Highland Hospice

“Upon patient record review 4 of 14 (Patient #1,#8,#9,#14) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient’s well-being, comfort, and dignity throughout the dying process. Patient #1: A Chaplain visited on 05-19-25, but there was no evidence of a completed spiritual assessment. Patient #8: A Chaplain visited on 09-09-25, but there was no evidence the spiritual assessment was completed. Patient #9: The Chaplain recorded a visit and documented speaking with son, but there is no evidence of a spiritual assessment being completed. Patient #14: The Chaplain made a visit within 5 days, but there is no evidence of a spiritual assessment being completed.”

“Upon patient record review, 4 of 14 (Patient #2,#8,#11,#14) 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 #2: There was no evidence of a route listed on the medication profile for Oxygen as ordered per the plan of care. In addition, Cephalexin was ordered on 08-29-25 for a skin rash, but remained on the medication profile until 10-21-25. Furthermore, Polyethylene glycol was listed on the medication profile without evidence of diluent instructions. Patient #8: Quetiapine and Metoprolol were listed on the medication profile without evidence of a quantity for administration per the order. Patient #11: MiraLAX was listed on the medication profile without evidence of a diluent. Patient #14: The SN visit note dated 04-16-25 indicated the patient was using O2 at 4LPM per NC, however, oxygen was not listed on the medication profile.”

“Upon patient record review, 2 of 14 (Patient #1,#8) 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 #1:There was no evidence a bereavement assessment was completed within 5 days of admission. Patient #8: There was no evidence that a bereavement assessment was completed within 5 days of admission.”

“Upon patient record review, 2 of 14 (Patient #1,#10) 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 #1: The patient had an order for and was receiving OT and PT services, but there was no evidence of PT and OT interventions or goals included on the plan of care. Patient #10: There were orders for wound care on Mon-Wed-Fri upon admission on 09-10-25. The orders for wound care were updated on 09-26-25 to include a dressing change every other day to an additional wound. However, there was no evidence the wound care was part of the written plan of care.”

“Upon patient record review, 5 of 14 (Patient #2, #3, #10, #11, #14) 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 #2: There was no evidence of a stop date ordered for Cephalexin on 08-29-25. Additionally, there was no evidence of a diluent ordered for Polyethylene glycol. Patient #3: On 10-16-25 wound care orders were written for “Petroleum gauze, cut to fit wound bed” without evidence of a specific route/wound area. Additionally, “TAO 1 x week as needed” was ordered without evidence of an indication, location or as needed reason. Patient #10: There were orders for wound care on Mon-Wed-Fri upon admission on 09-10-25. The orders for wound care were updated on 09-26-25 to include a dressing change every other day to an additional wound. However, there was no evidence in order of who was to complete the wound care. Patient #11: MiraLAX was ordered without evidence of a diluent. Patient #14: The SN visit note dated 04-16-25 indicated the patient was using O2 at 4LPM per NC, however, there was no evidence of an order for oxygen.”

“Upon client record review, 3 of 14 (Patient #1, #7, #9) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1: The patient had an order for and was receiving OT and PT visits however, there was no evidence of an order containing PT and OT frequencies. Patient #7: The plans of care dated 09-17-25 and 10-01-25 indicated the SN frequency was 2 x week, and the SW frequency was 1 x month. However, on the weeks beginning 10-5-25, 10-12-25 and 10-19-25, there was no evidence of a second SN visit or a missed visit note and during the month of September, there was no evidence of a SW visit or a missed visit note. Patient #9: The plans of care dated 09-03-25, 09-17-25 and 10-01-25 indicated SW visit frequency was 1 x month, however, there was no evidence of a SW visit in September.”

“Upon patient record review 5 of 14 (Patient #1,#2,#3,#5,#9) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care Patient #1: The aide care plan indicated “Shampoo” was assigned, but on aide notes dated 09-09-25, 09-12-25, and 09-23-25, a shampoo was not documented as completed and there was no evidence of the reason. Patient #2: The aide care plan indicated “Shampoo” and “shower” were assigned, but on aide notes dated 10-07-25, “shampoo” and “shower” were not documented as completed, and there was no evidence of a reason. On 10-14-25 the aide notes documented “shower”was not completed, but there was no evidence of a reason. Additionally, on10-08-25 there was no evidence any of he assigned tasks were documented as completed, though a visit by the aide was documented. Patient #3: The aide care plan indicated assigned tasks of “Shampoo” which was not completed per the aide visit notes dated 10-06,10-07, 10-09, and 10-10-25 and there was no evidence of a reason documented for noncompletion. Patient #5: The aide care plan indicated shower, foot care, skin care and nail care were assigned every visit. However, the aide notes dated 09-19-25, and 09-26-25 indicated the same tasks were not completed, but there was no evidence of a documented reason for not completing. Patient #9: The aide care plan indicated “Shampoo” was assigned every visit. However, per the aide notes dated 06-30-25, 07-30-25, 09-05-25 and 09-11-25, “shampoo” was not completed, but there was no evidence of a documented reason for not completing.”

“Upon patient client record review, 1 of 14 (Patient #5) 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 #5: On 10-14-25, the RN documented a visit with a male patient receiving PT services at home, however, this patient was a female patient in an assisted living center with no PT services ordered.”