White Orchid Hospice

“Upon patient record review, 7 of 20 (Patient #1,#2,#3,#8,#12,#14,#20) 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: • Drug side effects • Actual or potential drug interactions • Drug therapy currently associated with laboratory monitoring Patient #1:The initial assessment and plan of care dated 11/07/24 indicated the patient was using O2 at 2-5 LPM via NC, but O2 was not on the medication profile. Patient #2:O2 2-4 LPM was listed on the medication profile, but the order dated 09/11/25 indicated O2 was 5 L per NC. Patient #3:Per the RN assessment and plan of care dated 02/09/26 O2 was used by the patient at 2-4 L per NC, however, O2 was not listed on the medication profile. Patient #8: MiraLAX was listed on the medication but there were no instructions for a diluent. Patient #12:The RN assessment and plan of care dated 10/11/25 indicated the patient was using O2 2L NC but O2 was not listed on the medication profile. Patient #14: Per the MD CTI signed 09/05/25 the patient’s O2 was 5 LPM via NC, however, O2 was not listed on the medication profile. Patient #20: The MD Cert signed 09/16/25 indicated O2 was ordered at 2-4 L via NC and the following SN notes documented patient was using O2. However, O2 was not on the med profile.”

“Upon patient record review, 1 of 20 (Patient #2) 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 #2:There was no evidence a bereavement assessment was completed within 5 days of the admission.”

“Upon patient record review, 2 of 20 (Patient #5,#20) 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 RN initial assessment indicated the patient had a “Stage 3 pressure ulcer on L heel” and the plan of care indicated the RN would educate the facility staff on wound care. However, there was no evidence the RN did an initial assessment or measurement of the wound. Patient #20: The SN documented a wound “moisture lesion” 2x3x1 cm, but did not document a wound bed evaluation. The plan of care indicated wound assessment however, MD wrote in CTI that patient was requiring wound care for “moisture lesion” which indicated lack of coordination with the IDG.”

“Upon patient record review, 4 of 20 (Patient #3,#12,#18,#19) 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: There was no evidence of a reason documented for PRN visits by the MSW and RN on CP 01/28/26 and 02/11/26. Patient #12: There was no evidence of a reason documented for PRN visits by the RN, MSW and SCC on the IDG care plans dated 01/28/26 and 02/11/26. Patient #18: There is no evidence of a reason for PRN visits by RN documented on the plan of care for BP 01/11/26 through 03/07/26. Patient #19:There was no reason for PRN visits documented as, “2 PRN” for RN, MSW and SCC on the recert plan of care signed by the MD on 12/28/25.”

“Upon client record review, 2 of 20 (Patient #8,#12) did not have evidence that the IDG in collaboration with the attending physician reviewed, revised and documents the individualized plan as frequently as the patient’s condition requires but no less frequently then every 15 calendar days. Patient #8: The patient was admitted and an IDG plan of care and discussion was documented on 01/28/26, however, there was no evidence the plan of care was reviewed by the IDG during the 02/11/26 meeting or afterward. Patient #12: The IDG collaborated on the plan of care on 10/08/25, but there was no evidence of another IDG summary and the patient was discharged on 10/30/25.”

“Upon patient record review, 5 of 20 (Patient #2,#3,#4,#11,#16) 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:On 09/11/25, the RN documented the patient was using O2 at 2-4 LPM via NC, but there were no oxygen precautions listed on the aide profile. Patient #3:Per the plan of care dated 01/28/26 and 02/11/26, the aide visited 3 x week on Monday, Thursday and Friday. However, the aide care plan duties written on 02/09/26 were documented as assigned 2 days a week on Monday and Thursday. Patient #4: The medication profile indicated the patient was taking ASA 81mg, but there were no bleeding precautions on the aide care plan dated 01/21/26. Patient #11:Per the medication profile, the patient was taking 81mg ASA, but there was no evidence that bleeding precautions were listed on the aide plan of care written 12/23/25. Patient #16:Per the medication profile, the patient was taking 81mg ASA, but there was no evidence that bleeding precautions were listed on the aide plan of care written 12/16/25.”

“Upon patient record review 3 of 20 (Patient #6,#8,#9) 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 #6:The patient began aide visits on 12/22/25, but there is no evidence of an aide supervisory visit. Patient #8:The patient began aide visits on 01/30/26, but there is no evidence of an aide supervisory visit. Patient #9:The patient began aide visits on 11/21/25, but there is no evidence of an aide supervisory visit.”

“Upon observation, there was no evidence the annual report documents the use of volunteers providing day to day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract personnel. There was no evidence the agency used volunteers in an amount that equaled 5% of total patient care hours as evidenced by documentation of volunteer hours in the 2025 annual report equaling 2.9% in QTR 1, 0% in QTR 2, .01% in QTR 3 and 0.8% in QTR 4.”

“Upon patient client record review, 2 of 20 (Patient #4,#7) 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 aide supervisory was completed on 01/21/26, but there was no evidence of an aide visit until 01/23/26. Patient #7:During the RN initial assessment the patient declined aide visits and no aide visit frequencies were excluded from the plan of care. However, the IDG discussion on 01/28/26 indicated, “the plan of care includes...CNA visits...”.”

“Upon client record review, 1 of 20 (Patient #16) 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 #16: On 12/22/25 the aide notified the RN case manager that she was sick with the flu and could not visit the patient however, there was no evidence the RN coordinated a visit from a different aide or if aide visits were cancelled by the family/facility.”