Steel City Hospice

“Upon patient record review, 3 of 14 (Patient #3,4,9) 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 3: The Hospice medication profile contains Haloperidol 0.5mg tablet 2 times daily, 1 tab at bedtime. The facility has the Haloperidol is ordered as liquid 2mg/ml, 1ml 3 times daily. Corrected on site, order updated. Patient 4: The medication profile contains an order for Acetaminophen 500 mg, 2 tabs every 6 hours PRN mild pain, hydrocodone/acetaminophen 7.5/325, 1 tab every 6 hours PRN severe pain and 1 tab at bedtime. There is no evidence of maximum allowable acetaminophen amount. Corrected on site, order updated. Patient 9: The medication profile contains an order to irrigate the foley with 60 ml NS. The patient does not have a foley. Corrected on site, med profile updated.”

“Upon patient record review, 1 of 14 (Patient #5) 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 5: The patient has a wound to coccyx with ordered wound care. The agency has a Policy 4-121 the SN is to assess and measure all wounds weekly at time of visit. The patient is being seen twice weekly by the RN and the wound has not been measured yet this certification period.”

“Upon patient record review, 4 of 14 (Patient #3,8,9,10) 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 3: The POC 10/22/25 contains Haloperidol 0.5mg tablet 2 times daily, 1 tab at bedtime. The facility has the Haloperidol is ordered as liquid 2mg/ml, 1ml 3 times daily. The facility has applying A&D ointment to perirectal area and heels topically every shift these are not included on the hospice POC. Corrected on site, orders updated. Patient 8: The SN documented on 10/27/25 the patient using O2 at 2 liters per minute, there is no order for oxygen at 2 liters per minute. Corrected on site, order added. Patient 9: The POC 10/11/25 contains an order to irrigate the foley with 60 ml NS. The patient does not have a foley. Corrected on site, POC updated. Patient 10: Pt has a foley per POC 9/5/25 the SN has goals and interventions to teach regarding foley care and irrigation orders for a foley however, there is no evidence of orders with the foley size or how often to change the foley. Corrected on site, orders updated.”

“Upon patient record review, 2 of 14 (Patient #1,7) 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 1: The SN documented 10/14/25 patient using a quad cane to ambulate. This was not included on the POC. Corrected on site, order added. Patient 7: The POC has Oxygen 5 LPM concentrator with kit under DME supplies though no order with frequency on the POC. Pt is no longer on oxygen and this has not been removed from the POC. Corrected on site, oxygen removed from DME list.”

“Upon patient record review, 2 of 14 (Patient #7,8) 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 7: The IDG note on 10/23/25 contains an order to downgrade the diet to mechanical soft as patient having choking episodes. There was no risk for aspiration care plan added. Corrected on site, care plan added. Patient 8: The POC 9/24/25 contains an order to teach facility staff, patient, caregiver on performing wound care cleanse with NS, pat dry, apply calcium alginate and cover with dry dressing daily. The order for the wound remains on the current POC and the wound was resolved on 9/4/25. Corrected on site, POC updated.”

“Upon patient record review, 1 of 14 (Patient #3) did not have evidence the hospice medical director, physician employees, and contracted physician(s) of the hospice, in conjunction with the patient’s attending physician, are responsible for the palliation and management of the terminal illness and conditions related to the terminal illness. This is demonstrated by any of the following: Patient 3: The patient chose an attending physician other than the medical director on the election of benefits. The patient began having increase behaviors with changes to medications on 10/22/25, 10/29/25,10/31/25 and 11/3/25 there is evidence that the hospice medical director was called however, no evidence the attending physician of record was contacted.”

“Upon patient record review, 2 of 14 (Patient #7,8) 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 7: The aide POC contains oxygen precautions, patient is no longer on oxygen. Corrected on site, aide POC updated. Patient 8: The aide POC does not contain oxygen precautions and oxygen is ordered. Corrected on site, aide POC updated.”

“Upon patient client record review, 3 of 14 (Patient #4,5,8) 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 4: The SN documented performing wound care by restating the wound care order and then “wound care completed per order”. This is not complete and clear documentation as there is no evidence specific details of the order were followed on 10/27/25,10/30/25, 11/3/25. Patient 5: The SN documented performing wound care on 10/8/25, 10/22/25,10/24/25, 10/27/25 by restating the order. It is unclear of the details of the order were followed. Patient 8: The patient has PRN oxygen in the facility, there is an area where the SN must answer the question “Is oxygen safely stored?” on many of the visits including 10/16, 10/20, 10/23 it is answered as N/A.”