Trio Hospice Inc.

“Upon patient record review 3 of 14 (Patient #6,7,8) 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 6: Patient declined spiritual services as indicated in progress note dated 11/21/24. There is no evidence that a comprehensive spiritual assessment was completed within 5 days of admission. Patient 7: Patient declined spiritual care visits as indicated in documentation dated 2/27/25. There is no evidence that a comprehensive spiritual assessment was completed within 5 days of admission. Patient 8: Patient declined spiritual services as indicated in progress note dated 06/17/25. There is no evidence that a comprehensive spiritual assessment was completed within 5 days of admission.”

“Upon patient record review, 10 of 14 (Patient #1,2,3,4,5,6,7,8,9,10) did not have evidence in the patient record that the comprehensive assessment takes into consideration the imminence of death. Patient 1: The patient was admitted on 3/25/25. The comprehensive assessment does not assess for imminence of death. Patient 2: The patient was admitted on 8/19/25. The comprehensive assessment does not assess for imminence of death. Patient 3: The patient was admitted on 9/16/25. The comprehensive assessment does not assess for imminence of death. Patient 4: The patient was admitted on 11/18/24. The comprehensive assessment does not assess for imminence of death. Patient 5: The patient was admitted on 9/13/24. The comprehensive assessment does not assess for imminence of death. Patient 6: The patient was admitted on 11/02/24. The comprehensive assessment does not assess for imminence of death. Patient 7: The patient was admitted on 2/27/25. The comprehensive assessment does not assess for imminence of death. Patient 8: The patient was admitted on 06/12/25. The comprehensive assessment does not assess for imminence of death. Patient 9: The patient was admitted on 06/30/25. The comprehensive assessment does not assess for imminence of death. Patient 10: The patient was admitted on 10/21/25. The comprehensive assessment does not assess for imminence of death.”

“Upon patient record review, 3 of 14 (Patient# 1,2,9) 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: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient 1: Current medication record contains an order dated 8/29/25 for Miralax Powder for solution 17g orally without diluent. Corrected onsite, medication record updated. Patient 2: The medication record contains an order dated 9/5/25 for Miralax Powder for solution 17g orally without diluent. Corrected onsite, medication record updated. Patient 9: Medication record contains an order dated 6/30/25 for Lidocaine 2% gel without indication of site of application.”

“Upon patient record review, 1 of 14 (Patient #7) 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 7: The current POC dated 03/12/25 has a medication order for Eliquis (anticoagulant) without a risk for bleeding care plan with appropriate goals and interventions.”

“Upon patient record review, 3 of 14 (Patient #1,2,9) 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: Current POC dated 9/10/25 contains an order for Miralax Powder for solution 17g orally without diluent. Corrected on site, POC updated. Patient 2: Current POC dated 9/10/25 contains an order for Miralax Powder for solution 17g orally without diluent. Corrected onsite, POC updated. Patient 9: Most current POC dated 7/30/25 has an order for Lidocaine 2% patch without indication of site for application.”