Hospice of Orange & Sullivan Counties Inc.

“Observed in Record Review. In 1 of 5 patient records reviewed, During RR# 2’s patient record review it was noted the organization had not ensured staff assessed and reassessed patients per organization policy Comprehensive Assessment that included a comprehensive assessment would be completed as frequently as the patient’s conditions requires. For example: review of RR# 2’s patient record revealed RR# 2 had a terminal diagnosis of pancreatic cancer with metastasis. Review of RR# 2’s start of care (SOC) RN comprehensive assessment revealed RR# 2 was unresponsive, showing signs and symptoms of pain with audible moaning and groaning and was assessed to have a pain intensity of 7 out of 10 on the PAINAD scale. Further review of the start of care RN comprehensive assessment revealed RR# 2 had no shortness of breath during the admission process and the RN advised the wife to administer prescribed Percocet until the comfort pack arrived. Further review of RR# 2’s patient record revealed a Family Nurse Practitioner SOC phone call to RR# 2’s spouse approximately five hours after the SOC RN comprehensive assessment with documentation of a change in patient condition reported by RR# 2’s spouse that now included RR# 2 was agitated, combative, anxious with eyes wide open and has not been taking Percocet and discussed use of morphine and lorazepam - at night to start for anxiety and sleep. Further review of RR# 2’s patient record revealed the subsequent nurse visit was the death visit two days after the SOC. This was reviewed, discussed, and validated with the Clinical Informatics and Support Service Manger and the Director of Nursing. Observed in Record Review. In 1 of 5 patient records reviewed, During RR# 4’s patient record review it was noted the organization had not ensured staff followed the organization policy Pain Management that included pain would be assessed on character, location, duration, and intensity will be assessed using a pain rating scale of 0-10. For example: review of RR# 4’s patient record revealed a Licensed Practical Nurse (LPN) dated approximately 16 days prior to the surveyor review of the record with documentation still struggling with pain management and no documentation of pain duration, character, or intensity. This was reviewed, discussed, and validated with the Clinical Informatics and Support Service Manager and the Director of Nursing.”

“Observed in Record Review. In 1 of 5 patient records reviewed, During RR# 4’s patient record review it was noted the organization had not ensured the RN updated the comprehensive assessment no less than every 15 days. For example: in review of RR#4 patient record revealed RN comprehensive assessment was not performed in the past 30 days prior to the surveyor review of the record. Further review of RR# 4’s patient record revealed no subsequent RN comprehensive assessments. This was reviewed, discussed, and validated with the Clinical Informatics and Support Service Manger and Director of Nursing.”

“Observed in Record Review. In 1 of 5 patient records reviewed, During RR# 4’s patient record review it was noted the organization had not ensured the patient’s plan of care was based on the patient’s goals and the time frames, settings, and services required to meet those goals. For example: review of RR# 4’s patient record revealed the terminal diagnosis of cancer of the mouth secondary of lymph nodes. Review of RR# 4’s start of care RN comprehensive assessment revealed documentation that RR# 4 had difficulty swallowing and was able to eat pureed soup and liquids. Review of RR# 4’s plan of care revealed no goals related to RR# 4’s altered swallowing ability. This was reviewed, discussed, and validated with the Clinical Informatics and Support Service Manager and the Director of Nursing.”

“Observed in Record Review. In 1 of 5 patient records reviewed, During RR# 4’s patient record review it was noted the organization had not ensured the plan of care included all services need for the palliation and management of terminal illness and related conditions, including interventions to manage pain and symptoms. For example: review of RR# 4’s patient record revealed RR# 4 had a terminal diagnosis of cancer of the mouth secondary of lymph nodes. Review of RR# 4’s start of care RN comprehensive assessment revealed documentation that RR# 4 had difficulty swallowing and was able to eat pureed soup and liquids. Review of RR# 4’s plan of care revealed no documentation of interventions related to RR# 4’s altered swallowing ability or pureed diet. This was reviewed, discussed, and validated with the Clinical Informatics and Support Service Manager and Director of Nursing.”

“Observed in Record Review. In 1 of 1 patient records reviewed with hospice aide, During RR# 5’s patient record review it was noted the organization had not ensured the RN supervised the hospice aide during on-site visit to the patient’s home no less frequently than every 14 days. For example: review of RR# 5’s patient record revealed the hospice aide had been providing services for 27 days prior to the first documented RN Supervisory visit. This was reviewed, discussed, and validated with the Clinical Informatics and Support Service Manager and the Director of Nursing.”

“Observed in Record Review. In 1 of 5 patient records reviewed, clinical record did not contain all information. Review of the On call log for 4/30/25 revealed documentation that RR# 2’s spouse called approximately one hour before the organization opened with the concern not breathing well during the night. see EMR. Review of RR# 2’s patient record/EMR revealed no documentation of the RR# 2’s spouse calling the hospice or reporting RR# 2’s breathing. This was reviewed, discussed, and validated with the Clinical Informatics and Support Service Manger and the Director of Nursing.”

“Observed in Record Review. In 1 of 24 patient records reviewed, the organization had not followed its pain assessment policy. In the chart for RRDC#20, upon admission the patient had been assessed to have a fentanyl patch and prn Morphine ordered for pain control, yet the comprehensive assessment did not include a pain assessment, rather indicated that the patient denied pain. Pain Management policy required that a comprehensive pain assessment/evaluation would be assessed and documented on admission including a minimum set of items including location, severity, frequency, etc. This was discussed with the CNO and CCO.”

“Observed in Record Review. In 4 of 24 patient records reviewed, the written plan of care was not based on the patient’s goals and the time frames, settings, and services required to meet those goals. In the chart for RRHV#4, one of the patient’s most significant issues was pain control. The pain control goal of Patient will verbalize adequate relief of pain with the use of current pain medications did not include a timeframe for completion. In the chart for RRNHV#7, the diabetes goal was not measurable nor time based. Patient will have optimal glucose control through diet; the MSW goal ...husband wishes to hire more private caregivers to provide personal care to (patient name deleted), did not include a time frame for completion. In the chart for RRNHV#10, the goals on the POC were not measurable and/or time based. For example, patient’s pain will be controlled, prevention of falls and fall injury the caregiver will demonstrate oxygen management focused on safe use and safe storage with independence. In the chart for RRNHV#14, the time frame for anticipated goal attainment was not appropriate to the problem for this patient with metastatic cancer. Patient will verbalize adequate relief of pain with the use of current pain medications within the cert period. This was discussed with the CNO.”

“Observed in Record Review. In 2 of 24 patient records reviewed, the plan of care did not include all services needed for the palliation and management of the terminal illness and related conditions, including the following: A statement of the scope and frequency of the services necessary to meet the patient’s and family’s needs. In the chart for RRH#6, the patient has been receiving weekly volunteer visits for more than one year. While these visits are mentioned in the IDT notes for the MSW, when the plan of care is revised at each benefit period, there is no inclusion of the volunteer services on the revised plans of care. In the chart for RRNHV#13, the aide frequency range was written as 1-5 visits per week for 13 weeks, outside the acceptable range of no more than 2 visit range. This was discussed with the DON.”

“Observed in Record Review. In 3 of 24 patient records reviewed, the plan of care did not include all services needed for the palliation and management of the terminal illness and related conditions, including the following: Medical supplies and appliances necessary to meet the patient’s needs. In the charts for RRHV#1, RRHV#2 and RRNHV#13, the plans of care did not list the DME needed, it simply stated DME provided by SNF. The patient in RRHV#1 required a wheelchair as well as upper bed rails on the bed for fall precautions/spacial awareness. The patient in RRHV#2 required a wheelchair, low air loss mattress, oxygen prn, etc. In the chart for RRNHV#13, the interventions for falls precautions were not specific to the patient and simply stated Educate patient and family on patients fall risk and risk reduction strategies. The patient’s assessment revealed the patient was mostly bed bound, yet was at times able to pivot transfer, however required 2 person assist for transfers. This was discussed with the CNO and CCO.”

“Observed in Record Review. In 2 of 24 patient records reviewed, the organization had not provided the patient with care, treatment, or services according to the patient’s individualized plan of care. In the chart for RRNHV#10, on multiple visits the LPN documented the oxygen was at either 2lpm or 3lpm, yet the ordered rate is 4lpm. In the chart for RRNHV#11, nursing did not follow the visit frequency required by the hospice plan of care. SN visits were ordered 1-2 times weekly, yet there was no visit, nor documentation of a missed visit in week 5 of care. This was discussed with the CNO.”

“Observed in Record Review. In 3 of 24 patient records reviewed, the patient record was not available to review and/or was inaccurately documented. In the chart for RRHV#6, the volunteer is seeing the patient weekly. There are no volunteer notes scanned into the patient record for more than one year. In the chart for RRHV#4, the patient had been on service for more than one month with aide visits 1-2 times weekly. There were only 3 aide visit notes documented in the record at the time of survey. Paper notes had not been scanned into the record, but were available in the organization. In the chart for RRIPU#23 there was incorrect documentation. Another patient’s name and gender referenced in the narrative of the admission visit. This was discussed with the CCO.”