Wellspring Hospice

“Upon patient record review, 11 of 19 (Patient # 1,2,3,4,5,6,7,8,9,10,11) 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: Patient 1, 2: Upon home visit and record review, the medication profile contains four orders for acetaminophen with no limits to not exceed 4gms within 24 hrs. COS Patient 3: The medication profile contains four orders for acetaminophen with no limits to not exceed 4gms within 24 hrs. COS Patient 4: The medication profile contains four orders for acetaminophen with no limits to not exceed 4gms within 24 hrs. In addition, the agency medication list contains an order for apixaban 5mg BID and wife reports that she was instructed to discontinue this medication by hospice. All COS Patient 5: The medication profile contains four orders for acetaminophen with no limits to not exceed 4 gms within 24 hours and included two duplicate orders both for Acetaminophen 325mg 2 tabs every 4 hours prn for fever/pain and two duplicate orders for Acetaminophen 650mg rectal suppositories both every 4 hours as needed (one order for pain and one order for fever with no limits to not exceed 4000 grams within 24 hrs). COS Patient 6, 7: The medication profile contains four orders for acetaminophen with no limits to not exceed 4 gms within 24 hrs. COS Patient 8: The medication profile contains five separate orders for acetaminophen with no limits to not exceed 4gms within 24 hrs. COS Patient 9: The medication profile contains four orders for acetaminophen with no limits to not exceed 4gms within 24 hrs. In addition, a new order obtained on 6/26/25 contains an order for MiraLAX oral powder 17gms daily as needed with no diluent directions for mixing. COS Patient 10: The medication profile contains five separate orders for acetaminophen with no limits to not exceed 4gms within 24 hrs. Patient has a G tube and medications are being administered via g tube except trazodone 1.5 tabs oral at bedtime and Zoloft 2 tabs ordered to be given orally daily at bedtime with incorrect route noted. There is an order for Hydrocortisone cream apply 1 application topically every 12 hrs for redness itching without a proper dose and instructions where to apply. COS Patient 11: The medication profile contains four orders for acetaminophen with no limits to not exceed 4gms within 24 hrs. COS”

“Upon patient record review, 3 of 19 (Patient # 1, 6, 9) 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. The agency will need to ensure there is 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. Educate staff of requirement. Perform chart audits to ensure compliance. Patient 1: The Initial POC 5/19/25 contains four orders for acetaminophen with no limits to not exceed 4gms within 24 hrs. Corrected on site with orders and POC updated. Patient 6: Updated POC 6/18/25 contains four orders for acetaminophen with no limits to not exceed 4gms within 24 hrs. Corrected on site with orders and POC updated. Patient 9: The Initial POC 5/27/25 contains four orders for acetaminophen with no limits to not exceed 4gms within 24 hrs. A new order obtained on 6/26/25 contains an order for MiraLAX oral powder 17gms daily as needed with no diluent directions for mixing. Corrected on site with orders and POC updated.”

“Upon patient record review, 1 of 19 (Patient #6) did not have evidence in the patient record that hospice aide assignments and duties are: Patient 6: Aide care plan 6/16-8/14/25 has not been updated and remains without any tasks for personal care except check if no BM, assist to BSC, vital signs each visit and notify facility nurse and case manager if vital signs greater than 0. Patient is no longer residing in a facility and has moved to routine care at home. Tasks need to be updated to patient care needs. COS with updates to tasks and location of patient in aide POC.”

“Upon patient record review 3 of 19 (Patient # 1,2,14) 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 1: There is no evidence in record review that SN completed supervisory visits for aide. Supervisory visit was completed on 6/6/25 and not until 6/27 with weekly aide visits. Patient 2: There is no evidence in record review that SN completed supervisory visits every 14 days. There was an aide supervisory visit completed on 6/5/25 then no further supervisory visits completed by SN until 6/27. Patient 14: There is no evidence in record that SN completed an aide supervisory visit with SN visits completed on multiple times between 6/3/25 and 7/1/25 with no evidence of supervisory of aide.”

“Upon observation, there was no evidence the annual report documents the use of volunteers providing day to day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract personnel. The agency annual report documents the use of volunteers providing services in an amount of 1.59% at the end of 2024. There is a trend of increasing number of volunteers and increasing volunteer cost savings of 2.97% at end of quarter 1 in 2025.”

“Upon patient record review, 1 of 19 (Patient # 15) did not have evidence that each patient record contains responses to medications, symptom management, treatments, and services. Patient 15: SN documents during nurse visit 4/30/25 “cellulitis noted 4+ pitting edema and lungs severely diminished. Mod c/o SOB and oxygen sat 89% with O2. Call placed to MD to obtain orders for antibiotics and hemorrhoid cream.” No noted follow up for effectiveness of medication changes or symptom management documented in follow-up SN visit on 4/30/25. No evidence of charted SN visits documented prior to patient revoking services due to admission to hospital for an extended stay. Under IDG communication notes there is documentation that SN made two additional visits to home and assessment charted under communication of patient’s continued symptoms; not documented in a skilled nurse visit note.”

“Upon patient record review, 10 of 19 (Patient #2,3,4,5,7,8,10,11,12,15) 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 2: The Initial POC 4/21/25 contains 4 orders for acetaminophen including Acetaminophen 325mg 2 tabs every 4 hours PRN for pain, Acetaminophen 325mg 2 tabs every 4 hours PRN for fever, Acetaminophen 650mg rectal suppository every 4 hours prn for pain and Acetaminophen 650mg rectal suppository every 4 hours prn fever with no limits to not exceed 4gms within 24 hrs. Wound noted on initial comprehensive assessment on 4/21/25 to left heel and ischium with wound care assessment documentation on initial comprehensive assessment with no evidence of wound care dressing orders noted in POC. In addition, SN visit note on 6/10/25 remain incomplete and open records so unable to view any nursing documentation besides visit start and end time. COS with orders and POC updated. Patient 3: The Initial POC contains 4 orders for acetaminophen including Acetaminophen 325mg 2 tabs every 4 hours PRN for pain and Acetaminophen 325mg 2 tab every 4 hours PRN for fever, Acetaminophen 650mg rectal suppository every 4 hours prn for pain, Acetaminophen 650mg rectal suppository every 4 hours prn fever with no limits to not exceed 4gms within 24 hrs. COS with order and POC updated. Patient 4: The Initial POC contains 4 orders for acetaminophen including Acetaminophen 325mg 2 tabs every 4 hours PRN for pain and Acetaminophen 325mg 2 tab every 4 hours PRN for fever, Acetaminophen 650mg rectal suppository every 4 hours prn for pain, Acetaminophen 650mg rectal suppository every 4 hours prn fever with no limits to not exceed 4gms within 24 hrs. POC contains an order for apixaban 5mg with no risk for bleeding noted on POC. COS with order and POC updated. Patient 5: The Initial POC 5/5/25 contains 4 orders for acetaminophen including Acetaminophen 325mg 2 tabs every 4 hours prn for pain, Acetaminophen 325mg 2 tabs every 4 hours prn for fever, Acetaminophen 650mg rectal suppository every 4 hours prn for pain and Acetaminophen 650mg rectal suppository every 4 hours prn for fever with no limits to not exceed 4gms within 24 hrs. In addition, the POC contains an order for Apixaban 5mg BID with no risk for bleeding noted on POC. COS with orders and POC updated. Patient 7: The initial POC 4/18/25 contains multiple orders for acetaminophen with no limits to not exceed 4gms within 24 hrs. COS on site with order and POC updated. Patient 8: The Initial POC 1/31/25 and updated POC contains multiple orders for acetaminophen with no limits to not exceed 4gms within 24 hrs. COS orders obtained and recent POC updated. Patient 10: The Initial POC 5/20/25 contains multiple orders for acetaminophen with no limits to not exceed 4gms within 24 hrs. Patient has a G-tube and POC does not include any G-tube care, assess, treatment . Medications are being administered via g-tube except trazodone 1.5 tabs oral at bedtime and Zoloft 2 tabs ordered to be given orally daily at bedtime with incorrect route noted. There is an order for Hydrocortisone cream apply 1 application topically every 12 hrs for redness itching without a proper dose and where to apply. COS with new orders to include 4 grams in 24 hr period, Patient 11: The updated POC 6/11/25 contains 4 orders for acetaminophen with no limits to not exceed 4gms within 24 hrs. COS with new orders and POC updates. Patient 12: Updated POC from 6/20-8/18/25 does not show evidence of POC goals and timeframes being updated with all target dates for goals remaining by 6/19/25. COS and orders obtained with updated POC with time specific timeframes for goals. Patient 15: Skilled nurse documented visits on 5/1/25 and 5/2/25 in the team communication notes with details of assessment prior to patient’s death but did not document a SN visit on 5/1 and 5/2. SN team communication indicates two visits were made without adding a SN visit to EMR schedule and documenting within the visit notes in the EMR. This patient had 3 unused PRN visits available to be utilized within the certification period.”