Supportive Care of Orleans

“Based on review of clinical records and interviews with staff, the hospice failed to ensure in three (3) of fourteen (14) clinical records (Patient #s: 2, 8, and 12) the content of the comprehensive assessment is of sufficient scope to identify all of the patient’s needs in order to promote the patient’s well-being and comfort throughout the dying process. Failure to ensure assessments are comprehensive has the potential for unmet patient needs and the likelihood of patient harm.The hospice failed to ensure the content of the comprehensive assessment is of sufficient scope to identify all of the patient’s needs in order to promote the patient’s well-being and comfort throughout the dying process as evidenced by the following: Patient #2 – This 105-year-old patient with a terminal diagnosis of nutritional marasmus was admitted to the hospice on 02/03/2025.Review of the Initial Visit dated 02/03/2025 and Oncall/Unscheduled Visit dated 02/04/2025 and 02/05/2025 revealed the Registered Nurse documented the patient has a traumatic wound to their left forehead, that is not healing, and wound measurements were not obtained. The agency failed to measure wounds, to include a length, width, and depth.During interview on 06/09/2025 at 02:51 PM, the Home Care Registered Nurse stated wound measurements were not done. Patient #8 – This 100-year-old patient with a terminal diagnosis of acute combined systolic (congestive) and diastolic (congestive) heart failure was admitted to the hospice on 05/20/2025.Review of the Initial Visit dated 05/20/2025 and Routine Visits dated 05/22/2025 and 05/27/2025 revealed the Registered Nurse documented the following:- Pressure ulcer - coccyx, stage 1, length - 4.2 centimeters, and width – 3.5 centimeters, and- Pressure ulcer – right heel, suspected deep tissue injury, length 2.3 centimeters, and width 2.3 centimeters. Review of the Routine Visit dated 06/02/2025 and the Oncall/Unscheduled visit dated 06/06/2025 revealed the Registered Nurse documented the following:- Pressure ulcer – gluteal cleft, stage 1, length - 4.4 centimeters, and width – 3.7 centimeters;- Pressure ulcer – right heel, suspected deep tissue injury, length 3.4 centimeters, and width 3.7 centimeters;- Pressure ulcer – mid-back, stage 1, length – 0.4 centimeters, and width – 0.2 centimeters; and- Pressure ulcer – left upper coccyx, stage 1, length 1.2 centimeters, and width 0.8 centimeters. The agency failed to measure wounds, to include a length, width, and depth.During interview on 06/09/2025 at 11:51 AM, the Clinical Services Director stated that including a depth measurement has not historically been done but moving forward they will ensure a depth is included in all wound assessments. Patient #12 - This 76-year-old patient with a terminal diagnosis of malignant melanoma of overlapping sites of skin was admitted to the hospice on 02/21/2025.Review of the Initial Visit dated 02/21/2025 revealed the Registered Nurse documented the patient is a non-insulin dependent Type 2 diabetic who is prescribed Metformin.Review of the Physician Orders/Plan of Care for 02/21/2025 to 05/21/2025, revealed orders for the following:- Fingerstick blood sugar: Daily – contact Hospice if blood glucose more than 300; - Educate: signs and symptoms of hyper and hypoglycemia; and- Metformin HCL 500 mg every day by mouth; one (1) tablet daily as needed for elevated blood glucoseReview of the Routine Visits dated 02/27/2025 and 03/07/2025 lacked documented evidence of the following: an assessment of the patient’s endocrine status, a fingerstick blood glucose, and education for signs and symptoms of hyper and hypoglycemia.During interview on 06/09/2025 at 02:28 PM, the Clinical Services Director stated the agency does not perform fingerstick blood glucose checks for diabetic assessments and that the family of the patient typically monitors diabetic symptoms. The Clinical Services Director also stated the families are educated to report to the Registered Nurse if there is a concern. During interview on 06/09/2025 at 02:29 PM, the Home Care Coordinator stated the patient was reluctant to have daily finger sticks completed by his family for blood glucose checks.”

“Based on review of clinical records and interviews with staff, the hospice failed to ensure for one (1) of fourteen (14) clinical records (Patient #5), that the nursing staff completed an accurate and comprehensive drug review. Specifically, the hospice failed to ensure dosages are consistent with recommended guidelines. Failure to complete an accurate and comprehensive drug review has the potential for patients to experience drug interactions/side effects and may result in the Interdisciplinary Group (IDG) acting in inaccurate information. Patient #5 - This 78-year-old patient with a terminal diagnosis of chronic obstructive pulmonary disease with (acute) exacerbation was admitted to the hospice on 05/09/2025.Review of the Physician’s Orders/Plan of Care from 05/09/2025 to 08/06/2025 revealed the following orders:- Tylenol Extra Strength 500 milligram tablet, take one (1) tablet by mouth every six (6) hours as needed for pain/fever, and - Acetaminophen Rectal Suppository 650 milligram rectal suppository, take one (1) rectal suppository every six (6) hours as needed for pain/fever. Review of the Acetaminophen (Tylenol) manufacturers guidelines revealed the maximum daily dose of Acetaminophen (Tylenol) is 3,000 mg to 4,000 mg in twenty-four (24) hours. Based on the prescribed dosage, if the patient was administered the Acetaminophen (Tylenol) as ordered, the patient could receive 4,600 milligrams in twenty- four (24) hours. (600 milligrams to 2,600 milligrams above the maximum daily dose). Review of the clinical record from 05/09/2025 to 06/09/2025 lacked documented evidence of a comprehensive drug review to ensure dosages are consistent with recommended guidelines.During interview on 06/09/2025 at 10:50 AM, the Home Care Coordinator stated, the rectal Tylenol is in place for when the patient can no longer swallow. The Home Care Coordinator stated the patient would never use the oral and rectal Tylenol at the same time. The Home Care Coordinator stated that they would make the order more specific in the future.”

“Based on review of clinical records and interviews with staff, for ten (10) of fourteen (14) patients (Patient #’s: 1, 2, 4, 5, 6, 7, 8,10, 11 and 12) the hospice failed to develop individualized written plans of care that reflect patient and family goals and that are based on the problems identified in the initial and updated comprehensive assessments. Failure to develop complete, individualized plans of care has the potential for unmet patient needs and health status to be compromised, resulting in poor quality of care.The hospice failed to develop an individualized written Plan of Care that reflects the patient and family goals, and is based on the problems identified in the initial and updated comprehensive assessments as evidenced by the following: Patient #8 – This 100-year-old patient with a terminal diagnosis of acute combined systolic (congestive) and diastolic (congestive) heart failure was admitted to the hospice on 05/20/2025.A. Review of the Physician’s Orders/Plan of Care from 05/20/2025 to 08/17/2025 revealed an order for an as tolerated diet. The Plan of Care lacked an order for a therapeutic diet.During interview on 06/09/2025 at 11:37 AM, the Home Care Registered Nurse stated the patient was eating a regular diet with thin liquids, as tolerated. The Home Care Registered Nurse stated the patient’s diet was poor and that is why they wrote an order for an as tolerated diet.B. Review of Supplemental Order dated 05/28/2025 revealed the order MSS (Medical Social Services) one (1) to three (3) times a month for three (3) months and four (4) PRN (as needed) visits.During interview on 06/09/2025 at 11:45 AM, the Social Worker stated the as needed visits are for any additional psychosocial needs, but that this is not included in the order they wrote on 05/28/2025. Patient #2 – This 105-year-old patient with a terminal diagnosis of nutritional marasmus was admitted to the hospice on 02/03/2025.Review of Supplemental Order dated 02/03/2025 revealed the order MSS (Medical Social Services) one (1) to three (3) times a month for three (3) months and four (4) PRN (as needed) visits.During interview on 06/09/2025 at 03:07 PM, the Social Worker stated that the order does not contain an indication for the as needed visits, but the as needed visits are for any additional psychosocial needs. Patient #5 - This 78-year-old patient with a terminal diagnosis chronic obstructive pulmonary disease with (acute) exacerbation was admitted to the hospice on 05/09/2025.Review of Supplemental Order dated 05/09/2025 revealed the order MSS (Medical Social Services) one (1) to three (3) times a month for three (3) months and four (4) PRN (as needed) visits.During interview on 06/09/2025 at 03:07 PM, the Social Worker stated that the order does not contain an indication for the as needed visits, but the as needed visits are for any additional psychosocial needs. Patient #12 - This 76-year-old patient with a terminal diagnosis of malignant melanoma of overlapping sites of skin was admitted to the hospice on 02/21/2025.Review of the Initial Visit dated 02/21/2025 reveals the Registered Nurse documented the patient is a non-insulin dependent Type 2 diabetic who is prescribed Metformin.Review of the Physician Orders/Plan of Care for 02/21/2025 to 05/21/2025, revealed orders for the following:- Fingerstick blood sugar: Daily – contact hospice if blood glucose more than 300; - Educate: signs and symptoms of hyper and hypoglycemia; and- Metformin HCL 500 mg every day by mouth; one (1) tablet daily as needed for elevated blood glucoseReview of the Physician’s Orders/Plan of Care for 02/21/2025 to 05/21/2025, lacked an order for blood glucose monitoring supplies to include glucometer, lancets, and blood glucose test strips.During interview on 06/09/2025 at 02:31 PM, the Clinical Services Director stated there is no physician order for blood glucose monitoring supplies. Patient #7 – This 74-year-old patient with a terminal diagnosis of metastatic ovarian cancer was admitted to the Hospice on 05/05/2025.A. Review of the Physician Orders/Plan of Care from 5/5/2025 to 8/2/2025 revealed the following orders:“Fingerstick blood sugar as ordered: Blood sugars are checked three times (3x) per day (before meals) and as needed for signs and symptoms of hypo/hyperglycemia.Novolin 70/30 flexpen subcutaneous suspension pen-injector 100 units/milliliter. 10 units before meals subcutaneously.Review of the Physician Orders/Plan of Care from 5/5/2025 to 8/2/2025 revealed the following durable medical equipment/supplies: “ordered through respiratory services hospital bed four (4) half rails, alternating pressure (APP) mattress, bedside table, commode 22 inches, wheelchair – exchanged for transport chair on 5/6.”The plan of care lacked durable medical equipment and supplies orders for the following: a glucometer and diabetic supplies (lancets, testing strips, insulin pen needles) necessary to monitor blood glucose levels and administer insulin.During interview on 6/9/2025 at 2:08 PM, the Clinical Services Director confirmed that the glucometer, lancets, testing strips, and insulin pen needles are not listed on the plan of care. B. Review of the Physician Orders/Plan of Care from 5/5/2025 to 8/2/2025 revealed the following orders:“Fingerstick blood sugar as ordered: Blood sugars are checked 3x per day (before meals) and as needed for signs and symptoms of hypo/hyperglycemia.Novolin 70/30 flexpen subcutaneous suspension pen-injector 100 units/milliliter. 10 units before meals subcutaneously.”The plan of care lacked blood glucose parameters for the administration of insulin.During interview on 6/9/2025 at 2:06 PM, the Clinical Services Director stated that the agency’s policy does not state that parameters must be included but believes it should be included as best practice. C. Review of the Physician Orders/Plan of Care from 5/5/2025 to 8/2/2025 revealed the following order:“Ipratropium-albuterol inhaler solution 0.5-2.5 3 milligrams per 3 milliliters four times a day as needed. Inhale 3 milliliters via nebulizer 4 times daily as needed for wheezing/shortness of breath.”Review of the Physician Orders/Plan of Care from 5/5/2025 to 8/2/2025 revealed the following durable medical equipment/supplies: “ordered through respiratory services hospital bed four (4) half rails, alternating pressure (APP) mattress, bedside table, commode 22 inches, wheelchair – exchanged for transport chair on 5/6.”The plan of care lacked durable medical equipment and supplies orders for medical equipment (nebulizer) necessary to administer inhalation treatments.During interview on 6/9/2025 at 2:08 PM, the Clinical Services Director confirmed that the nebulizer is not listed on the plan of care. D. Review of Supplemental Order dated 5/5/2025 revealed the following: “Master of Social Service (MSS) 4 as needed (PRN): additional Social Work (SW) visits as needed.”The as needed (PRN) frequency order for Social Work (SW) lacked a qualifier for the as needed additional visits.During interview on 6/9/2025 at 2:09 PM, the Clinical Services Director stated that the Social Worker was unaware of the requirement to include a qualifier for as needed orders and will add to orders moving forward. In addition, the Social Worker stated that the order should state “as needed for additional psychosocial issues.” Patient #1 – This 60-year-old patient with a terminal diagnosis of malignant neoplasm of overlapping sites of bladder was admitted to the Hospice on 05/09/2025.A. Review of the Initial visit comprehensive assessment on 5/9/2025 revealed the Registered Nurse documented the following:“Genitourinary – voiding method: urinary diversion. Urinary symptoms: none. Genitourinary observation: urine clear, direct observation.Urinary Diversion – type: ileal conduit. Site: date performed: 5/9/2025. Pouch type: two (2) piece. Frequency of pouch change in days: two to three (2-3) days and as needed. Date of last pouch change: 05/09/2025. Assess stoma: yes. Stoma details: pink, round shape. Stoma appearance: moist, edematous, protruding. Peristomal skin: intact.”Review of the Physician Orders/Plan of Care from 5/9/2025 to 8/6/2025 revealed the following durable medical equipment/supplies: “at home cane, commode, wheelchair ramp, ordered at start of care hospital bed four (4) half rails, alternating pressure (APP) mattress, bedside table, wheelchair.”The durable medical equipment/supplies lacked the supplies necessary to manage the patient’s urostomy site.During interview on 6/9/2025 at 09:58 AM, the Clinical Services Director stated that the urostomy supplies should have been included in the plan of care but were missed. B. Review of Supplemental Order dated 5/9/2025 revealed the following: “Master of Social Service (MSS) four (4) as needed (PRN): additional Social Work (SW) visits as needed.”The as needed (PRN) frequency order for Social Work lacked a qualifier for use of additional visits.During interview on 6/9/2025 at 10:02 AM, the Clinical Services Director stated that the Social Worker was unaware of requirement of qualifier for as needed orders and will add to orders moving forward. Patient #11 – This 90-year-old patient with a terminal diagnosis of End Stage Alzheimer’s Disease was admitted to the Hospice on 03/13/2025.A. Review of Supplemental Order dated 3/13/2025 revealed the following order: “Master of Social Service (MSS) four (4) as needed (PRN): additional visits as needed.”The as needed (PRN) frequency order for Social Work lacked a qualifier for use of additional visits.During interview on 6/9/2025 at 10:24 AM, the Social Worker stated she did not know that was a requirement. Patient #4 – This 77-year-old patient with a terminal diagnosis of malignant neoplasm of the bladder was admitted to the hospice on 05/16/2025. Review of the Supplemental Order dated 05/16/2025 revealed an order for MSS (Medical Social Services) one (1) to three (3) times a month for three (3) and four (4) PRN (as needed): additional SW (Social Work) visits PRN (as needed). There is a lack of documented evidence of the reason for the PRN (as needed) visits. During an interview on 06/09/2025 at 09:47 AM, the Social Worker stated that the PRN (as needed) visits would be if a need arises. The Director of Clinical Services stated that adding a reason to the PRN (as needed) frequency would be an easy fix. Patient #6 – This 97-year-old patient with a terminal diagnosis of acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure was admitted to the hospice on 04/09/2025. Review of the Supplemental Order dated 04/09/2025 revealed an order for MSS (Medical Social Services) one (1) to three (3) times a month for three (3) months and three PRN (as needed): additional SW (Social Work) visits PRN (as needed). There is a lack of documented evidence of the reason for the PRN (as needed) visits. During an interview on 06/09/2025 at 10:35 AM, the Social Worker stated that the PRN (as needed) visits would be for additional psychosocial needs and that the reason for the PRN (as needed) visits would need to be included. Patient #10 – This 87-year-old patient with a terminal diagnosis of malignant neoplasm of unspecified part of unspecified bronchus or lung was admitted to the hospice on 01/23/2025. Review of the Supplemental Order dated 01/23/2025 revealed an order for MSS (Medical Social Services) two (2) to four (4) times a month for three (3) months and four (4) PRN (as needed): additional SW (Social Work) visits PRN (as needed). There is a lack of documented evidence of the reason for the PRN (as needed) visits. During an interview on 06/09/2025 at 11:16 AM, the Social Worker stated that the PRN (as needed) visits would be for additional psychosocial needs and that the reason for the PRN (as needed) visits would need to be included.”

“Based on review of clinical records and interviews with staff, the Hospice failed to ensure in two (2) of fourteen (14) patients (Patient #s: 2 and 10) that care and services are provided in accordance with the Plan of Care (POC). Specifically, the Registered Nurse failed to obtain an order for arthritis compression and an order for an antibiotic. Failure to provide care in accordance with the patient’s established plan of care has the potential to result in inappropriate care, unmet patient needs, and negative patient outcomes. Patient #2 – This 105-year-old patient with a terminal diagnosis of nutritional marasmus was admitted to the hospice on 02/03/2025.Review of the Case Conference Summary report dated 05/29/2025 revealed the Registered Nurse documented the patient had a general decline last week and was treated for a suspected aspiration pneumonia with a z-pack (an antibiotic used to treat various bacterial infections).Review of the clinical record from 05/29/2025 to 06/09/2025 lacked documented evidence of an order for a z-pack.During interview on 06/09/2025 at 03:16 PM, the Clinical Services Director stated they would ask the responsible Registered Nurse about the missing order. The Clinical Services Director later stated that there was never an order placed for the z-pack discussed in the 05/29/2025 interdisciplinary meeting. Patient #10 – This 87-year-old patient with a terminal diagnosis of malignant neoplasm of unspecified part of unspecified bronchus or lung was admitted to the hospice on 01/23/2025. Review of the Charts/Clinical Notes dated 05/06/2025 revealed the Registered Nurse documented the following: the patient is wearing an arthritis compression glove to the patient’s right hand and states that it helps provide some relief when the patient is using their hand. Review of the clinical record from 01/23/2025 to 06/09/2025 lacked documentation of an order for the arthritis compression glove. During an interview on 06/09/025 at 11:30 AM, the Registered Nurse state that the arthritis compression glove should be on the plan of care but that the arthritis compression glove is not.”

“Based on review of clinical records and interviews with staff for one (1) of fourteen (14) clinical records (Patient #6), the hospice failed to ensure ongoing sharing of information between all members of the Interdisciplinary Group. Failure to ensure ongoing sharing of information can result has the potential unmet patient needs. The Registered Nurse failed to update the Interdisciplinary Group as evidence by: Patient #6 – This 97-year-old patient with a terminal diagnosis of acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure was admitted to the hospice on 04/09/2025. Review of the clinical record revealed the Registered Nurse completed a Hospice v25.1 (Comprehensive Update 25) Routine Visit on 04/30/2025 and 05/07/2025. Review of the Case Conference Summary Report (Interdisciplinary Group Meeting) dated 05/08/2025 lacked documented evidence of a discussion/outcomes regarding the patient since the last IDG review by the Registered Nurse (Case Manager) on 04/24/2025. During an interview on 06/09/2025 at 10:40 AM, the Director of Clinical Services stated that I don’t know why there is not an update on the patient’s status/progress by the Registered Nurse and all I can do is show you that the Registered Nurse was at the Interdisciplinary Group meeting.”

“Based on review of clinical records and interview with agency staff, for nine (9) of fourteen (14) patients (Patient #s: 1, 2, 5, 6, 7, 8, 10, 11, and 14) the hospice failed to ensure the clinical record is complete and contains all pertinent information, is consistent, and accurately reflects the care and delivery of service to the patient. Failure to ensure clinical records are complete and contain all pertinent and accurate information related to patient care and services has the potential to result in inadequate and inappropriate care.The agency failed to ensure clinical records are complete, contain all pertinent information, and consistently and accurately reflects the care and delivery of service to the patient as evidenced by: Patient #1 – This 60-year-old patient with a terminal diagnosis of malignant neoplasm of overlapping sites of bladder was admitted to the Hospice on 05/09/2025.A. Review of the medication list provided on 06/03/2025 revealed the following“Methadone Hydrochloride by mouth tablet 10 milligrams. Start date: 05/27/2025. Covered by Hospice: No”During an interview on 06/10/2025 at 1:00 PM, the Clinical Services Director stated that the medication is covered by the agency, and that there was a clerical error while entering the medication into the electronic medical records medication profile.The agency failed to ensure the clinical record accurately captures the coverage of medications.B. Review of the Case Conferences Summary report revealed the following: “5/15/2025 Interdisciplinary Group 5 day, Team B”Review of the Interdisciplinary Team Attendance Sheet revealed the following date: “5/14/2025”During an interview on 06/10/2025 at 12:07 PM, the Clinical Services Director stated that the date on the sign in sheet was a clerical error and confirmed the Interdisciplinary group occurred on 5/15/2025.The agency failed to ensure the clinical record accurately and consistently captured the date of the Interdisciplinary Group meeting. Patient #7 – This 74-year-old patient with a terminal diagnosis of metastatic ovarian cancer was admitted to the Hospice on 05/05/2025.A. Review of the medication list provided on 06/04/2025 revealed the following:“Lorazepam by mouth tablet 0.5 milligrams. Start date: 05/16/2025. End date:05/18/2025 Covered by Hospice: NoXanax by mouth tablet 0.5 milligrams. Start date: 05/18/2025. Covered by Hospice: NoLevaquin by mouth tablet 250 milligrams. Start date 5/16/2025. Covered by Hospice: NoBuspirone Hydrochloride by mouth tablet 15 milligrams. Start date 05/15/2025. Covered by Hospice: No.”During an interview on 06/10/2025 at 1:00 PM, the Clinical Services Director stated that the medications are covered by the agency, and that there was a clerical error while entering the medications into the electronic medical records medication profile.The agency failed to ensure the clinical record accurately captures the coverage of medications. Patient #11 – This 90-year-old patient with a terminal diagnosis of End Stage Alzheimer’s Disease was admitted to the Hospice on 03/13/2025.A. Review of the medication list provided on 06/04/2025 revealed the following:“Gabapentin by mouth 100 milligrams. Start date: 03/13/2025. Covered by Hospice: NoSeroquel by mouth tablet 50 milligrams. Start date: 4/09/2025. Covered by Hospice: No”During an interview on 06/10/2025 at 1:00 PM, the Clinical Services Director stated that the medications are covered by the agency, and that there was a clerical error while entering the medications into the electronic medical records medication profile.The agency failed to ensure the clinical record accurately captures the coverage of medications. Patient #14 – This 70-year-old patient with a terminal diagnosis of End Stage Heart Failure was admitted to the Hospice on 04/17/2024.A. Review of the medication list provided on 06/05/2025 revealed the following:“Morphine Sulfate (Concentrate) by mouth solution 100 milligrams per 5 milliliters. Start Date: 4/20/2024. End Date 04/22/2024. Covered by Hospice: NoOndansetron Hydrochloride by mouth tablet 4 milligrams. Start date: 4/17/2024. End date: 6/1/2024. Covered by Hospice: NoLorazepam by mouth tablet 1 milligram. Start date: 5/28/2024. End Date 6/1/2024. Covered by Hospice: NoLorazepam by mouth tablet 0.5 milligram. Start date: 4/22/2024. End date 4/23/2024. Covered by Hospice: No.Bumetanide by mouth tablet 2 milligrams. Start date: 4/17/2024. End date 6/1/2024. Covered by Hospice: No.Midodrine Hydrochloride by mouth tablet 5 milligrams. Start date: 4/17/2024. End date 6/1/2024. Covered by Hospice: No.Spironolactone by mouth tablet 50 milligrams. Start date: 4/17/2024. End date: 6/1/2024. Covered by Hospice: No.Tamsulosin Hydrochloride by mouth capsule 0.4 milligrams. Start date: 4/17/2024. End date: 6/1/2024. Covered by Hospice: No.Allergy relief (loratadine) by mouth 10 milligrams. Start date: 4/17/2024. End date: 6/1/2024. Covered by Hospice: No.Morphine Sulfate (concentrate) by mouth solution 100 milligrams per 5 milliliters. Start date: 4/22/2024. End date: 6/1/2024. Covered by hospice: No.Lorazepam by mouth tablet 0.5 milligrams. Start date: 4/17/2024. End date: 4/22/2024. Covered by Hospice: No.Senna S by mouth tablet 8.6 milligrams – 50 milligrams. Start date: 4/22/2024. End date: 6/1/2024. Covered by Hospice: No.Morphine sulfate (concentrate) by mouth solution 100 milligrams per 5 milliliters. Start date: 4/17/2024. End date: 4/20/2024. Covered by Hospice: No.Lorazepam by mouth tablet 1 milligram. Start date: 4/23/2024. End date: 5/28/2024. Covered by Hospice: No.Ipratropium-albuterol inhaler solution 0.5-2.5 3 milligrams per 3 milliliters. Start date: 5/18/2024. End date: 6/1/2024. Covered by Hospice: No.Atropine sulfate ophthalmic solution 1%. Start date: 5/29/2024. End date: 6/1/2024. Covered by Hospice: No.” During an interview on 06/10/2025 at 1:00 PM, the Clinical Services Director stated that the medications are covered by the agency, and that there was a clerical error while entering the medications into the electronic medical records medication profile.The agency failed to ensure the clinical record accurately captures the coverage of medications. Patient #2 – This 105-year-old patient with a terminal diagnosis of nutritional marasmus was admitted to the hospice on 02/03/2025.A. Review of the Case Conferences Summary Report dated 05/15/2025 revealed the Interdisciplinary Group meeting was held on 05/15/2025.Review of the IDT (Interdisciplinary Team) Attendance Sheet dated 05/14/2025 revealed the Interdisciplinary Team meeting was held on 05/14/2025 from 12:00 PM to 01:00 PM.There is inconsistent documentation regarding the date that the Interdisciplinary Group met.During interview on 06/10/2025 at 12:07 PM, the Director of Clinical Services stated that the date of the sign in sheet is a clerical issue and confirmed the date of the Interdisciplinary meeting was 05/15/2025. B. Review of the Initial Visit dated 02/03/2025 revealed the Registered Nurse documented the following:- Patient is oriented to person and place, has intermittent confusion, is cooperative, lethargic and withdrawn;- Patient manages medications appropriately;- Patient caregiver manages medications appropriately; and- All medications reviewed with daughter and son.Review of the Team Care Plan developed on 02/03/2025 revealed the following:- Problem: Unique Nursing Visit Needs;- Interventions: Pill box fill done by daughter; and- Medications to be administered by family/private hire staffReview of the Routine Visits dated 04/30/2025, 05/06/2025, 05/12/2025, and 05/19/2025 revealed the Registered Nurse documented the following:- Alert to person, place and situation, has intermittent confusion, is cooperative, and forgetful; - Patient unable to manage medications- Patient caregiver manages medications appropriately; and - All medications reviewed with daughter.There is inconsistent documentation regarding the patient’s ability to manage medications.During interview on 06/09/2025 at 03:03 PM, the Home Care Registered Nurse stated they may have clicked on more than one option. The Home Care Registered stated that per the care plan developed on 02/03/2025 the daughter prepares the medications and the daughter and the private hire administer the medications. Patient #5 - This 78-year-old patient with a terminal diagnosis of chronic obstructive pulmonary disease with (acute) exacerbation was admitted to the hospice on 05/09/2025.Review of the Case Conferences Summary Report dated 05/15/2025 revealed the Interdisciplinary Group meeting was held on 05/15/2025.Review of the IDT (Interdisciplinary Team) Attendance Sheet dated 05/14/2025 revealed the Interdisciplinary Team meeting was held on 05/14/2025 from 12:00 PM to 01:00 PM.There is inconsistent documentation regarding the date that the Interdisciplinary Group met.During interview on 06/10/2025 at 12:07 PM, the Director of Clinical Services stated that the date of the sign in sheet is a clerical issue and confirmed the date of the Interdisciplinary meeting was 05/15/2025. Patient #8 – This 100-year-old patient with a terminal diagnosis of acute combined systolic (congestive) and diastolic (congestive) heart failure was admitted to the hospice on 05/20/2025.Review of the Routine Visit dated 05/22/2025 at 09:18 AM revealed the Registered Nurse documented the patient has pain…changes necessary, primary care physician contacted for pain medication orders, patient having increased difficulty swallowing Tylenol, and morphine concentrate requested from the primary care doctor. Review of the 05/22/2025 Case Conferences Summary Report dated 05/22/2025 at 12:30 PM revealed the Registered Nurse documented the patient denies pain but grimaces when their legs are moved and the family manages the pain with as needed Tylenol with good effect reported. The clinical record lacks documentation of complete and pertinent information related to the patient’s pain management.During interview on 06/10/2025 at 12:05 PM, the Clinical Services Director stated that the note that pulled into the 05/22/2025 Case Conference Summary report was from the nurse visit that took place on 05/20/2025. The Clinical Services Director stated that because the documentation was not updated the addition of the Morphine did not get discussed at the 05/22/2025 interdisciplinary meeting. Patient #6 – This 97-year-old patient with a terminal diagnosis of acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure was admitted to the hospice on 04/09/2025.Review of the Supplemental Order dated 04/09/2025 revealed an order for aide services, one (1) to two (2) times a week for thirteen (13) weeks. Review of the Hospice v25.1 (Comprehensive Update 25) Routine Visit dated 04/14/2025 revealed the Registered Nurse documented the following:Aide Supervision: Yes, hospice aide present.Aide Employment: Employed by this company.Is the Hospice Aide following the Care Plan? Yes, care plan reviewed.Are the patient/family satisfied with care? Yes.Has there been a change in service? Yes: HHA (Home Health Aide) placed for 2x (two times) weekly.Did the clinician observe the Aide performing any duties? No.Review of the clinical record from 04/09/2025 to 06/09/2025 revealed a home health aide provided care on 04/18/2025, 04/22/2025, 04/25/2025, 04/29/2025, 05/02/2025, 05/06/2025, 05/09/2025, 05/13/2025, 05/16/2025, 05/20/2025, 05/27/2025, 05/30/2025, 06/04/2025, 06/06/2025, and 06/09/2025. There is a lack of documented evidence that the Home Health Aide provided care on 04/14/2025.During an interview on 06/09/2025 at 10:43 AM, the Registered Nurse stated that no, the aide was not present for the supervision and that the error was in the documentation. Patient #10 – This 87-year-old patient with a terminal diagnosis of malignant neoplasm of unspecified part of unspecified bronchus or lung was admitted to the hospice on 01/23/2025.A. Review of Physician Orders/Plan of Care from 01/23/2025 to 04/22/2025 revealed a diagnosis of Type II Diabetes Mellitus with hyperglycemia.Review of the Hospice v24.1 (Comprehensive Update 23) Initial Visit dated 01/23/2025 revealed the Registered Nurse documented the following:Metabolic Symptoms: No - Symptoms.Diabetes Detail: Not Diabetic.Review of the Physician Orders/Plan of Care from 04/23/2025 to 07/21/2025 lacked documented evidence of a diagnosis of Type II Diabetes Mellitus with hyperglycemia.Review of the Supplemental Orders as of 05/02/2025 revealed the order “patient does not check fasting blood sugar.”Review of the Hospice v25.1 (Comprehensive Update 25) Routine Visits dated 04/29/2025, 05/06/2025, 05/13/1025, 05/20/2025, 05/27/2025, and 06/03/2025 revealed the Registered Nurse documented the following:Metabolic Symptoms: No -Symptoms.Diabetes Detail: Not Diabetic. Review of the Supplemental Orders as of 05/02/2025 revealed the order “patient does not check fasting blood sugar.”There is inconsistent documentation regarding whether the patient has a diagnosis of Type II Diabetes Mellitus with hyperglycemia.During an interview on 06/09/025 at 11:25 AM, the Registered Nurse was observed shaking her head no, when asked if the patient has Type II Diabetes Mellitus. The Director of Clinical Services stated not having a clue as to how the diagnosis of Type II Diabetes Mellitus got on the Physician Orders/Plan of Care from 01/23/2025 to 04/22/2025. B. Review of the Case Conferences Summary Report dated 05/15/2025 revealed the Interdisciplinary Group meeting was held on 05/15/2025.Review of the IDT (Interdisciplinary Team) Attendance Sheet dated 05/14/2025 revealed the Interdisciplinary Team meeting was held on 05/14/2025 from 12:00 PM to 01:00 PM.There is inconsistent documentation regarding the date that the Interdisciplinary Group met on.During an interview on 06/10/2025 at 12:07 PM, the Director of Clinical Services stated that the date on the sign in sheet is a clerical issue and confirmed the Interdisciplinary meeting was held on 05/15/2025.”

“Based on review of clinical records and interviews with staff, the hospice failed to ensure for one (1) of fourteen (14) patients (Patient #8), that the content of the clinical records include each individual patient’s formulated Advance Directives. Failure to ensure the patient’s advanced directives are obtained and included in the clinical record places the patient at risk for not having his/her choices about medical treatment followed. Patient #8 – This 100-year-old patient with a terminal diagnosis of acute combined systolic (congestive) and diastolic (congestive) heart failure was admitted to the hospice on 05/20/2025.Review of the forms entitled Admission Packet Contents, HIPAA Compliant Authorization for Release of Medical Information, HIPAA/Confidential Communication Information, Hospice Election Form, and Notice of Financial Responsibility all dated 05/2025 revealed they were all signed by the patient’s daughter who identifies as the patient’s Health Care Proxy.Review of the Initial Visit dated 05/20/2025 revealed the Registered Nurse documented the patient is oriented to person, place and situation and the MOLST is in place.Review of the Social Work Initial Visit dated 05/20/2025 revealed the Social Worker documented MOLST/DNR/DNI is in place. Review of the Chart/Clinical Note dated 05/20/2025 revealed the Social Worker documented the patient is alert and oriented times three, disoriented to time, calm, minimally participatory, tired but able to make decisions related to her care, and the MOLST/DNR/DNI are in place and they have been scanned into the medical record.Review of the clinical record from 05/20/2025 to 06/09/2025 lacked documented evidence of MOLST/DNR/DNI form and/or a Health Care Proxy.The hospice failed to ensure that the content of the clinical records include each individual patient’s formulated Advance Directives. During interview on 06/09/2025 at 11:34 AM, the Home Care Registered Nurse stated they do not see one in the record.During interview on 06/09/2025 at 11:40 AM, the Clinical Services Director stated that if the patient was alert and oriented the patient could have requested her daughter to sign the paperwork and the nurse could have stated as such in their documentation. The Clinical Services Director stated that this is not in the record either.”

“Based on review of clinical records and interviews with agency staff, the agency failed for one (1) of fourteen (14) patients (Patient #1) to ensure all documentation by professional staff is appropriately authenticated in accordance with accepted standards of practice. Failure to authenticate documentation with professional credentials has the potential for patients to receive care from unlicensed staff.The hospice failed to ensure that all documentation by professional staff is appropriately authenticated as evidenced by the following: Patient #1 – This 60-year-old patient with a terminal diagnosis of malignant neoplasm of overlapping sites of bladder was admitted to the Hospice on 05/09/2025.Review of the Supplemental Orders dated 05/09/2025, 05/10/2025 and 05/12/2025 revealed an illegible signature with a date of 06/03/2025. The signature lacked any legible identifier.Review of the Supplemental Orders dated 05/09/2025, 05/10/2025 and 05/12/2025 lacked documented evidence of the attending physician’s professional credentials. During an interview on 06/09/2025 at 09:56 AM, the Clinical Services Director stated the signature was that of the patient’s attending physician. She confirmed legibility was an issue and that there should be written or stamped name with credentials. The Clinical Services Director further stated there may be a signature log containing the physician’s signature to provide. As of time of exit conference on 6/10/2025 at 1:00 PM, the Clinical Services Director stated, “I must have just not have written that physician down to be honest with you” and was unable to provide any documented evidence of a signature log.”