Family Centered Hospice

“Upon patient record review, 8 of 19 (Patient # 1, 3, 4, 5, 6, 7, 10, and 12) 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: Facility medication profile contains orders for Ferrous sulfate, Magnesium, Melatonin, Memantine, Mirtazapine, Polyethylene Glycol, and zinc not on agency medication profile. Corrected on site with updated profile. Patient 3: Agency medication profile contains orders for K-Chlor not present on facility medication profile. Facility medication profile contains orders for Benadryl, Bumex, Calcium Carbonate not present on the agency medication profile. Corrected on site with updated profile. Patient 4: Facility medication profile contains orders for Aricept and Norco that are not present on agency medication profile. Agency medication profile contains orders for Biscodyl and Xarelto not present on facility medication profile. Corrected on site with updated profile. Patient 5: The updated medication list contains an order for Dextran eye drops with no specifics for which eye to administer. Corrected on site with updated profile. Patient 6: The medication list contains orders for Acetaminophen 325 mg 2 tabs every 6 hours and 650 mg rectal suppositories every 4 hours with no limit to not exceed 4 grams in 24 hours. Corrected on site with updated profile to include 4 gram dose limit in 24 hour period. Patient 7: The initial medication profile on 6/19/25 contains orders for Acetaminophen 325 mg 2 tabs every 4 hours and 650 mg rectal suppositories every 4 hour with no limit to not exceed 4 grams in 24 hours. Corrected on site with updated profile to include 4 gram dose limit in 24 hour period. Patient 10: The initial medication profile contains orders for Acetaminophen orders for 500mg 2 tabs every 8 and 650mg rectal suppository every 4 hours with no limit to not exceed 4 grams in 24 hours. Corrected on site with updated profile to include 4 gram dose limit in 24 hour period. Patient 12: The updated medication list contains orders for Acetaminophen 325 mg 2 tabs q 6 hours and 650 mg rectal suppositories every 4 hours with no limit to not exceed 4 grams in 24 hours. Corrected on site with updated profile to include 4 gram dose limit in 24 hour period.”

“Upon patient record review, 8 of 19 (Patient # 1, 3, 4, 5, 6, 7, 10, 12) 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: Facility medication profile contains orders for ferrous sulfate, Magnesium, Melatonin, Memantine, Mirtazapine, Polyethylene Glycol, and zinc not on agency medication profile. Corrected on site with updated orders. Patient 3: Agency POC/medication profile contains orders for K-Chlor not present on agency POC/med profile. Facility POC/Medication profile contains orders for Benadryl, Bumex, Calcium Carbonate. Corrected on site with updated medication orders and updated POC. Patient 4: Facility POC contains orders for Aricept, Norco not present on agency POC. Agency medication profile contains orders for Biscodyl, Donepezil, and Xarelto not present on agency POC. Corrected on site with updated medication orders and updated POC. Patient 5: The updated POC contains an order for Dextran eye drops with no specifics for which eye to administer. Corrected on site with updated plan of care. Patient 6: The medication list contains orders for Acetaminophen 325 mg 2 tabs every 6 hours and 650 mg rectal suppositories every 4 hours with no limit to not exceed 4 grams in 24 hours. Corrected on site with updates to include limit of 4 grams per 24 hour period. Patient 7: The initial medication profile on 6/19/25 contains orders for Acetaminophen 325 mg 2 tabs every 4 hours and 650 mg rectal suppositories every 4 hour with no limit to not exceed 4 grams in 24 hours. Corrected on site with updated POC. Patient 10: The initial medication profile contains orders for Acetaminophen orders for 500mg 2 tabs every 8 and 650mg rectal suppository every 4 hours with no limit to 4gms in 24 hours. Corrected on site with updated POC. Patient 12: The updated medication list contains orders for Acetaminophen 325 mg 2 tabs q 6hr and 650 mg RS every 4 hours with no limit to 4 grams in 24 hours. Corrected on site with updated POC.”

“Upon patient record review 1 of 19 (Patient #11) 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 11: 7/22/25 SN documentation reflects patient with complicated grief patient told SN she “had been shot in her eye. Nurse clarified if injection or gun and patient said gun. Staff confirms that patient had been shot and that her sister was shot and killed in the not too distant past.” There is not evidence of further discussion regarding complicated grief in IDG or referral made to other counseling services or community agencies.”

“Upon patient record review, 2 of 19 (Patient #7, 10) did not have evidence in the patient record that hospice aide assignments and duties are: Patient 7: The Aide POC contains orders for both shower and bed bath options. Patient lacks cognitive ability to determine bathing preference. Corrected on site with updates to Aide POC. Patient 10: The Aide POC at SOC 8/7/25 does not include any tasks for aide to complete during aide visits except for assist with shower. SN documents in comprehensive assessment at SOC the plan for aide services and “patient is chairbound; aide services for personal care, hygiene and ADLs will be provided.” Corrected on site with updates to Aide POC.”

“Upon patient record review, 5 of 19 (Patient # 1, 2, 4, 11, 13) 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: Facility POC contains orders for Cath 18Fr 30cc balloon may change bag and catheter PRN and agency 7/23/25 POC does not show evidence of Foley Cath orders and care instructions. Corrected on site with updates to POC. Patient 2: Facility POC contains orders for heel boot and xeroform gauze apply to left elbow topically every evening and PRN not present on agency POC. Corrected on site with updated wound care orders and POC. Patient 4: Initial POC on 4/1/25 contains an order for Xarelto with no risk for bleeding noted on updated POC 6/15/25. Corrected on site with updated POC. Patient 11: SN documents in SOC comprehensive assessment on 2/2/25, “ Patient has 5 wounds” and indicates locations of the 5 wounds. Initial POC does not include what wound care should be provided to each wound on 2/2/25 POC. Corrected on site with updated POC. Patient 13: Initial POC on 8/7/25 contains order for coumadin with no risk for bleeding noted on POC. PRN visit completed 8/24/25 SN documents “fell a few days ago on coumadin, sent to ER for lethargy. MD spoke with family and sent back to SNF for comfort care.” Patient expired on 8/28/25.”

“Upon patient record review, 1 of 19 (Patient # 11) 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 11: Order received on 4/4/25 clean with NS daily, apply bacitracin, cover with gauze and ABD dressing. No specifics on order where, how often, and who will complete dressing change. In facility, no indication on who will provide care of the wounds. Corrected on site with updated POC.”