Hospice of New Jersey, LLC

“Upon patient record review, 2 of 5 (Patient #1, 2) 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: 4/24/25 order: Insert cath and change as prescribed (specify cath and balloon size, type and frequency). 22 French Supra Pubic Cath. Balloon size not specified. Patient #2: 4/30/25 order: Insert catheter and change as prescribed (specify cath and balloon size type and frequency) - Foley catheter change every 30 days #16. Balloon size not specified.”

“Upon patient record review 2 of 5 (Patient #1, 3) 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: Shave ordered 2x/week. Performed 3x (May 12, 15, 16); 1x only (May19); 1x only (May 29th) Patient #3: Shampoo ordered 2x/wk. Performed 3x; (May19, 21, 23); May 26, 29, 30)”

“Upon patient record review, 11 of 19 (Patient #1,#3,#4,#5,#6,#8,#9,#10,#11,#13,#14) 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:The medical record includes SN documentation on 12/11/24 of O2 in use at 3LPM via NC and SN contact with physician for orders for breathing treatments and lidocaine patch for symptom management. The initial CTI dated 12/3 with notation of requirement by patient of oxygen supplementation at 5 lpm. There is no evidence that the medication profile includes entries for oxygen, breathing treatments or lidocaine patches. Patient 3:The medical record includes SN documentation on 7/11/24 that Nystatin powder and supplemental oxygen was ordered. On 1/8/25 Nystatin cream was ordered to treat breast fungal infection. There is no evidence that medication profile includes orders for Nystatin powder, nystatin cream or oxygen. The medication profile includes an entry for Acetaminophen 325 mg 1 tab q 4 hours PRN with no indication for use. Patient 4:The medication profile includes entries for PRN acetaminophen and lorazepam and an entry for oxygen 2-4 LPM via NC. There is no evidence the entries include the indication for use for acetaminophen and lorazepam and no titration instructions for oxygen. Updated on site. Patient 5 and 11:The medication profile includes entries for Acetaminophen 650 PO Q6 Hrs. PRN and Acetaminophen 650 PO every 6 Hrs. PRN. This is a duplicate entry and there is no indication that the entries include parameters for a daily max dose. Patient 6: The medication profile includes entries for Oxygen, Voltaren Gel and Systane eye drops. There is no evidence that the entries include the route of administration and titration instructions for oxygen and the location for administration and indication for use of Voltaren gel and Systane Ophthalmic drops. Patient 8:The medical record includes SN documentation on admission that the patient requires O2 2LPM NC continuous for dyspnea. There is no evidence that the medication profile includes an entry for oxygen. Patient 9:The medication profile includes entries for Morphine, hyoscine and lorazepam and oxygen. There is no evidence that the entries include an indication for use for morphine, hyoscine and lorazepam and no route or titration instructions for oxygen. Patient 10:The medical record includes SN documentation on 1/17/25 that patient has scopolamine patch order for increased secretions and that enteral feedings are required for nutrition. There is no evidence that the medication profile includes entries for scopolamine and enteral feedings. Patient 13:The medication profile includes entries for oxygen and albuterol treatments. There is no evidence that the entries include flow rate and route for oxygen and the indication for use for the PRN Albuterol Sulfate Nebulizers. Patient 14:The medical record includes SN documentation on 12/30/24 that Nystatin cream was ordered due to redness under bilat breast and 01/07/25 the SN documented a non productive cough and Robitussin ordered. There is no evidence that the medication profile includes entries for Nystatin Cream and Robitussin.”

“Upon patient record review, 2 of 19 (Patient #2,#4) 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 2 and 4: There is no evidence that a bereavement risk assessment was completed within 5 days.”

“Upon patient record review, 5 of 19 (Patient #1,#3,#7,#12,#14) 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 1:The medical record includes nursing documentation on admission of a deep tissue injury to left heel. There is no evidence of assessment and measurements of wound from 12/3/24 through 1/21/25 and 1/21/25 through 3/21/25. Patient 3:The medical record includes nursing documentation on admission of a stage II pressure ulcer to the sacrum. There is no evidence of assessment and measurements of wound from admission to present. Patient 7:The medical record includes nursing documentation on admission of a pressure ulcer to the sacrum. There is no evidence of assessment and measurements of wound from admission to present. Patient 12:The medical record includes nursing documentation on admission of a stage III pressure ulcer to the sacrum. There is no evidence of assessment and measurements of wound from admission to present. Patient 14:The medical record includes nursing documentation on admission of a skin tear to elbow measuring 1x2 skin tear to right knee Measuring 3x2. There is no evidence of assessment and measurements of wound from admission to present.”

“Upon patient record review, 12 of 19 (Patient #1,#2,#3,#4,#5,#6,#8,#9,#10,#11,#13,#14) 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:SN documentation on admission that the patient requires oxygen therapy and breathing treatments for dyspnea, has a primary diagnosis of Nutritional deficiency with an altered diet of pureed, requires feeding and has poor nutrition and hydration. There is no evidence that the plan of care includes problems, goals and interventions for the safety and use of oxygen and altered nutrition and hydration. Patient 2: SN documentation on admission that the patient is noted to be at risk of aspiration. There is no evidence that the plan of care includes problems, goals and interventions to manage the risk of aspiration. Patient 3: SN documentation on admission that the patient requires oxygen therapy and breathing treatments for dyspnea, has a primary diagnosis of Alzheimer’s and has a fungal rash to the breast. There is no evidence that the plan of care includes problems, goals and interventions for the safety and use of oxygen, the neurological management of Alzheimer’s disease or the management of an active fungal infection. Patient 4 and 6:The medical record includes SN documentation on admission that the patient requires oxygen therapy and breathing treatments for dyspnea and has a primary diagnosis of Senile Dementia. There is no evidence that the plan of care includes problems, goals and interventions for the safety and use of oxygen or the neurological management of Senile Dementia. Patient 5:SN documentation on admission that the patient requires oxygen therapy for dyspnea. There is no evidence that the plan of care includes problems, goals and interventions for the safety and use of oxygen. Patient 8:The medical record includes a primary diagnosis of Alzheimer’s, documented comorbidity of Cardiac disease to include placement of pacemaker and Atrial fibrillation and is at risk of for aspiration. There is no evidence that the plan of care includes problems, goals and interventions for the management of Alzheimer’s, cardiac disease and the risk of aspiration. Patient 9:SN documentation on admission that the patient requires oxygen therapy and breathing treatments for dyspnea and has a primary diagnosis of Cancer. There is no evidence that the plan of care includes problems, goals and interventions for the safety and use of oxygen or the management of the primary diagnosis of Cancer. Patient 10:SN documentation on admission that the patient requires enteral feeding via an NG tube and that the patient is at risk for falls. There is no evidence that the plan of care includes problems, goals and interventions for enteral feedings and the management of the risk for falls. Patient 11:SN documentation on admission that the patient has a history of Gastrointestinal bleeding and is currently on anticoagulation therapy. There is no evidence that the plan of care includes problems, goals and interventions to manage the risk of bleeding. Patient 13: SN documentation on admission that the patient requires oxygen therapy for dyspnea and is at risk for falls. There is no evidence that the plan of care includes problems, goals and interventions for the safety and use of oxygen and the management of the risk for falls. Patient 14:There is no evidence of problems, goals and interventions for urinary incontinence and the management of the Pickwick system though documented by SN.”

“Upon patient record review, 8 of 19 (Patient #1,#3,#5,#8,#9,#11,#13,#14) 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:The medical record includes SN documentation on 12/11/24 of O2 in use at 3LPM via NC and SN contact with physician for orders for breathing treatments and lidocaine patch for symptom management. The initial CTI dated 12/3 with notation of requirement by patient of oxygen supplementation at 5 lpm. There is no evidence that the plan of care includes orders for oxygen, breathing treatments or lidocaine patches. Patient 3:The medical record includes SN documentation on 7/11/24 that Nystatin powder and supplemental oxygen was ordered. On 1/8 Nystatin cream was ordered to treat breast fungal infection. there is no evidence that the plan of care includes orders for Nystatin powder, nystatin cream or oxygen. The plan of care includes an order for Acetaminophen 325 mg 1 tab q 4 hours PRN with no indication for use. SN documentation in narrative on 1/21/25 that wound care is being provided as follows: Cleanse with mild soap and water, pat dry, apply xeroform and cover wit Meri plex daily and PRN, however there is no evidence that the plan of care includes wound care orders. Patient 4:There are orders for PRN acetaminophen and lorazepam and for oxygen 2-4 LPM via NC. There is no evidence the entries include the indication for use for acetaminophen and lorazepam and no titration instructions for oxygen. Updated on site. Patient 5 and 11:The medication profile includes entries for Acetaminophen 650 PO Q6 Hrs. PRN and Acetaminophen 650 PO every 6 Hrs. PRN. This is a duplicate entry and there is no indication that the entries include parameters for a daily max dose. Patient 6: There are orders for Oxygen, Voltaren Gel and Systane eye drops. There is no evidence that the orders include the route of administration and titration instructions for oxygen and the location for administration and indication for use of Voltaren gel and Systane Ophthalmic drops. Patient 7:The medical record includes SN documentation that the patient is currently using Remedy antifungal zinc oxide for wound care. There is no evidence of an order for Remedy antifungal zinc oxide. Patient 8:The medical record includes SN documentation on admission that the patient requires O2 2LPM NC continuous for dyspnea. There is no evidence that the plan of care includes an order for oxygen. Patient 9:The plan of care includes orders for Morphine, hyoscine and lorazepam and oxygen. There is no evidence that the orders include an indication for use for morphine, hyoscine and lorazepam and no route or titration instructions for oxygen and has no indication for admin and O2 with no route or titration instructions Patient 13:The plan of care includes an order for oxygen and albuterol treatments. There is no evidence that the orders include flow rate and route for oxygen and the indication for use for the PRN Albuterol Sulfate Nebulizers. Patient 14:The medical record includes SN documentation on 12/30/24 that Nystatin cream was ordered due to redness under bilat breast and 01/07/25 the SN documented a non productive cough and Robitussin ordered. There is no evidence that the plan of care includes orders for Nystatin Cream and Robitussin.”

“Upon patient record review, 2 of 19 (Patient #3,#8) 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 equipment and supply needs. Patient 3:The medical record includes SN documentation on admission that the patient requires a rolling walker for ambulation. There is no evidence that the plan of care includes a rolling walker as an equipment need of the patient. Patient 8:The medical record includes SN documentation on admission that the patient requires the use of a hospital bed. There is no evidence that the plan of care includes a hospital bed as an equipment need of the patient.”

“Upon patient record review, 2 of 19 (Patient #1,#11) 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 1: The medical record includes an order on 03/02/24 for x-ray to right thumb due bruising. There is no documented evidence of SN follow up with IDG team. Patient 11: The medical record includes SN documentation on 2/10 that bloodwork and a urine C/S was ordered with no clinical symptoms noted for reason labs obtained. On 2/12 the MSW noted daughter wanted urine test asap to r/o UTI. Documentation by the SN of refusal for labs to be drawn by patient on 2/12 and that a subsequent lab draw to be completed on 2/14. There is no follow up documentation of labs obtained or follow up by SN.”

“Upon patient record review, 9 of 19 (Patient #1,#2,#4,#5,#7,#10,#11,#12,#14) 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 1:The aide plan of care does not include a frequency for the task of turning and repositioning to be performed. Patient 2:The patient is noted to be at risk for falls and aspiration. The aide plan of care does not include Fall and aspiration precautions. Patient 4:The patient is noted to be at risk for falls and requires oxygen as needed. The aide plan of care does not include Fall and oxygen precautions. Patient 5:The aide plan of care does not include a frequency for the task of shave to be performed. Patient 7:The patient is noted require oxygen as needed and a bed bath is assigned 3 times weekly. The aide plan of care does not include oxygen precautions and there is no task of dressing and undressing assigned. Patient 10:The patient is noted to be at risk for falls. The aide plan of care does not include Fall precautions. Patient 11:The aide plan of care includes the BED Bath 5x weekly and shower 2x weekly. Patient visit frequency is 5 times weekly. Patient 12:The patient is noted to require oxygen as needed. The aide plan of care does not oxygen precautions. Patient 14:The aide POC with bed bath noted that patient/CG is able to make decision of if bath is to be provided. Paid care givers in home 24/7 and patient is unable to make decisions due to dementia.”

“Upon patient record review 4 of 19 (Patient #4,#7,#8,#13) 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 4:The aide plan of care includes task of bed bath assigned 3 times weekly. The aide documentation notes that task was completed 4 times the week of 4/7. Patient 7:The aide plan of care includes a visit frequency of 5 times per week and the task of bed bath ordered 3 times weekly. The aide documentation notes that the patient was seen 6 times the week of 3/16 and that the bed bath was completed 6 times. Patient 8:The aide plan of care includes the task of shampoo hair to be completed 1 time weekly. The aide documentation notes that the task of shampoo hair was completed 3 times the week of 3/17, on 3/17, 3/18 and 3/19. Patient 13:The aide plan of care includes visit frequency of 5 times weekly. The week of 3/31, 3 visits are documented by aide and one note by RN on 3/4 that patient refused visit.”

“Upon patient record review 1 of 19 (Patient #8) 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 8: There is no evidence in the clinical 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”

“Upon patient client record review, 4 of 19 (Patient #3,#4,#11,#12) 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:The medical record includes documentation by the SN that the patient requires a soft diet and the plan of care includes an order for diet as regular as tolerated. Patient 4:The medical record includes documentation by the SN that the patient requires a pureed diet with thin liquids and the MSW notes diet as pureed with thickened liquids. The diet ordered and the plan of care is reg as tolerated Patient 11 and 12: The SN documentation includes the unapproved abbreviations of DCD for dressing type and OD as frequency respectively.”

“Upon client record review, 2 of 19 (Patient #7,#10) 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 7:The medical record includes documentation that the patient requires wound care. The patient is in a facility and there is no evidence of a wound care order on the plan of care. Patient 10:The medical record includes documentation that the patient requires enteral feedings. The patient is in a facility and there is no evidence of an enteral feeding order on the plan of care. The medical record includes SN documentation on 3/21/25 and 3/26 that patient is using oxygen at 3LPM via nasal cannula. The plan of care includes an order for oxygen to be delivered at 2 LPM via nasal cannula as needed for dyspnea.”