures are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by clinical record review and interview. In 2 of 42 (5%) clinical records reviewed, the agency did not ensure that the comprehensive assessment included a drug profile that contained the patient’s current medications. CLINICAL RECORD 10: The patient elected hospice care on 05/01/2026 with a diagnosis of malignant neoplasm of the left upper lobe. The Skilled Nurse (SN) assessment documented that the patient was utilizing oxygen per nasal cannula at 3 Liters per minute (L/min). The hospice medication profile did not include documentation of oxygen. CLINICAL RECORD 34: The patient elected hospice care on 02/20/2026 with a diagnosis of cerebral infarction. The SN recertification assessment was dated 03/24/2024. The plan of care physician orders created on 04/01/2026 for the certification period, ordered Sertraline 100mg PO daily under interventions and ondansetron 4 mg PO Q 6 hours as needed (PRN) for nausea and vomiting (N/V). Sertraline and ondansetron were not documented on the hospice medication profile between the order date of 04/01/2026 and the clinical record review date of 05/13/2026. The Executive Director stated in an interview on 05/13/2026, “ You are right, we have identified that as an issue.””

“It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. In 5 of 42 (12%) clinical records reviewed, the agency did not ensure that each plan of care included treatments to meet the patient’s needs. CLINICAL RECORD 8: The patient elected hospice on 04/17/2026 with a diagnosis of hydrocephalus and a stage 4 pressure ulcer on the sacrum. The patient had previously suffered a fall and broken femur and had a stage 4 decubitus ulcer on the sacrum, according to the nursing assessment completed on 04/17/2026. The patient resided in an assisted living facility (ALF) where the patient received wound care from the facility and his wife. The plan of care did not include interventions to address wound care for the stage 4 decubitus ulcer. Wound care orders were obtained on 04/20/2026. CLINICAL RECORD 10: The patient elected hospice care on 03/20/2026 with a diagnosis of malignant neoplasm of the left upper lobe lung with secondary malignancies of the brain, bone, and adrenal gland. The plan of care documented secondary diagnoses of nicotine dependence and dependence on supplemental oxygen. The Skilled Nursing (SN) visit notes dated 03/23/2026, 04/02/2026, 04/10/2026, and 05/01/2026 documented that the patient was using oxygen at 2-4 L continuous flow. The plan of care documented, “Assess liter flow and effectiveness of O2 treatment, educate family about oxygen safety.” The plan of care did not document orders for oxygen administration, including the flow rate, frequency of use, duration, or route. CLINICAL RECORD 14: The patient elected hospice care on 05/01/2026 with a diagnosis of esophageal cancer. The SN assessment on 05/01/2026 documented that the patient had a gastrostomy tube (G-tube) and was receiving oxygen at 3 L via nasal cannula. The plan of care dated 05/01/2026, “Assess liter flow and effectiveness of O2 treatment, educate family about oxygen safety.” The plan of care did not document orders for the care and maintenance of the G-tube or for oxygen administration, including the flow rate, frequency of use, duration, or route. Clinical record 16: The patient elected hospice on 03/28/2026. The skilled nursing assessment was completed on 03/28/2026, documenting bilateral lower extremity wounds. The plan of care dated 03/28/2026 included goals to monitor for drainage and signs and symptoms of infection from the wound but did not document orders for wound care. Orders for wound care were obtained on 04/07/2026. CLINICAL RECORD 34: The patient elected hospice care on 02/20/2026 with a diagnosis of cerebral infarction. The SN recertification assessment was dated 03/24/2024, documenting that the patient had a skin tear on the right forearm, a wound on the right distal thigh, and a pressure ulcer on the coccyx. The recertification plan of care dated 04/13/2026 ordered, “Dress wounds as ordered and promote nutrition for healing.” The recertification plan of care dated 04/13/2026 did not include wound care orders for the skin tear or pressure wound. The Executive Director/Registered Nurse confirmed the findings after record review and interview on 05/14/2026.”

“It is required that each patient’s individualized written plan of care: identifies planned interventions based on problems identified in the initial and updated comprehensive assessments; includes all services necessary for the palliation and management of the terminal illness, including the following: medical supplies and appliances necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. In 3 of 42 (7%) clinical records reviewed, the agency did not ensure that all medical supplies and appliances necessary to care were included on the individualized plans of care. CLINICAL RECORD 9: The patient elected hospice care on 04/08/2026 with a diagnosis of acute myeloblastic leukemia. The Skilled Nurse (SN) initial comprehensive assessment dated 04/08/2026 documented that the patient utilized oxygen therapy (as needed) PRN. The plan of care medical supplies did not document “None” and did not include documentation of oxygen supplies. CLINICAL RECORD 14: The patient elected hospice care on 05/01/2026 with a diagnosis of malignant neoplasm of the esophagus. The SN’s initial comprehensive assessment dated 05/01/2026 documented that the patient was receiving oxygen at 3 liters via nasal cannula (N/C) and had a gastrostomy tube (G-tube). The plan of care dated 05/01/2026 did not include documentation of medical supplies, including oxygen or G-tube supplies. Clinical record 16: The patient elected hospice care on 03/28/2026 with a diagnosis of hypertensive heart disease. The SN’s initial comprehensive assessment dated 03/28/2026 documented bilateral lower-extremity wounds. The plan of care dated 03/28/2026 read “NONE” for Durable Medical Equipment (DME) and supplies and did not document wound care supplies. The Executive Director/Registered Nurse confirmed the findings after the record review and an interview on 05/14/2026.”

“It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 3 of 17 (18%) clinical records reviewed of patients receiving Hospice Aide (HA) services, the agency did not ensure that the Hospice Aide received written patient care instructions to meet the patient’s needs. CLINICAL RECORD 1: The patient elected hospice care on 05/01/2026 with diagnoses of malignant neoplasms of the brain and a recent fall resulting in a thoracic fracture. The initial nursing assessment documented that the patient was bedbound, had skin tears on their arm that were dressed by the family, and a dime-sized open area on their scalp exposing a metal plate. The HA care plan developed on 05/01/2026 assigned the HA the task: Bathing-(Tub/Shower). The care plan did not specify the type of bath to be provided and did not include instructions related to the arm bandage or the scalp wound during bathing should the dressings become wet, soiled, or dislodged. CLINICAL RECORD 8: The patient elected hospice care on 04/17/2026 with diagnoses of hydrocephalus and a pressure ulcer stage 4 on the sacrum. The patient resided in an assisted living facility (ALF). Wound care orders for the pressure ulcer stage 4 on the sacrum were received on 4/20/2026. The plan of care ordered HA services effective 04/20/2026. The HA care plan dated 04/21/2026 assigned the HA the tasks: bed bath, shampoo, hair care, skin care, change linens, and safety check. The HA care plan did not provide the HA with instructions on how to manage the sacral wound dressing if it became soiled, wet, or dislodged during personal care. CLINICAL RECORD 10: The patient elected hospice care on 03/20/2026 with a diagnosis of malignant neoplasm of the left upper lobe. On 03/24/2026, HA services were ordered twice a week, and the HA care plan was developed. The HA care plan assigned the HA the task: bathing (Tub/Shower). The care plan did not provide the HA with clear instructions on the type of bath to be provided. During the interview and after review of care plans on 05/12/2026, the Executive Director stated, “We have identified the problem with aide care plans and have done a performance improvement project and education. It appears we still have work to do.””

“It is required that a hospice aide provides services, included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 2 of 17 (12%) clinical records reviewed of patients who received Hospice Aide (HA) services, the agency did not ensure that the Hospice Aide provided services included in the plan of care. CLINICAL RECORD 1: The patient elected hospice care on 05/01/2026 with diagnoses of malignant neoplasms of the brain and a recent fall resulting in a thoracic fracture. The HA care plan developed on 05/01/2026 assigned the HA the task: Bathing-(Tub/Shower). The HA visit note dated 05/06/2026 documented that the HA provided a bed bath during the visit. CLINICAL RECORD 8: The patient elected hospice care on 04/17/2026 with diagnoses of hydrocephalus and a pressure ulcer stage 4 on the sacrum. The patient resided in an assisted living facility (ALF). The HA care plan created on 04/21/2026 assigned the HA the tasks: Bed bath, shampoo, hair care, skin care, change linens, and safety check. The HA visit note dated 05/11/2026, documented, “Shampoo- Completed - No (N) Note: Will wash patient hair and shave him every Wednesday.” On 05/13/2026, the Executive Director stated in an interview, “We have identified that as a problem and have been working on it.””

“It is required that Hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. This standard was not met as evidenced by clinical record review and interview. In 3 of 17 (18%) clinical records reviewed of patients who received Hospice Aide (HA) services, the agency did not ensure that the Hospice Aide reported changes in the patient’s needs to a Registered Nurse (RN) when the changes related to the plan of care. CLINICAL RECORD 1: The patient elected hospice care on 05/01/2026 with diagnoses of malignant neoplasms of the brain and a recent fall resulting in a thoracic fracture. The HA care plan developed on 05/01/2026 assigned the HA the task: Bathing-(Tub/Shower). The HA visit note dated 05/06/2026 documented that the HA provided a bed bath during the visit. A review of the clinical record revealed no evidence of the HA reporting the change in the care plan to the Registered Nurse (RN). No updates were made to the HA care plan. CLINICAL RECORD 8: The patient elected hospice care on 04/17/2026 with diagnoses of hydrocephalus and a pressure ulcer stage 4 on the sacrum. The patient resided in an assisted living facility (ALF). The HA care plan created on 04/21/2026 assigned the HA the tasks: Bed bath, shampoo, hair care, skin care, change linens, and safety check. The HA visit note dated 05/11/2026, documented, “Shampoo- Completed - No (N) Note: Will wash patient hair and shave him every Wednesday.” A review of the clinical record revealed no evidence of the HA reporting the change in the care plan to the RN. No updates to the HA care plan have been made by an RN since 04/21/2026. CLINICAL RECORD 10: The patient elected hospice care on 03/20/2026 with a diagnosis of malignant neoplasm of the left upper lobe. On 03/24/2026, HA services were ordered twice a week, and the HA care plan was developed. The HA visit note dated 03/26/2026 documented that the assigned HA tasks were refused by the patient/caregiver, stating that the patient had a friend coming to assist with the bath. A review of the clinical record revealed no evidence of the HA reporting the change in the care plan to the RN. On 04/06/2026, the HA documented that all tasks were already completed or refused; on 4/09/2026, the HA documented that all tasks were already completed except for bathing and nail care, which were refused; and on 04/13/2026, 04/16/2026, 04/20/2026, 04/23/2026, and 05/07/2026, the HA documented “already completed” for each assigned task except bathing and nail care, which the HA documented “Patient/caregiver refused.” A review of the clinical record revealed no evidence of the HA reporting the changes in the care plan to the RN. On 05/13/2026, the Executive Director stated in an interview, “We have identified that as a problem and have been working on it.””

“It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: physician orders. This standard was not met as evidenced by clinical record review and interview. In 1 of 42 (5%) clinical records reviewed, the agency did not ensure that all the patient’s clinical record included physician orders to meet the patient’s needs. CLINICAL RECORD 32: The patient elected hospice care on 05/21/2025 with a diagnosis of chronic respiratory failure. The patient was transferred to the IPU for respite care on 05/10/2026 due to caregiver fatigue. The RN assessment dated 05/10/2026 documented that the patient requested and received a Foley catheter. The assessment documented that an order was received for a Foley catheter, 16 French from the Advanced Practice Registered Nurse (APRN). The Foley catheter insertion was documented in the clinical note. A clinical record review revealed no orders documented for the Foley catheter size or insertion. During a record review and interview on 05/14/2026, the Executive Director confirmed that the identified clinical record did not include required physician orders.”

“It is required that drugs and biologicals are labeled and stored in accordance with state law and regulation, as well as accepted standards of practice. At a minimum, labels include: expiration date. This standard was not met as evidenced by interview and observation. The agency did not ensure that drugs and biologicals in stock, or provided to patients, were not expired. IPU 1 TOUR: During a tour of the IPU1 medication room on 05/11/2026, the following expired medications and supplies were identified as expired: one (1) box of Saf-T-Intima Pediatric needles expired on 03/31/2026; one (1) tube of Walgreens pain relieving cream and Lidocaine LOT 69538 expired 04/2026, three (3) tubes of Walgreens Hydrocortisone cream each expired 01/2026 Lot 4HT0445, one (1) box of Preparation H with 21 suppositories, LOT TO6256 expired 08/2025, and one (1) tube of Lidocaine ointment LOT AD161181 expired 06/2025. During an interview on 05/11/2026, the Executive Director, who was present for the tour of IPU 1,confirmed that the listed items were expired and were not appropriately separated from medications available for use. IPU 3 TOUR: During a tour of the IPU 3 medication room and laboratory refrigerator on 05/12/2026, the following expired medications, biologicals, and supplies were identified as expired: two (2) boxes of Influenza Vaccination 2024-2025 formula with a combined total of 19 syringes, LOT AW1663A, expired 06/30/2025, Scopolamine Transdermal Patches, quantity of 40, expired 03/2026, and Insulin Lispro Injection SQ, discard after 08/18/2025. During an interview on 05/12/2026, the Executive Director of the East Coast, who was present for the IPU 3 tour, confirmed that the listed medications and biologicals were expired and were not appropriately separated from medications available for use. IPU 5 TOUR: During a tour of the IPU 5 medication room on 05/13/2026 of the medication room, the following expired medications and supplies were identified as expired: one (1) bottle of Hydrogen Peroxide, LOT CJ77250 expired on 08/2025, two (2) vials of Methadone Hydrochloride injection solution, LOT B245090 expired 04/2026, and Morphine Sulfate ER tablets 30mg x 130 tablets, LOT 1024965 with a pharmacy label indicating an expiration date of 03/16/2026. During an interview on 05/13/2026, the Executive Director, who was present for IPU 5 tour, confirmed that the listed medications were expired and were not appropriately separated from medications available for use.”

“It is required that the hospice providing inpatient care directly provides 24-hour nursing services that meet the nursing needs of all patients and are provided per the patient’s plan of care. Each patient receives the care ordered and is kept comfortable, clean, well-groomed, and protected from accident, injury, and infection. This standard was not met as evidenced by clinical record review and interview. In 2 of 15 (13%) clinical records reviewed of inpatient patients receiving Hospice Aide (HA) services, the agency did not ensure that the Hospice Aide received patient care instructions to meet the patient’s needs. Clinical record 37: The patient elected hospice care on 02/17/2026 with a diagnosis of hypertensive heart disease with heart failure. The HA care plan was developed on 02/27/2026 and updated on 03/12/2026. The plan of care ordered HA services three times a week. The HA care plan assigned the HA the task: bathing (Tub/Shower). The care plan did not provide the HA with clear instructions on the type of bath to be provided. Clinical record 42: The patient elected hospice care on 04/06/2026 with a diagnosis of other pulmonary embolism without acute cor pulmonale. On 04/09/2026, HA services were ordered twice a week, and the HA care plan was developed. The HA care plan assigned the HA the task: bathing (Tub/Shower). The care plan did not provide the HA with clear instructions on the type of bath to be provided. During the interview and after review of care plans on 05/12/2026, the Executive Director stated, “We have identified the problem with aide care plans and have done a performance improvement project and education. It appears we still have work to do.””

“It is required that the hospice inpatient facility provides meals to each patient that are obtained, stored, prepared, distributed, and served under sanitary conditions. This standard was not met as evidenced by interview and observation. In 1 of 5 (20%) inpatient units observed, the agency did not ensure that all food available for patient use was not expired. IPU TOUR 2: During the tour of the main kitchen at the agency’s IPU2 on 05/12/2026 , the following expired items were identified: SideKicks Kiwi Strawberry Italian Ice single serve cups, 4.4 fl oz, with an expiration date of 04/08/2026, quantity of 64; pancake mix in a resealable bag marked with an expiration date of 05/10/2026, quantity of 1; and paprika in a 16 oz container, partially filled, with an expiration date of 02/24/2026, quantity of 1. During an interview on 05/12/2026, the Executive Director, who was present for the IPU tour, confirmed that the listed items were expired and had been available for patient use.”

“Based on interview and record review, the hospice failed to appropriately track and analyze adverse patient events to enable to hospice to assess processes of care, hospice services, and operations. Findings include: During an interview on 11/12/2025 at 12:15 PM the Director of Quality stated that regarding falls with major injuries, she was not aware of them being a reportable event. There was not a process in place to review incident reports to identify areas of concern. During an interview on 11/12/2025 at 3:26 PM the Director of Quality stated, “We don’t currently have a process in place that would trigger a report to AHCA [the Agency for Health Care Administration]. I agree that we need a process in place. We currently don’t have a procedure in place to review a fall to see if an RCA [Root Cause Analysis] needs to occur.” Review of policy titled “Sentinel Events – Incident Reporting,” with the last review date of 3/25/2024 read, “I. Policy and Procedure Statement: [Name of the facility] requires that all incidents of a “sentinel nature” reported to the Compliance Officer and the Patient Care Manager of the patient care team involved by phone immediately upon learning the seriousness of the event, including after hours. The Compliance Officer will investigate all sentinel events. The event will also be reported via the Safety Zone Portal. II. Definitions: A Sentinel Event is any unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof not related to the patient’s illness or underlying condition. Major permanent loss of function is defined as sensory, motor, physiologic, or intellectual impairment not present on admission that requires continued treatment or lifestyle change. III. Procedure to Policy: C. Senior management will make the decision regarding whether or not the event fits the accrediting bodies definition of a Sentinel event and therefore is reportable to them. D. A root cause analysis will be coordinated by company on all events causing patient harm or having the potential to cause patient harm. The root cause analysis will be conducted by a member of the quality department as soon as possible, and findings will be reported to the quality council and the director of risk management as needed. E. Results of the analysis must be used to identify any changes that could be made in systems or processes to reduce the risk of a particular serious adverse event occurring in the future. F. The root cause analysis must be completed within 30 days of the sentinel occurrence. G. To prevent reoccurrence of the Sentinel event an action plan will be developed and implemented with oversight from the quality council. I. Management may require a root cause analysis of other incidents that although not covered by the definition of Sentinel, are of such a serious nature they demand such a review.””

“Based on interview and record review, the facility failed to document in the medical record Patient #1’s treatment and services related to an unwitnessed event/fall. Findings include: Review of Patient #1’s admission data revealed the start of care was 6/12/2025. The hospice admitting diagnosis was Alzheimer’s disease. Review of Patient #1 Social Worker Note, dated 10/08/2025 read, “[Patient #1’s name] “with a hospice DX [diagnosis] of Alzheimer’s Disease. Patient is admitted to [name of the facility] for a 5-night respite stay. Patient will return home on Sunday October 12, 2025.” During an interview on 11/12/2025 at 1:01 PM the Director of Clinical Operations stated, “If a patient falls, I expect the nurse to do an initial assessment, notify the doctor, notify the family, find out the wishes of the family, and whether they want the patient sent to the hospital. I do expect the nurse to write a note about the falls. [Nurse A, RN’s name] called me the night [Patient #1’s name] fell. I reminded [Nurse A, RN’s name] to do the incident report, and I would have thought that one of the nurses would have written a nursing note. I did not know they did not put a note in until just now.” During an interview on 11/12/2025 at 3:09 PM Nurse B, RN (Registered Nurse) stated, “I did not document her fall, I believe [Nurse A, RN’s name] made a note because [Nurse A, RN’s name] spoke with the nurse practitioner, the family and EMS (Emergency Medical Services). I was going off shift.” During an interview on 11/12/2025 at 3:51 PM Nurse A, RN stated, “The details were in the incident report, but not in the EMR (electronic medical record), because I didn’t do an assessment in the EMR.” During an interview on 11/12/2025 at 3:55 PM the Executive Director stated to Nurse A that he should have documented Patient #1’s fall, an assessment and intervention including notification to the ARNP (Advanced Registered Nurse Practitioner) and the daughter, and the information regarding Patient #1’s transfer to the hospital. The documentation in the medical record would be in addition to the incident report. Review of the policy and procedure titled “Fall and Injury Prevention,” with the last review date of 05/05/2023 read, “I. Policy and Procedure Statement: To promote patient safety and prevent injuries from falls. II. A. Fall – An unintentional change in position resulting in coming to rest on the ground or at a lower level. III. Procedure to Policy: B. After a fall, the nursing staff will: 1. Assess patient’s condition and need for treatment. Seek appropriate treatment as needed for injuries or suspected injuries. 5. Document the fall in the EMR same day as incident”. Review of the policy and procedure titled, “Patient Medical Record Documentation,” with the last review date of 8/05/2020 read, “I. Policy and Procedure Statement: In a clinical operation, it is critical to document each patient’s condition and history of care. To ensure the patient receives the best available care, the information must be passed among all members of the interdisciplinary group of caregivers. Proper and timely same day documentation is always expected at [Name of Facility] for all interdisciplinary team of caregivers regardless of their exempt or non-exempt employment status. III. Procedure to Policy: A. Understand and guide staff’s responsibility to provide and document patient history, condition, interventions, and education. The required essential components of the patient record includes, but is not limited to: . 6. symptom management, with response to interventions 7. Functional status, Completeness: D. ALL Documentation provided from admission, through each POS (point of service) and discharge must be included in the medical record. Timeliness: G. There are specific time requirements for completion of the medical record documentation related to patient condition, interventions, and education: all documentation must occur at POS. POS documentation is the process of documenting patient encounters as they occur, or immediately after. 2. Documentation at POS is the expected standard of practice at [Name of Facility]. Regardless of time of day, or employee status (exempt or non-exempt) all documentation is required to be entered into the patient’s medical record as a patient is assessed or immediately after. Patient history at assessment or new relevant information arises, condition, interventions and responses to interventions, and education must be charted at the end of each shift to provide continuity of care from shift to shift in care center setting and by visit for home and facility team setting. It is the expectation that all staff document at POS and before their workday ends.””

“Upon patient record review, 2 of 7 (Patient #3, 5) 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. Pt # 3 - No evidence of MRSA precautions and Hep C on nursing care plans . (Corrected on site) Pt #5 - Foley care not listed on care plan and no goals or interventions. (Corrected on site)”

“Upon client record review, 3 of 7 (Patient #1, 5, 6) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Pt #1 - No evidence of a volunteer order. Documentation in care plans states on 2/5/24 for volunteer services. Vol made a visit 2/24/24 - no order. (corrected on site) Pt #5 - Chaplain order of 2/12/24 states 1xday only. Chaplain saw patient 2/12 - chaplain documents family wants more visits and pt was seen again on 2/20/24. No order past the 1xvisit order (Corrected on site) Pt #6- Record reflects volunteer visit on 2/24/24. No order evident on medical IPU record (corrected on site)”

“Upon patient record review, 2 of 7 (Patient #3, 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 Pt #3 - No mention of Hep C or MRSA precautions on aide POC. (Corrected on site) Pt #7 - Aide POC states patient is on a regular diet. Record review shows that patient has a feeding tube and is getting Jevity over 14 hours each evening along with food during the day as tolerated. (Corrected on site)”

“Upon patient record review 10 of 41 (Patient #2, #9,#10, #11,#15,#16,#17, #19, #26, #27) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual’s attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient #2: SOC 7/7/2023. Spiritual assessment on 7/13/2023. Patient #9: SOC 9/6/2023. Psychosocial assessment occurred on 9/19/2023 Patient #10: SOC 5/31/2023. Spiritual assessment occurred on 6/7/2023. Patient #11: SOC 11/9/2023. Spiritual assessment occurred on 11/20/2023. Patient #15: SOC 10/3/2023, Spiritual assessment occurred 10/31/2023. Patient #16: SOC 8/7/2023, Spiritual assessment occurred 8/14/2023. Patient #17: SOC 11/3/2023, Spiritual assessment and Psychosocial assessment occurred 11/9/2023. Patient #19: SOC 8/3/2023, Spiritual assessment occurred 8/11/2023. Patient #26: SOC 12/19/2022, Psychosocial assessment occurred 12/27/2022. Patient #27: SOC 3/9/2023, Spiritual assessment occurred 3/15/2023.”

“Upon patient record review 8 of 41 (Patient #14, #16, #23, #24, #25, #26, #38, #39) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient’s well-being, comfort, and dignity throughout the dying process. Patient #14: SOC 5/24/2023, there was no evidence of a Spiritual assessment. Patient #16: SOC 8/7/2023, there was no evidence of a Psychosocial assessment. Patient #23: SOC 9/23/2023, there was no evidence of a spiritual care assessment. Patient #24: SOC 1/4/2023, there was no evidence of a spiritual care assessment. Patient #25: SOC 3/29/2023, there was no evidence of a spiritual or psychosocial assessment. Patient #26: SOC 12/19/2022, there was no evidence of a spiritual assessment. Patient #38: SOC 2/22/22, there was no evidence of psychosocial assessment. Patient #39: SOC 8/11/23, there was no evidence of psychosocial assessment.”

“Upon patient record review, 22 of 41 (Patient #1, #2, #3,#4,#6,#7,#8,#10,#11,#12,#13,#14,#15,#16,#17,#21,#23, #27,#37,#38,#40,#41) 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: Medication profile dated 9/27/2023 included Diclofenac 1% tropical 2-3 GM PRN 3X day for pain, there was no evidence of an area to apply. Miralax 17GM oral powder 1 dose 1x day for constipation, there was no evidence of a diluent. Corrected on site. Patient #2: Medication profile dated 7/7/2023 included Miralax 17GM oral powder 1 dose 1x day for constipation, there was no evidence of a diluent. Corrected on site. Patient #3: Medication profile dated 12/18/2023 included O2 1-2L inhalation PRN SOB, there was no evidence of a route. Corrected on site. Patient #4: The medication profile includes Nystatin 100,00 unit/gram topical powder, it does not indicate an application site. (Medication profile corrected on site.) Patient #6: The patient record includes orders on 1/11/24 for oxygen PRN, this is not included in the medication profile. Patient #7: Medication profile dated 1/1/2023 included Miralax 17GM oral powder 1 dose 1x day for constipation, there was no evidence of a diluent. Corrected on site. Patient #8: Med. profile dated 4/25/2023 included O2 1-2L inhalation PRN SOB, there was no evidence of a route. Corrected on site. Patient #10: O2 dated 5/31/2023 2-4L PRN SOB, no evidence of a route. Corrected on site. Patient #11: Med. profile dated 11/9/2023 included O2 2-4L PRN SOB, no evidence of a route. Corrected on site. Patient #12: Med profile dated 11/4/2023 included O2 2-4L PRN SOB, no evidence of a route. IDG notes dated 11/16/2023 state Miralax added as an order due to constipation, No evidence of Miralax on Med. profile. Patient #13: Med. profile dated 10/12/2023 Monural oral packet 1 pkg Q 10 days for UTI , no evidence of a diluent. Corrected on site. Patient #14: Med. profile dated 5/24/2023 O2 Inhalation 2-4 LP PRN SOB, no evidence of a route. Corrected on site. Patient #15: Med. profile dated 10/12/2023 included O2 inhalation 2-4 PRN SOB, no evidence of a dose or route. Corrected on site. Patient #16: Med profile dated 8/7/2023 included O2 2-4 intranasal continuous, no evidence of a dose. Corrected on site. Patient #17: Med. profile dated 11/3/2023 included Polyethylene glycol 17GM oral powder 1 scoop 1x day, there was no evidence of a diluent. Corrected on site. Patient #21: POC included O2 concentrator under DME listed, SOC SN assess identified O2 need for SOB, there was no entry in the Med. profile for O2. Patient #23: Med. profile dated 9/30/2023 included O2 inhalation 2-4L PRN SOB, there was no evidence of a route. Patient #27: Med. profile dated 3/14/2023 included O2 inhalation 2-4L intranasal PRN, there was no evidence of an indication for use. Patient #37: The medication profile includes oxygen, it does not include a route of administration ie, nasal cannula, mask etc. Patient #38: The orders upon admit to Respite care includes orders for oxygen 2-4LPM via nasal canula PRN, the order is not included in the medication profile. Patient #40: The patient record includes orders on 1/5/24 for oxygen PRN, this is not included in the medication profile. Patient #41: The medication profile includes polyethylene glycol 3350 17gram powder 1 prn for constipation, it does not include instructions for dilution.”

“Upon patient record review, 13 of 41 (Patient #4,#9,#10,#16,#17,#19,#25,#26,#32,#36,#38,#39,#40) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient’s family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient’s death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient #4: The patient was admitted on 11/29/23, the bereavement risk assessment has not been completed. Patient #9: SOC 9/6/2023. Bereavement assessment occurred on 9/19/2023. Patient #10: SOC 5/31/2023. Bereavement assessment occurred on 6/7/2023. Patient #16: SOC 8/7/2023. There was no evidence of a Bereavement assessment. Patient #17: SOC 11/3/2023. Bereavement assessment occurred on 11/9/2023. Patient #19: SOC 8/3/2023. Bereavement assessment occurred on 8/11/2023. Patient #25: SOC 1/4/2023. There was no evidence of a bereavement assessment. Patient #26: SOC 12/19/2023. Bereavement assessment occurred on 12/27/2023. Patient #32: SOC 10/21/23, the bereavement risk assessment was not completed. Patient #36: SOC 1/4/24, the bereavement risk assessment was not completed. Patient #38: SOC 2/22/23, the bereavement risk assessment was not been completed. Patient #39: SOC 8/11/23, the bereavement risk assessment was not been completed. Patient #40: SOC 1/5/24, the bereavement risk assessment was not completed.”

“Upon patient record review, 1 of 41 (Patient #19) 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 #19: Comprehensive RN assessment dated 8/31/2022 next visit/assessment 9/16/2022 greater than 15 days.”

“Upon patient record review, 1 of 41 (Patient #36) 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 #36: The narrative note included on the RN assessment on 1/6/24 indicates that the patient has a “DTI to the left heel, an open stage II wound to the rectum, and 2nd toe to left foot is black.” There is no evidence in the record that this was reported to the MD/NP and a complete wound care assessment was not completed for the GIP admission.”

“Upon patient record review, 10 of 41 (Patient #6,#17,#20,#23,#28,#32,#36,#37,#38,#39) 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: The patient was admitted on 6/3/23 and the patient record indicates that the patient uses diabetic medications and insulin that includes Lantus 14 units at bedtime, Tradjenta 5mg daily, and Humalog 4 units before meal and performs acu-checks 3 times a day. The initial plan of care does not include a problem statement with interventions and goals for the management and assessment of the diabetes. The bereavement risk assessment indicated a “moderate” risk for grief/bereavement, the plan of care does not include interventions and goals to address the caregiver needs. Patient #17: SOC SN assess identified pt. has trach tube, CPAP, and a g-tube. The POC had no evidence of problems/interventions goals for C/R including trach and CPAP, and Peg tube care. Corrected on site. Patient #20: CTI at SOC identifies Aspiration risk, no evidence on POC of aspiration precautions. corrected on site. Patient #23: SN SOC assess identifies colostomy and JP drain, there was no evidence on the POC for problem/interventions/goals for colostomy or JP drain. Patient #28: The patient was admitted on 12/7/23 and receives Eliquis 5mg BID, the plan of care does not include bleeding precautions. Patient #32: The patient was admitted on 10/21/23, the initial comprehensive assessment performed by the RN indicated “wife is very tearful” and documented patients daughter died of cancer, son has been diagnosed with leukemia and PCG is currently being tested for breast cancer, patient and PCG are taking care of 13 year old granddaughter. The plan of care does not include a problem statement with interventions and goals for the current and anticipated grief of the PCG. Patient #36: The patient was admitted on 1/4/24 and had a foley catheter placed due to urinary retention within the first 24 hours of her GIP admission, the plan of care does not include a problem statement for the urinary retention or for the use of the foley catheter with interventions and goals. Patient #37: The patient was admitted on 1/10/24, the initial comprehensive RN assessment includes documentation of a stage II pressure ulcer to the sacrum/coccyx and an unstageable wound to the right heel with eschar. The plan of care does not include a problem statement with interventions and goals for the wound management. Patient #38: The patient was admitted on 2/22/23, the plan of care was not completed until 3/1/23 with problems, goals and interventions. Patient #39: The patient was admitted on 8/11/23 with a secondary condition of COPD and requires continuous use of oxygen, the plan of care does not include a problem statement with interventions and goals for respiratory.”

“Upon patient record review, 3 of 41 (Patient #12,#24,#27) 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 #12: Order dated 11/4/2023 included SN PRN visits x 15 between 11/4-2/1/2024. Patient #24: Order dated 1/4/2023 SN visits 1x week and 10 PRN. Patient #27: Order dated 3/9/2023 SN visits 1x week and 19 PRN 3/9-3/25/2023.”

“Upon patient record review, 22 of 41 (Patient #1,#2#3,#4,#6,#7,#8,#10,#11,#12,#13,#14,#15,#17,#21,#23, #27,#37,#38,#39,#40,#41) 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:Order dated 9/27/2023 included Diclofenac 1% tropical 2-3 GM PRN 3X day for pain, there was no evidence of an area to apply. Order dated 9/27/2023 included Miralax 17GM oral powder 1 dose 1x day for constipation, there was no evidence of a diluent. Corrected on site. Patient #2: Order dated 7/7/2023 included Miralax 17GM oral powder 1 dose 1x day for constipation, there was no evidence of a diluent. Corrected on site. Patient #3: Wound orders dated 12/18/2023 included wound cleanser, apply Opti foam, change Q 5-7 days PRN, start 12/19/2023. There was no evidence of where the wound care was to be applied and who was to do it. Order dated 12/18/2023 included O2 1-2L inhalation PRN SOB, there was no evidence of a route. Corrected on site. Patient #4: The medication orders for Nystatin powder 100,000 unit/gram topical powder, does not include an application site. The patient record indicates that the patient has a foley catheter, the date of placement is not identified in the record, the plan of care does not include orders for placement of the foley catheter. (Order corrected on site) Patient #6: The order for oxygen prn on 1/11/24, does not include an indication for use. Patient #7: Order dated 1/1/2023 included Miralax 17GM oral powder 1 dose 1x day for constipation, there was no evidence of a diluent. Corrected on site. Patient #8: Order dated 4/25/2023 included O2 1-2L inhalation PRN SOB, there was no evidence of a route. Patient #10: O2 dated 5/31/2023 2-4L PRN SOB, no evidence of a route. Corrected on site. Patient #11: Order dated 11/9/2023 included O2 2-4L PRN SOB, no evidence of a route. Corrected on site. Patient #12: Order dated 11/4/2023 included O2 2-4L PRN SOB, no evidence of a route. IDG notes dated 11/16/2024 state Miralax added as an order due to constipation, No evidence of an order. Patient #13: Order dated 10/12/2023 Monural oral packet i pkg Q 10 days for UTI , no evidence of a diluent. Corrected on site. Patient #14: Order dated 5/24/2023 O2 Inhalation 2-4 LP PRN SOB, no evidence of a route. Corrected on site. Patient #15: Order dated 10/12/2023 included O2 inhalation 2-4 PRN SOB, no evidence of a dose or route. corrected on site. Patient #17: Order dated 11/3/2023 included Polyethylene glycol 17GM oral powder 1 scoop 1x day, there was no evidence of a diluent. Corrected on site. Patient #21: POC included O2 concentrator under DME listed, SOC SN assess identified O2 need for SOB, there was no order for O2. Patient #23: Order dated 9/30/2023 included O2 inhalation 2-4L PRN SOB, there was no evidence of a route. Patient #27: Order dated 3/14/2023 included O2 inhalation 2-4L intranasal PRN, there was no evidence of an indication for use. Patient #37: The patient record includes an order on 1/9/24 for foley catheter, PRN, there is no indicator for use. (Corrected on site.) Patient #38: The order for oxygen prn on 1/8/24, does not include an indication for use. Patient #39: The order for oxygen prn on 11/24/23, does not include an indication for use. Patient #40: The order for oxygen prn on 1/5/24, does not include an indication for use. Patient #41: The order for oxygen prn on 1/7/24, does not include an indication for use.”

“Upon patient record review, 7 of 41 (Patient #6,#15,#28,#29,#36,#38,#39) did not have evidence that a revised plan of care includes information from the patient’s updated comprehensive assessment and must note the patient’s progress towards outcome/goals from the plan of care. Patient #6: The patient was admitted on 6/3/23, there is no evidence in the patient record that the plan of care has been updated since 6/6/23. Patient #15: Eliquis added to med profile, orders 10/26/2023, no evidence on updated POC of bleeding precautions. Corrected on site. Patient #28: The patient record indicates that the patient receives MSW visits, the plan of care does not include a problem statement with interventions and goals for the services. The plan of care is not updated to include caregiver needs, interventions and goals for respite services. Patient #29: The patient was placed into respite care on 1/5/24 and received a foley catheter on that date, the plan of care was not updated to include the problem, interventions or goals for genitourinary needs. Patient #36: The patient received new orders on 1/5/24 to infuse bolus feedings using the g-tube that is in place. The plan of care was not updated to include the nutrition and use of the g-tube with interventions and goals for care. Patient #38: The patient was admitted to respite care from home on 1/8/23, the patient record does not include documentation of the respite needs, coordination of care or the goals for the level of care changes. The patient record does not include a plan of care update for the benefit period starting 10/20/23. Patient #39: The patient record does not include a plan of care update for the benefit period starting 11/9/23.”

“Upon client record review, 16 of 41 (Patient #2,#4,#6,#7,#8,#14,#16,#19,#21,#29,#31,#33,#34,#37,#39,#40) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #2: Order dated 7/10/2023 included Spiritual Care visits 1x month. there was no evidence of a SC visit in the month of November 2023. Patient #4: The patient received visits from the social worker on 12/1/23, 12/19/23, 12/28/23 and 1/8/24, the plan of care does not include orders for SW visits. The patient received visits on 12/29/23 and 1/5/24 from spiritual care services, the plan of care does not include orders for spiritual care services. Patient #6: The patient record includes evidence of volunteer services and visits being received, there are no frequency orders in the plan of care for volunteers. The visit frequency for nursing starting 6/3/23 is ordered for 1 time per week for 14 weeks. The patient did not receive a visit for the week of July 2 -8, 2023 Patient #7: Volunteers making visits with no Plan of care for volunteers or visit frequencies ordered. VC POC for volunteers is blank. Corrected on site. Patient #8: Volunteers making visits with no Plan of care for volunteers or visit frequencies ordered. VC POC for volunteers is blank. Corrected on site. Patient #14: SN visits ordered 11/20/2023 SN 1x week x 9. Week of 11/26/2023 no evidence of a visit or missed visit. Patient #16: Order dated 9/18/2023 SW visits 1x month x 2. No evidence of SW visits or missed visits for September or October 2023. Patient #19: Volunteers making visits with no POC or orders for visit frequencies. VC POC for volunteers is blank. Corrected on site. Patient #21: Volunteers making visits with no Plan of care for volunteers or visit frequencies ordered. VC POC for volunteers is blank. Patient #29: The orders for nursing visits starting 12/16/23 are for 2 times per week. The patient received 1 visit the week of 12/24/23 and no visits the week of 12/31/23. Patient #31: The patient record includes documentation on 12/19/23 of bilateral stage III wounds to buttocks and wound care being provided. The plan of care does not include wound care orders. (Corrected on site.) Patient #33: The patient record includes evidence of a stage II pressure ulcer to the coccyx, wound care was performed on 1/7/24 without orders. Patient #34: The patient record indicates the patient received volunteer services and 6 visits from 9/5/23 – 9/29/23, the plan of care does not include frequency orders for volunteer services. The patient received SW calls and services on 10/3/23, 11/15/23, 1/6/24 and 1/8/24 with no frequency orders since 7/30/23. Patient #37: The patient record upon admit includes evidence of a stage II wound to the sacrum/coccyx and an unstageable wound to the patients right heel. The RN assessment on 1/11/23 does not include documentation of the wounds and the plan of care does not include care orders for the right heel wound although wound care was provided. Patient #39: The patient received SW visits on 1/11/24, 1/5/24, 12/28/23, 12/22/23, 12/21/23, 12/14/23, 12/7/23, 12/1/23, 11/30/23, 11/28/23 and 11/27/23 with no visit orders included in the plan of care. The patient received spiritual care visits on 1/9/24 and 11/29/23 with no orders included in the plan of care. The patient began receiving volunteer services effective 11/25/23, there are no frequency orders for volunteer records included in the plan of care. Patient #40: The patient received SW visits on 1/12/24 & 1/11/24 with no frequency orders included in the plan of care.”

“Upon patient record review, 19 of 41 (Patient #4, #5, #6, #10, #18, #19, #20, #21, #22, #25, #27, #28, #29, #30, #31, #36, #37, #38, #39) 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 #4: The hospice aide task assignment does not specify frequency for performing bathing, shampoo, oral care, linen changes. (Corrected on site.) Patient #5: The hospice aide task assignment does not specify the frequency for performing linen changes and catheter care. (Corrected on site.) Patient #6: The hospice aide task for shower does not include a frequency. Patient #10: SOC SN assess identifies Seizure disorder, diagnosis of Intra cranial injury, on seizure medications. Aide assignment does not include seizure precautions. Corrected on site. Patient #18: SOC SN assess identifies dysphagia, aspiration risk. There was no evidence on the Aide assignment for swallowing precautions. Corrected on site. Patient #19: Order dated 11/26/2023 Aide visits PRN x 3 from 11/26-1/24/2024. Patient #20: SOC SN assess identifies swallowing difficulties, no evidence of swallowing precautions, no evidence of frequencies for personal care tasks on aide assignment. Corrected on site. Patient #21: Pt on O2, prescribed Eliquis, no evidence on aide assignment of bleeding or O2 precautions. Patient #22: Pt on Eliquis, no evidence on Aide assignment for bleeding precautions. Patient #25: Order for aide visits 4/3/2023, visits done, no evidence of an Aide assignment/POC. Patient #27: SN SOC assess identifies O2, fall risk, and risk for aspiration, no evidence on aide assignment of O2, fall or swallowing precautions. Order dated 3/9/23 Aide visits 25 PRN 3/9-3/25/2023. Patient #28: The hospice aide task for bath, shaving, shampoo, apply lotion, nail care and linen change does not include a frequency. (Corrected on site.) Patient #29: Hospice frequency orders entered on 12/16/23 include PRN visits x 3. Hospice aide task assignments starting on 1/5/24 for shampoo, hair care and nail care do not include a frequency. (Corrected on site.) Patient #30: The hospice aide task assignments for hair care and shampoo do not include a frequency, the frequency for changing linens is written “as desired.” Patient #31: The hospice aide task assignments for bath, nail care, hair care and linen changes do not include a frequency. Patient #36: The hospice aide tasks for bed bath, shampoo, comb hair, nail care, skin care and linen changes are not assigned a frequency. Patient #37: The task assignment for linen change is indicated as “when soiled” and is not assigned a specific task frequency. Patient #38: The patient is receiving respite care and has aide tasks assignment of a bedbath, the patient is ambulatory and independent of toileting. The hospice aide tasks for bedbath, shampoo, combing hair, nail care, skin care and linen changes are not assigned a task frequency. Patient #39: The hospice aide tasks for shower, bath, linen change, nail care, shampoo hair, comb hair, skin care with lotion and oral hygiene do not include a frequency.”

“Upon patient record review 11 of 41 (Patient #1,#3,#7,#9,#13,#20,#32,#36,#37,#40,#41) 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 #1: Order dated 10/4/2023 for Aide visits 1x week for 13 weeks. Soc. 9/27/2023, no visit or missed visit for week one (9/17/2023) or week 2 - 10/1/2023, first Aide visit occurred on 10/18/2023. Patient #3: Order 12/24/2023 Aide visits 2x12, week of 12/24/2023 one visit occurred on 12/26/2023 with no evidence of a missed visit. Patient #7: Order dated 10/30/2023 for Aide visits 3x week. For week 11/19/2023 and week 12/31/2023, 2 Aide visits occurred with no missed visits. Patient #9: Order 12/10/2023 Aide visits 3x week, week of 12/24, 12/31/2023 each with 2 visits. Patient #13: Order 10/20/23 Aide visits 3x week, weeks 11/19, 11/26, 12/17,12/24 and 12/31 each with 2 visits per week. Patient #20: Order 10/17/2023 Aide visits 2x week, week of 12/31/2023 one visit completed, with no missed visits. Patient #32: The hospice aide orders starting on 11/26/23 to 12/29/23 were indicated for 3 times per week. The record includes 12 missed visits during that time period. Patient #36: The patient was admitted on 1/4/24 to general in-patient care and has hospice tasks assigned daily, there is no evidence in the record of tasks being performed for care. Patient #37: The patient was admitted on 1/10/24 to general in-patient care and has hospice tasks assigned daily, there is no evidence in the patient record of tasks being performed for care. Patient #40: The patient is admitted to GIP care effective 1/5/24, aide tasks assigned daily, there is no evidence in the patient record of hospice aide cares being provided until 1/10/24. Patient #41: The patient was admitted to GIP services effective 1/7/24 with hospice aide services to be provided daily, there is no evidence in the patient record of a hospice aide cares being provided.”

“Upon patient client record review, 1 of 41 (Patient #9) 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 #9: 85 year old male with diagnosis of Parkinson’s disease as primary. IDG notes for 9/28/2023 included summary “67 year old male with malignant neoplasm of prostate”. No evidence of appropriate authentication. Corrected on site with addendum.”

“Upon patient record review, 1 of 41 (Patient #33) did not have evidence in the patient record that patients receiving care in a hospice that provides inpatient care directly in its own facility have medications administered by only one of the following individuals: • A licensed nurse, physician, or other health care professional in accordance with their scope of practice and state law • Personnel who have completed a state-approved training program in medication administration • The patient, upon approval by the interdisciplinary group Patient #33: The patient was admitted to general inpatient care within an agency owned facility. Documentation on 1/5/24 by the RN indicates that a family member administered dexamethasone 4mg and miralax to the patient without approval or consent from the IDG. The dexamethasone was not included in the plan of care and the agency policy is that patients/families are not allowed to bring in medications or self administer medications.”

“Upon patient record review, 2 of 41 (Patient #7, #8) did not have evidence that the hospice provided the following information to the SNF: • The most recent hospice plan of care specific to each patient • Hospice election form and any Advance Directives specific to each patient • Physician certification and recertification of the terminal illness specific to each patient • Names and contact information for hospice personnel involved in hospice care of each patient • Instructions on how to access the hospice’s 24-hour on-call system • Hospice medication information specific to each patient • Hospice physician and attending physician (if any) orders specific to each patient Patient #7: There was no evidence of a Hospice election form, consents for care, and name and contact info for hospice personnel. Corrected on site. Patient #8: There was no evidence of a Hospice election form, consents for care, Physician certification of terminal illness, and name and contact info for hospice personnel. Corrected on site.”

“Upon observation, there was no evidence the fire alarm systems of a facility are provided consistent with the 2012 editions of the LSC of the National Fire Protection Association and NFPA 99. The provisions of the adopted edition of the Life Safety Code do not apply in a State if CMS finds that a fire and safety code imposed by State law adequately protects patients in hospices. Existing Construction During the document review, the facility fire alarm testing report dated 11/16/2023 showed three (3) devices failed. At the time of survey, the facility has not corrected the failed devices per NFPA 72-2010, or completed an Alternative Life Safety Measures assessment to compensate for the failed devices per NFPA 101-2012. The agency did not have a fire watch plan in place. During the inspection, it was observed that an enclosed and screened patio contained two ashtrays with multiple cigarette butts in each in an area that is clearly marked as a NO SMOKING area. The facility and its entire property is designated as a non-smoking facility.”