Holy Redeemer Hospice-NJ, South

“Upon patient record review, 3 of 19 (Patient #2, 3, 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 #2: Patient admitted with indwelling Foley catheter. No related problems, goals and interventions. Patient #3: Patient with history of falls including preadmission fall resulting in fractured humerus. No initial problems, goals and interventions for safety precautions and also skin tear leg with no initial problems, goals interventions related to wound/skin integrity Patient #6: Patient admitted with Eliquis prescribed and no problems, goals, interventions related to bleeding precautions.”

“Upon patient record review, 3 of 19 (Patient #2, 6, 12) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient #2: Patient with indwelling Foley catheter. Aide Care Plans do not include reference to Foley. Patient #6: Patient with Eliquis prescribed and Aide Care Plan do not include related bleeding precautions. Patient #12: Patient with nephrostomy tube/drainage bag and Aide Care Plan do not include related alert/reference.”

“Upon patient client record review, 7 of 19 (Patient #6, 7, 8, 11, 12, 13, 14) 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 #6: SN visit 10/24/25 RN documented gross hematuria. MD contacted. RN did not reference/acknowledge that patient was on Eliquis at the time. Patient was treated for UTI and hematuria resolved. Patient #7: Initial RN SOC assessments includes goals not met: Foley catheter patent (requires more time), but GU includes incontinence only and no reference to Foley. Interview with staff verifies patient did/does not have indwelling catheter. Patient #8: Initial RN SOC assessment includes goals met: Foley patent, understanding of Foley catheter care. GU includes incontinence only and no reference to Foley. Interview with staff verifies patient did/does not have indwelling catheter. Patient #11 Initial RN SOC assessment includes goals met: Foley catheter patent, understanding of Foley catheter care. No other reference to Foley catheter. Interview with staff verifies patient did/does not have indwelling catheter. Patient #12: Page 2 of Consent form states projected disciplines and visit frequencies... “At this time, I understand that my physician has ordered the following services for me at the stated visit frequency: SN 1-3/wk., SC 1-2/mo., PT eval, SW 1-2/mo., Vol eval, OT eval, Home Health Aide eval, Dietician eval, ST eval..... “ Interview with staff agree service not actually ordered with intent, more to validate advised patient/CG of all services available. Patient #13: Admission Consent form Page 2 states projected disciplines and visit frequencies: “At this time, I understand that my physician has ordered the following services for me at the stated visit frequency: SN 1-3/wk., SC 1-2/mo., PT eval, SW 1-2/mo., Vol eval, OT eval, HA eval, dietician eval, ST eval...” Interview with staff agree service not actually ordered with intent, more to validate advised patient/CG of all services available. The 2/7/26 initial RN SOC assessment note lists last catheter change as 2/2/26. SN note 3/2/26 states patient catheter last changed 1/28/26. 3/4/26 note says catheter last changed 3/3/26, but there is no note for that date. 3/2 note says catheter will not be changed. Patient #14: Admission Consent form Page 2 states projected disciplines and visit frequencies: At this time, I understand that my physician has ordered the following services for me at the stated visit frequency: SN 1-3/wk., SC 1-2/mo., PT eval, SW 1-2/mo., Vol eval, OT eval, HA eval, dietician eval, ST eval...” Interview with staff agree service not actually ordered with intent, more to validate advised patient/CG of all services available.”