Hospice in the Pines

“Upon patient record review, 5 of 24 (Patient #3, 5, 6, 11, 13) 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 03: The medication profile includes Nystatin topical ointment apply 4 times a day as needed for rash, Bacitracin Zinc 500 units/gram, apply 1 dose daily for rash, and Terbinafine Topical 1%, apply topically twice a day, these medications do not indicate an application site. (corrected on site.) Patient 05: The medication profile includes Desonide 0.05% topical cream apply topically 2 times per day as needed for rash, it does not include an application site. The medication profile includes mupirocin 2% topical ointment apply one application twice a day as needed for rash, it does not include an application site. The medication profile includes Miralax oral powder give 17G once a day as needed for constipation, it does not include a diluent. (corrected on site.) Patient 06: The medication profile includes Miralax, oral powder, administer 17G orally once a day as needed for constipation, does not include a diluent. (corrected on site.) In addition, upon home visit it is discussed/observed that the patient has prescribed tamsulosin 0.4mg QHS which is not included in the medication profile. Patient 11: The medication profile includes oxygen 1-10L via nasal cannula continuously, the range is out of acceptable standards for orders. The medication profile includes Simbrinza opth 0.2-1% one drop in each affected eye twice a day, (no indication for range), Lumigan 0.01% opth 1 drop in affected eye daily and brimonidine 0.2% opth apply 0.2 drops (incorrect amount). None of the above treatments indicate which eye/eyes to place drops into. The medication orders on 2/4/25 for Humalog Insulin and Humulin Insulin are written to inject 100 units 4 times per day for each medication, the injection amount is not within acceptable standards and should refer to a sliding scale for dosing. (corrected on site.) Patient 13: The medication profile includes polyethylene glycol 17g powder, administer by g-tube daily. It does not include a diluent. (corrected on site.)”

“Upon patient record review, 2 of 24 (Patient #19, 20) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient’s family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient’s death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient 19: The patient was admitted on 5/23/24, the record does not include an initial bereavement risk assessment. Patient 20: The patient was admitted on 4/15/24, the record does not include an initial bereavement risk assessment.”

“Upon patient record review, 1 of 24 (Patient #7) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual’s attending physician, if any) • Changes that have taken place since the initial assessment • Information on the patient’s progress toward desired outcomes • Reassessment of the patient’s response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days Patient 07: The patient record indicates there was no RN visit completed between 11/18/24 to 12/16/24 and no update to the RN comprehensive assessment during that time.”

“Upon patient record review, 1 of 24 (Patient #16) 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 16: The patient record includes repeated documentation regarding necrotic wounds to bilateral feet and started on doxycycline on 2/12/25 implemented by the physician at the SNF. The patient record does not include an integumentary assessment of the necrotic wound, no documented wound measurements, location of wound, or wound treatment. (POC updated and corrected on site.)”

“Upon patient record review, 3 of 24 (Patient #1, 3, 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 01: The patient was admitted on 2/9/25 with an admitting diagnosis of intestinal obstruction and secondary diagnosis’ of gastritis, diverticulosis, and chronic pain. The plan of care does not include a problem statement with interventions and goals for pain management. The patient record indicates the patient has malnutrition with a weight loss of 50 lbs, noted cachexia and a BMI of 14, the plan of care does not include a problem statement with intervention and goals for nutrition. Patient 03: The patient was admitted on 10/14/24 with a primary diagnosis of atherosclerotic heart disease of native coronary artery with unstable angina, and secondary conditions of hyperlipidemia, hypertension and chest pain. The patient takes Eliquis 5mg PO BID daily, aspirin 81 mg PO daily, and NITRO-TD patch daily, the plan of care does not include a problem statement with interventions and goals for cardiovascular management. The plan of care does not include bleeding precautions. The patient has a secondary diagnosis of diabetes mellitus and uses glargine 60 units daily and Lispro 5 units 4 times a day, the plan of care does not include a problem statement with interventions and goals for the management of the diabetes. Patient 08: Evidence in the patient record includes prescribed Eliquis 5mg by mouth twice daily for treatment of atrial fibrillation, the patient has a significant history of falls, the plan of care does not include bleeding precautions.”

“Upon patient record review, 7 of 24 (Patient #3,4,5,6,11,13,15) 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. • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Educate staff of requirement. Perform chart audits to ensure compliance. Patient 03: Medication orders on 1/17/25 for Nystatin topical ointment apply 4 times a day as needed for rash, the order does not include an application site. Orders on 1/3/25 for Bacitracin Zinc 500 units/gram, apply 1 dose daily for rash, it does not include an application site. Orders on 10/14/24 for Terbinafine Topical 1%, apply topically twice a day, it does not include an application site. (Orders corrected on site.) Patient 04: Evidence in the patient record includes orders for oxygen 1-4L via nasal cannula continuous for shortness of breath, upon home visit it is noted that the patient is utilizing oxygen at 4.5L via nasal cannula. Patient 05: Medication orders on 9/21/24 for desonide 0.05% topical cream apply topically 2 times per day as needed for rash, does not include an application site. Medication orders on 9/21/24 for mupirocin 2% topical ointment apply one application twice a day as needed for rash, does not include an application site. Medication orders on 9/21/24 for Miralax oral powder give 17G once a day as needed for constipation, it does not include a diluent. The patient record includes documentation on 1/28/25 that the patient is receiving 4.5L of oxygen via NC, on 2/5/25 she is receiving 6L of oxygen via NC and on 2/11/25 she is receiving 8L of oxygen via NC, the oxygen order in the plan of care is written for 1-4L oxygen. (Orders corrected on site.) Patient 06: Medication orders on 5/8/24 for Miralax, administer 17G orally once a day as needed for constipation, does not include a diluent. (Orders corrected on site.) Patient 11: The medication orders on 2/10/25 for oxygen1-10L via nasal cannula continuously, the range is out of acceptable. Medication orders on 2/4/25 for Simbrinza opth 0.2-1% one drop in each affected eye twice a day, Lumigan 0.01% opth 1 drop in affected eye daily and brimonidine 0.2% opth apply 0.2 drops (incorrect amount). None of the above treatments indicate which eye/eyes to place drops into. The medication orders on 2/4/25 for Humalog Insulin and Humulin Insulin are written to inject 100 units 4 times per day for each medication, the injection amount is not within acceptable standards and should refer to a sliding scale for dosing. (Orders corrected on site.) Patient 13: Medication orders on 2/14/25 include polyethylene glycol 17g powder administer via g-tube once daily, it does not include a diluent. The plan of care includes wound care orders for a sacral wound, it does not specify the frequency of wound care or the delegation of responsibility for the wound care. (Orders corrected on site.) Patient 15: The medication profile includes orders for oxygen for 1-4L via nasal cannula, documentation on 2/4/25 indicates the patient utilizes oxygen at 6L via nasal cannula.”

“Upon patient record review, 2 of 24 (Patient #6, 15) 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 06: The patient record includes orders for oxygen via nasal cannula with evidence of patient having shortness of breath. The record does not include oxygen/oxygen concentrator in the DME. (Orders corrected and updated on site.) Patient 15: Evidence in the patient record includes orders for Duoneb treatments (prescribed on 7/8/24) and refers to the patient using a rollator for ambulation (2/4/25 & 2/19/25) the plan of care does not include a nebulizer or rollator. (Orders corrected and updated on site.)”

“Upon patient record review, 2 of 24 (Patient #3, 7) 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 03: The patient receives volunteer visits/services, the plan of care is not updated to include interventions and goals for the volunteer needs. Patient 07: The patient has a primary diagnosis of acute on chronic systolic congestive heart failure with secondary related diagnosis’ of hypertension, atherosclerotic heart disease, history of myocardial infarct, and presence of aortocoronary bypass graft, he takes aspirin, clopidogrel, atorvastatin, metoprolol, lasix, potassium chloride and nitroglycerin for symptom management, the plan of care does not include a problem statement with interventions and goals related to the cardiovascular diagnosis and symptoms. The plan of care does not include bleeding precautions.”

“Upon patient record review, 2 of 24 (Patient #3, 6) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 03: Effective 1/25/25 the patient has been receiving volunteer visits, there is no order in the plan of care for volunteer services. (Orders updated on site.) Patient 06: The plan of care includes frequency order for Spiritual Care visits as 1 time per month effective 9/1/24 - 11/23/24, there was no visit made for the month of October.”

“Upon observation and home visits, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient #3: Upon home visit with patient, it was observed that the visiting RN established a barrier for nursing tools (thermometer, stethoscope, pulse oximeter, and blood pressure cuff) and utilized the same barrier for clean and dirty tools during the visit. Upon cleaning the tools, they were placed onto the dirty/contaminated barrier and allowed to dry. Patient #4: Upon home visit with patient, it was observed that the visiting LVN established a barrier for nursing tools (thermometer, stethoscope, pulse oximeter, and blood pressure cuff) and utilized the same barrier for clean and dirty tools during the visit. Upon cleaning the tools, they were placed onto the dirty/contaminated barrier and allowed to dry.”

“Upon patient record review, 3 of 24 (Patient #1, 6, 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 01: The hospice aide task assignment for “change adult diaper” is indicated “as needed.” (Updated and corrected on site.) Patient 06: The hospice aide task assignment initiated on 5/28/24 for all cares is assigned as M-W-F, effective 1/12/25, the hospice aide is scheduled for 5 times per week. The aide task has not been updated by the RN for the additional days of services. Hospice aide orders for frequency of visits was changed on 1/12/25 and ordered by the LVP/LPN and not the RN. (Updated and corrected on site.) Patient 11: The hospice aid task assignment for bed bath, change linens, meal preparation, assistance with dressing do not include a frequency. (Updated and corrected on site.)”

“Upon patient record review 2 of 24 (Patient #4, 12) 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 04: The record does not include evidence of a hospice aide supervisory visit performed from 5/24/24 until 6/14/24. Patient 12: The record does not include evidence of a hospice aide supervisory visit performed from 1/27/25 to 2/20/25”

“Upon patient record review, 2 of 24 (Patient #2, 12) 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 02: The patient record includes documentation on 2/16/25 that the patient received 4 doses of Morphine 4MG IV push for pain relief. The plan of care does not include orders for morphine, upon review, it was identified that the documenting nurse mistyped the medication that the patient received. (Amendment to document updated and corrected on site.) Patient 12: The plan of care includes a problem statement with interventions and goals for Chronic Obstructive Pulmonary Disease, entered by the LBSW on 1/10/25, the patient record does not include a diagnosis of COPD or symptom management related to the illness. (Updated and corrected on site.)”

“Upon patient record review, 1 of 24 (Patient #3) 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 03: On 1/17/25 the RN documentation included a notation of a small wound to the left buttock which was verbally shared with the facility wound care nurse, who asked the Hospice RN to obtain a wound care order and a plan of care, there is no evidence in the patient record of wound care orders for the buttocks. Further evidence shows that the facility is providing wound care to the patient with no orders, interventions, or goals included in the hospice plan of care.”

“Upon observation, there is no evidence the corridor walls and doors of a facility is provided consistent with the 2012 editions of the LSC of the National Fire Protection Association and NFPA 99. Hospices are exempt from chapter 19.3.6.3.5 “exception number 1 and 2 and 19.3.6.3.6 number 2”. If recommended by state survey agency, CMS may waive for periods deemed appropriate, specific provisions of the LSC which, if rigidly applied, would result in unreasonable hardship to the hospice, but only if the waiver would not adversely affect the health and safety of patients. The provisions of the adopted edition of the Life Safety Code do not apply in a State if CMS finds that a fire and safety code imposed by State law adequately protects patients in hospices. Existing Construction NFPA 101 (2012 edition) The Life Safety Code requires that smoke barrier doors are self-closing or automatic-closing, constructed of 1 3/4-inch or thicker solid bonded wood core or rated for a minimum of 20-minutes, and fitted to resist the passage of smoke. In accordance with NFPA 99: The gap between the smoke barrier door and frame should not exceed the manufacturer’s specifications, and the clearance at the bottom of the door should not exceed 3/4 inch. Upon observation it is noted that the corridor doors identified as set 1, and set 2, a smoke barrier door, do not prevent the passage of smoke and exceed a gap of greater than 3/4”. In addition, the location of the leased space for hospice inpatient services in not in compliance with 19.3.6.1 General code: Corridors shall be separated from all other areas by partitions complying with 19.3.6.2 through 19.3.6.5. It is observed that there are no doors that separate the leased patient care area from common corridors. The corridors are open to patient sleeping areas and treatment rooms that do not meet compliance.”

“Upon observation, there is no evidence the smoke compartmentation and control of a facility is provided consistent with the 2012 editions of the LSC of the National Fire Protection Association and NFPA 99. The provisions of the adopted edition of the Life Safety Code do not apply in a State if CMS finds that a fire and safety code imposed by State law adequately protects patients in hospices. Existing Construction The facility is in compliance with NFPA 99 chapter 15, Fire Protection (section 15.1 to 15.13). 19.3.7.6 Openings in smoke barriers shall be protected using one of the following methods: (1) Fire-rated glazing (2) Wired glass panels in steel frames (3) Doors, such as 1 3/4 in. (44 mm) thick, solid-bonded wood-core doors (4) Construction that resists fire for a minimum of 20 minutes The corridor of the leased space that includes patient sleeping areas and patient treatment areas is not protected from a main corridor of the facility.”

“Upon observation, there was no evidence the automatic sprinkler system of a facility is provided consistent with the 2012 editions of the LSC of the National Fire Protection Association and NFPA 99. The provisions of the adopted edition of the Life Safety Code do not apply in a State if CMS finds that a fire and safety code imposed by State law adequately protects patients in hospices. Existing Construction Upon inspection it was identified that the area designated as the Hospice In-Patient Unit (a leased space within the hospital) does not have a portable fire extinguisher/extinguishers within the leased space in accordance with NFP 10: 6.1.1.1 The installation of extinguishers shall be independent of whether the building is equipped with automatic sprinklers, standpipe and hose, or other fixed protection equipment. 6.1.3 Placement. 6.1.3.1 Fire extinguishers shall be conspicuously located where they are readily accessible and immediately available in the event of fire. 6.1.3.2 Fire extinguishers shall be located along normal paths of travel, including exits from areas. 6.1.3.3 Visibility. 6.1.3.3.1 Fire extinguishers shall be installed in locations where they are visible except as permitted by 6.1.3.3.2 6.2.1.2.2 Fire extinguishers shall be located so that the maximum travel distances shall not exceed 75 fi: (22.9 m), except as modified by 6.2.1.4.”