Crescent Hospice, Inc.

“Upon patient record review, 1 of 28 (Patient #17) 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: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #17: Medication profile reflects incomplete order 4/7/26 Lorazepam 1 mg oral tablet, take 1 tab(s) orally as needed for anxiety or restlessness. Frequency of dose not specified.”

“Upon patient record review, 1 of 28 (Patient #17) 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 #17: Upon review, surveyor noted 4/27/26 order for Lorazepam 0.5 mg oral tab one tab orally 2 times a day for anxiety. There is also a 4/7/26 order for 1 mg oral tab as needed. 4/28/26 on call nurse documented that facility staff called to report during 1-pm rounding, patient was on the phone with 911, seeing people in the room that were not there and anxious. She reported the facility didn’t give any of the scheduled Lorazepam today due to being out. Facility nurse reported that they only have the prn dose of Lorazepam in their med cart. (Hospice nurse) instructed to give dose of PRN Lorazepam per orders and to see if that dose relieves symptoms. Instructed to call on-call number back if ineffective or other concerns arise. Verbalizes understanding. 2 days later, another PRN visit 4/30/26 related to patient agitation. RN documented educated staff related to Ativan, but regular dose has not come in. No additional documentation of follow up or resolution by date of record review.”

“Upon patient record review, 2 of 28 (Patient #2, 8) 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 #2: Patient admitted with pacemaker. There are no related problems, goals, interventions. Patient #8: Patient has documented seizure disorder according to CTI and diagnoses; however, there are no related problems, goals, interventions including seizure safety precautions.”

“Upon patient record review, 2 of 28 (Patient #1, 17) 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 #1: Wound care order to clean mid upper and mid left friction pannus wound daily and PRN with wound cleanser, pat dry with gauze and place bordered dressing. PRN is not qualified Patient #17: 4/7/26 order for Lorazepam 1 mg oral tablet, take 1 tab(s) orally # as needed for anxiety or restlessness. Frequency of dose not specified.”

“Upon patient record review, 1 of 28 (Patient #28) 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 #28: SN visit 4/29/26 RN noted skin lesion of scalp - large necrotic area on head - continue to monitor. Upon observation during visit and interview with RN, the lesion is expected to be skin cancer and family chose no further diagnostics or treatments. The lesion is changing in size and appearance. The care plan is not updated with problems, goals or interventions related to at a minimum to assess for discomfort and alteration in skin integrity.”

“Upon patient record review, 3 of 28 (Patient #2, 5, 19) 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 #2, 5: Oxygen is prescribed, but hospice aide care plan does not include Oxygen safety precautions. Patient #19: Patient admitted with urostomy. There is no alert, precaution or reference of any kind to urinary diversion included in hospice aide care plan.”

“Upon client record review, 3 of 28 (Patient #1, 8, 15) did not have evidence that the hospice plan of care identifies the care and services that are needed and specifically identify which provider (nursing facility or hospice) is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care. Patient #1: Patient has orders for wound care to abdominal pannus with no clarification of facility staff vs hospice role. Patient #8: Patient has order for wound care to right heel with no clarification of facility staff vs hospice role for PRN wound care between hospice visits. Admitted with indwelling foley catheter in place. Order says change as ordered, every 30 days, without clarification of facility/hospice staff role in maintaining catheter and/or changes. Subsequently catheter was discontinued by facility staff with no prior coordination with hospice. Patient #15: SNF resident with wound care order 3/20/26 for skin tears x 2 right forearm, without clarification of facility staff vs hospice role for wound care”