Firsthealth Hospice

“Upon patient record review, 2 of 25 (Patient #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 09: Upon admission on 6/9/25, the patient reported complaints of ongoing and uncontrolled nausea and constipation, the plan of care does not include a problem statement with interventions and goals for the management of nausea or constipation. Patient 10: Upon admission on 5/14/25, it was identified that the patient had a previous fall resulting in a laceration requiring staples to the back of her head. The plan of care does not include interventions and goals for managing the wound or the removal of the staples. The initial assessment identifies that the patient experiences shortness of breath when laying flat and utilizes a trilogy machine at night, the plan of care does not include a problem statement with interventions and goals for the respiratory symptoms.”

“Upon patient record review, 1 of 25 (Patient #5) 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 05: The patient record indicates that the patient had two wounds to the sacrum effective 5/19/25 which were effectively treated and healed per SN documentation on 6/2/25. The plan of care has not been updated to include discharge orders for the wound care or discontinuing the interventions and goals for the wound. (Plan of care updated and corrected on site, wound care orders discharged.)”

“Upon personnel record review, 1 of 15 (Personnel #6 ) 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. #6: The personnel file for the employee does not include appropriate and safe techniques in personal hygiene and grooming to include shampooing performed at the sink, tub and bed.”

“Upon patient record review, 1 of 25 (Patient #1) 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 01: The patient record indicates that an indwelling foley catheter is in place upon admit and remains in use to this date, the hospice aide task assignment does not include tasks regarding catheter care or emptying the urine bag. (Hospice task assignment corrected and updated on site.)”

“Upon patient record review 2 of 25 (Patient #14, 17) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient’s needs. Patient 14: Hospice aide visits were initiated on 5/13/25, the patient record includes a supervisory visit performed on 6/5/25, there is no additional evidence of supervisory visits. Patient 17: Hospice aide visits were initiated on 4/15/25, a supervisory visit was performed on 5/15/25, there is no additional evidence of supervisory visits.”

“Upon patient client record review, 12 of 25 (Patient #1, 6, 9, 11, 13, 14, 15, 16, 17, 19, 20, 24) 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 01: The agency policy indicates that documentation will be completed within 48 hours of the end of shift, the patient record includes a patient visit made on 6/18/25, the documentation was completed on 6/22/25. Patient 06: The agency policy indicates that documentation for the initial assessment performed by the registered nurse will be completed and entered into the EMR within 48 hours of the election of hospice. The initial RN assessment performed on 5/23/25 was not completed and authenticated until 5/26/25. Patient 09: Pt required skilled nursing visits or calls for follow up visits required after identified symptoms on visits dated 6/10/25, 6/17/25 and 6/24/25. The skilled nurse attempted visits and phone calls with communication with the primary caregiver. Documentation and signature was performed late on for follow up care provided 6/11/25, 6/13/25, 6/18/25, 6/19/25, 6/20/25, and 6/23/25 which were entered into the patient record on 6/24/25 and 6/25/25. Patient 11: A skilled nursing visit was performed on 6/19/25, documentation and signature not completed until 6/22/25. Patient 13: A skilled nursing visit was performed on 6/18/25, documentation and signature not completed until 6/22/25. Patient 14: A skilled nursing visit was performed on 3/24/25, documentation and signature not completed until 3/24/25. Patient 15: A skilled nursing visit was performed on 5/29/25, documentation and signature not completed until 6/2/25. Additional skilled nursing visit performed on 6/10/25, documentation and signature not completed until 6/13/25. Skilled nursing visit performed on 6/17/23, documentation and signature not completed until 6/23/25. Patient 16: A skilled nursing visit was performed on 5/19/24, documentation and signature not completed until 5/24/25. Skilled nursing visit performed on 5/26/25, documentation and signature not completed until 5/31/25. Skilled nursing visit performed on 6/2/25, documentation and signature not completed until 6/9/25. Patient 17: A skilled nursing visit was performed on 6/5/25, documentation and signature not completed until 6/9/25. Patient 19: A skilled nursing visit was performed on 6/17/25, documentation and signature not completed until 6/22/25. Patient 20: A Spiritual care visit was performed on 1/16/25, documentation and signature not completed until 1/19/25. A skilled nursing visit was performed on 3/22/25, documentation and signature not completed until 4/1/25. A skilled nursing visit performed on 3/26/25, documentation and signature not completed until 4/1/25. A MSW visit performed on 6/19/25, documentation and signature not completed until 6/22/25. Patient 24: A continuous care visit was performed by skilled nursing on 1/12/25, and 1/13/25, documentation and signature was not completed until 1/23/25. A Death visit was performed by skilled nursing on 1/13/25, documentation and signature was not completed until 1/23/25.”

“Upon observation, there was no evidence the hospice inpatient facility tests their power systems in accordance with NFPA 99 and NFPA 110 including the maintenance and testing of alternate power sources and transfer inspection and testing and maintenance and testing of circuitry. Upon inspection, it is noted that the facility’s alternate power source does not include a remote manual stop/emergency power off switch located outside of the generator housing. NFPA 110, 2010 Edition 5.6.5.6* All installations shall have a remote manual stop station of a type to prevent inadvertent or unintentional operation located outside the room housing the prime mover, where so installed, or elsewhere on the premises where the prime mover is located outside the building. 5.6.5.6.1 The remote manual stop station shall be labeled. “CMS’s longstanding interpretation is that a manual stop needs to be “remote” from the generator as prescribed by 2010 NFPA 110, 5.6.5.6. As such, to be “remote,” a manual stop should not be located on the generator housing.””