Every finding on record at 210 Hospice Care LLC

Upon patient record review 2 of 14 (Patient #5, 10) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient #5 The patient was admitted on 2/10/23, the SW assessment was completed on 2/20/23. Patient #10 The patient was admitted on 7/1/22, the SW assessment was completed on 7/14/22.

Upon patient record review 4 of 14 (Patient #7, 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 #7 The patient was admitted on 7/20/21, there was no psychosocial assessment completed on the patient. Patient #8 The patient was admitted on 5/5/22, there was no psychosocial assessment completed on the patient. Patient #9 The patient was admitted on 5/5/22, there was no psychosocial assessment completed on the patient. Patient #14 The patient was admitted on 1/19/23, there was no psychosocial assessment completed on the patient.

Upon patient record review, 6 of 14 (Patient #1, 2, 3, 5, 6, 10) 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 The medication profile includes clotrimazole 1% topical cream, but does not include an application site. The medication profile includes Namenda 10mg but does not include a route of administration or scheduled dosing. (Corrected on site.) Patient #2 The medication profile includes clotrimazole 1% topical cream, but does not include an application site. (Corrected on site.) Patient #3 The medication profile includes Miralax 17gram powder but does not include a diluent for mixing and administering the powder. (Corrected on site.) Patient #5 The medication profile includes Cortisone 1% topical cream, but does not include an application site. (Corrected on site.) Patient #6 The medication profile includes Miralax 17 gram powder, but does not include a diluent for mixing and administering the powder. Patient #10 The medication profile does not include oxygen.

Upon patient record review, 2 of 14 (Patient #5, 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 #5 The plan of care does not include a problem statement with interventions and goals for the use and maintenance of a foley catheter. (Corrected on site.) Patient #10 The plan of care does not include a problem statement with interventions and goals for the implanted cardiac defibrillator.

Upon patient record review, 6 of 14 (Patient #1, 2, 3, 5, 6, 10) 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 The medication order on 12/6/22 for clotrimazole 1% topical cream apply to affected area, does not include an application site. The medication order on 7/29/21 for Namenda 10 mg does not indicate a route of administration or scheduled dosing. (Corrected on site.) Patient #2 The medication order on 4/4/23 for clotrimazole 1% topical cream, apply to affected area daily does not include an application site. The nursing assessment on 11/22/22 indicates that an oxygen concentrator was ordered for the patient, the plan of care does not include orders for oxygen. (Corrected on site.) Patient #3 The medication order on 11/22/22 for Miralax 17 gram powder take one daily PRN constipation, does not include a diluent for mixing the medication. (Corrected on site.) Patient #5 The medication order on 2/10/23 for Cortisone 1% topical cream, apply twice daily, does not include the application site. (Corrected on site.) Patient #6 The medication order on 3/17/23 for Miralax 17 gram powder take daily as needed, does not include a diluent for mixing the medication. Patient #10 The admission assessment on 1/5/23 indicates that the patient uses oxygen, there is no order for oxygen.

Upon patient record review, 7 of 14 (Patient #1, 2, 3, 4, 5, 6, 10) 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 #1 The admission assessment on 7/29/21 indicates that the patient requires a walker for ambulation and is incontinent, these items are not included in the plan of care. (Corrected on site.) Patient #2 The admission assessment on 11/22/22 indicates an oxygen concentrator was ordered for the patient, the patient is also incontinent, these items are not listed in the plan of care. (Corrected on site.) Patient #3 The admission assessment on 11/22/22 indicates that the patient is transferred via hoyer lift and is incontinent, these items are not included in the plan of care. (Corrected on site.) Patient #4 The admission assessment on 12/2/22 indicates that the patient uses a rollator for ambulation and that she is incontinent, these items are not included in the plan of care. (Corrected on site.) Patient #5 The admission assessment on 2/10/23 indicates that the patient uses a rollator and has a foley catheter in place, these items are not included in the plan of care. (Corrected on site.) Patient #6 The admission assessment on 3/17/23 indicates that the patient uses a walker for ambulating, this is not included in the plan of care. Patient #10 The admission assessment on 1/5/23 indicates that the patient uses oxygen, this is not included in the plan of care.

Upon patient record review, 1 of 14 (Patient #1) 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 #1 The plan of care does not include a problem statement with goals or interventions for the management of Type II diabetes, the patient remains on Levemir 20 units SQ daily with decreasing oral intake, pt has had significant weight loss AEB decreased MAC from 17cm to 15 cm since 1/9/23. (Corrected on site.)

Upon client record review, 2 of 14 (Patient #3, 5) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #3 The plan of care includes orders for SW visits every 4 weeks, there is no record of visits being made by the SW since the initial SW assessment on 11/23/22. (Corrected on site.) Patient #5 The plan of care includes orders for SW visits every 4 weeks, there is no record of visits being made by the SW since the initial SW assessment on 2/20/23. (Corrected on site.)

Upon patient record review, 2 of 14 (Patient #1, 7) 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 #1 The aide tasks for bathing, incontinent care, shampooing, hair care, skin care, linen change, tidy bathroom, tidy patient area and provide companionship do not specify a frequency for care. (Corrected on site.) Patient #7 The aide tasks for bathing indicate "shower or bedbath as patient tolerates."

Upon patient record review 2 of 14 (Patient #8, 10) 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 • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #8 The hospice aide/aides provided care to the patient with no care orders in place, the patient received hospice aide services on 5/6/22, 5/9/22, 5/11/22, 5/16/22, and 5/18/22. Patient #10 The hospice aide/aides provided care to the patient with no care orders in place, the patient received hospice aid services 3 x per week for week 7/12/22, 7/19/22, 7/26/22 and 1x for 8/1/22

Upon patient client record review, 1 of 14 (Patient #10) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient #10 On admit, the patient record indicated "yes" to receive a copy of the Patient Notification of Hospice Non-Covered Items, Services and Drugs. There is no document in the patient record that this was provided to the patient or primary caregiver.

Upon patient client record review, 4 of 14 (Patient #4, 6, 8, 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 #4 The patient was admitted on 12/2/22, the admission assessment note was signed/authenticated by the RN on 2/3/23. Agency policy is within 48 hours. Patient #6 The patient revocation form effective 4/21/23, has not been signed by a hospice member. Patient #8 The hospice aide provided services on 7/1/22, the documentation for the visit was completed on 8/6/22. Agency policy is within 48 hours. Patient #12 The Spiritual Care Assessment completed on 1/17/23 has not been signed/authenticated by the Spiritual Care Counselor. Agency policy is within 48 hours.