Holy Redeemer Hospice - Pa

“Upon patient record review, 2 of 19 (Patient #5, 9) 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 #5: Patient has cardiac pacemaker listed as diagnosis, with no related problems, goals, interventions. Patient #9: Patient has Eliquis prescribed with no related problems, goals, interventions, including bleeding precautions”

“Upon patient record review, 2 of 19 (Patient #3, 15) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient’s plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient #3, 15: Initial Plan of Care includes Volunteer services prn as ordered with no specified frequency.”

“Upon client record review, 3 of 19 (Patient #5, 11, 15) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #5: Patient admitted 5/3/26 with initial POC order for OT 1wk1. There is no documented evidence service provided or refused. Patient #11: Patient admitted 3/30/26 with 4/1/26 order for OT eval. There is no documented evidence service was provided or refused. Patient #15: Patient admitted 1/24/26. Initial Plan of Care includes VOL prn as indicated. Volunteer visits documented January 29, March 7, 10, 17, 24, 31 with no update to ordered frequency.”

“Upon patient record review 4 of 19 (Patient #3, 9, 11, 13) did not have evidence that the IDG ensures that the care and services provided are based on all assessments of the patient and family needs. Patient #3: Patient admitted 5/15/26. Initial RN assessment includes Volunteer services desired at this time. Order says Volunteer services prn as ordered. There is no evidence of service provided or refused. Patient #9: Patient admitted 4/16/26. Nursing documentation includes need for Volunteer. There is no documented evidence service was provided or refused. Patient #11: Patient admitted 3/30/26 with 4/1/26 order for OT. There is no documented evidence service was provided or refused. Patient #13: Patient admitted 5/20/26. Nursing documentation includes need for Volunteer. There is no documented evidence service was provided or refused.”

“Upon patient record review, 6 of 19 (Patient #1, 3, 6, 7, 9, 11) 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: Patient has Keppra prescribed for seizures, with no seizure precautions referenced in hospice aide care plan.. Patient #3: Patient has colostomy, pressure wounds, bladder pessary and Oxygen therapy. There are no alerts/references/precautions in hospice aide care plan. Patient #6: Patient has Oxygen flow rate, but not related safety precautions in hospice aide care plan. 6/2/26 plan of care includes oxygen flow rate, but not related safety precautions Patient #7: Patient has PEG tube and burn wound left shoulder, but there is no alert/reference in hospice aide care plan. Unclear if/how to protect wound during shower assist every visit. Patient #9: Patient has Eliquis prescribed with no related bleeding precautions Patient #11: Patient has Oxygen prescribed with no flow rate or Oxygen safety precautions in hospice aide care plan.”

“Upon patient client record review, 2 of 19 (Patient #2, 3) 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 #2: 5/17/26 goals met first visit includes Foley catheter patent and CG understands care of Foley catheter. However, detailed assessment does not include Foley catheter. Interview with staff confirms patient does not have Foley catheter in place. Patient #3: SOC 5/15/26 initial RN visit goals met first visit includes Foley catheter patent and CG understands care of Foley catheter. However, detailed assessment does not include Foley catheter. Interview with staff confirms patient does not have Foley catheter in place.”

“Upon personnel record review, 1 of 15 (Personnel #11) did not have evidence of criminal background checks being obtained in accordance with state requirements in the state of Pennsylvania at the time of rehire. In the absence of state requirements, criminal background checks are obtained within three months of the date of employment for all states that the individual has lived or worked in the past 3 years. Personnel #11: Personnel originally hired 2006. She separated employment at some point and returned in 2023 with new hire date. There is no Pennsylvania required criminal background check performed at time returned to employment with new hire date.”