Every finding on record at A Ray of Light Hospice, LLC

Upon observation, there was no evidence the Emergency Plan communication plan must includes a primary and alternate means for communicating with Federal, state, tribal, regional, and local emergency management agencies. Corrected on site.

Upon patient record review 1 of 14 (Patient #13) 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 #13: SOC 8/28/2022, there was no evidence of a SC assessment in the comprehensive assessment.

Upon patient record review, 6 of 14 (Patient #1, #2, #6, #8, #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 #1: The medication profile dated 5/27/2022 included O2 2LPM inhaled PRN dyspnea. There was no evidence of how to administer, NC or mask. The medication profile dated 5/27/2023 included Albuterol 2.5mg/3ml 0.083% 1 vial inhaled PRN Q 6 hours as needed respiratory. There was no evidence of a delivery system or indication for prn. Corrected on site. Patient #2: The medication profile dated 7/10/2023 included Oxygen 2 nasal PRN dyspnea. There was no evidence of a correct dose or delivery system n/c or mask. Corrected on site. Patient #6 : The medication profile dated 4/14/2022 included O2 2Lpm inhaled daily dyspnea. There was no evidence of a delivery route. Patient #8: The medication profile dated 9/12/2022 included Oxygen 2LPM via nc daily. There was no evidence of frequency PRN or continuous. Patient #11: The medication profile dated 2/28/2023 included Oxygen 3LPM may increase to 5LPM inhaled PRN Dyspnea. There was no evidence of how to administer. Dated 2/28/2023 included Albuterol 90mcg inhaled PRN Q 4 Hours Respiratory, there was no evidence of how to administer/route or indication. Dated 2/28/2023 included Nystatin 100,000/G topical cream apply BID to yeast infection, there was no evidence of where to apply. Patient #13: The medication profile dated 8/28/2022 included Oxygen 2LPM inhaled PRN dyspnea, there was no evidence of how to dispense/route.

Upon patient record review, 2 of 14 (Patient #8, #14) 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 #8: SOC 9/12/2022. There was no evidence of an initial Bereavement assessment completed within 5 days. Patient #14: SOC 11/16/2023. There was no evidence of an initial Bereavement assessment completed within 5 days.

Upon patient record review, 3 of 13 (Patient #1, #6, #8) 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 #1: SOC assessment identified two wounds, one was a Stage ll pressure ulcer, which were assessed and measured. There were no wound assessments or measurements on subsequent SN visits. SN documentation on each SN note included "Pt with wound to sacral area, caregiver performing daily wound care." Patient #6: SOC assessment identified three wounds, Lt hip stage ll, Rt hip unstageable, Rt heel stage ll, there was no evidence of wound assessment or measurements. There were no wound assessments or measurements on subsequent SN visits. SN documentation included "pt refused assessment", "caregiver performs daily wound care", "upset refused assessment". Patient #8: SOC assessment identified Stage ll sacral wound, there was no evidence of wound assessment or measurement. Documentation lacking in subsequent SN notes related to wound assessment or measurement.

Upon patient record review, 4 of 14 (Patient #1, #6, #9, #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 SOC assessment identified two wounds. There was no evidence on the POC of altered skin integrity r/t to the sacral wound with interventions/goals. Corrected on site. Patient #6: SOC assessment identified three wounds. There was no evidence on the POC for altered skin integrity r/t wounds with interventions/goals. corrected on site. Patient #9: SOC 5/22/2023. Terminal diagnosis included Covid-19, STEMI, ASHD, COPD and critical limb ischemia. SOC SN assessment included Necrosis bilateral feet. There was no evidence on the POC of problem/interventions/goals for Skin integrity related to limb ischemia, or Cardiac and Respiratory. Patient #10: Patient had staples in rt side of neck from venus access device on admission. Has history of seizures is on anti- seizure medication. Takes Eloquis to thin blood. There was no evidence in the POC problem/intervention/goals for altered skin integrity RT wound/staples in neck, neuro/risk of seizures or Bleeding precautions.

Upon patient record review, 6 of 14 (Patient #1, #2, #6, #8, #11, #13) 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: Orders dated 5/27/2022 included O2 2LPM inhaled PRN dyspnea. There was no evidence of how to administer, NC or mask. Order dated 5/27/2023 included Albuterol 2.5mg/3ml 0.083% 1 vial inhaled PRN Q 6 hours as needed respiratory. There was no evidence of a delivery system or indication of dyspnea. Corrected on site. Patient #2: Order dated 7/10/2023 included Oxygen 2 nasal PRN dyspnea. There was no evidence of a correct dose or route. Corrected on site. Patient #6: Order dated 4/14/2022 included O2 2Lpm inhaled daily dyspnea. There was no evidence of a route. Order dated 4/24/2022 included Cara Klenz wound spray, topical 2x week per caregiver. There was no evidence of an area. Dated 4/24/2023 included Wounds medihoney small amount topical daily. There was no evidence of who would apply or an area to apply. Corrected on site. Patient #8: Order dated 9/12/2022 included Oxygen 2LPM via NC daily. There was no evidence of frequency, PRN or continuous. Patient #11: Order dated 2/28/2023 included Oxygen 3LPMmay increase to 5LPM inhaled PRN Dyspnea. There was no evidence of how to administer. Order dated 2/28/2023 included Albuterol 90mcg inhaled PRN Q 4 Hours Respiratory, there was no evidence of how to administer/route or indication. Order dated 2/28/2023 included Nystatin 100,000/G topical cream apply BID to yeast infection, there was no evidence of where to apply. Patient #13: An order dated 8/28/2022 included Oxygen 2LPM inhaled PRN dyspnea, there was no evidence of how to dispense/route.

Upon client record review, 1 of 14 (Patient #1) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1: Oder for SN visits from 5/4/2023 SN 2x week. Week of 7/30/2023 one visit documented, no second visit documented or missed.

Upon observation, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient #1: RN removed clean barrier from nursing bag, appropriately cleansing and utilizing hand sanitizer throughout visit, when completed visit folded now dirty barrier and placed back into his clean nursing bag. Patient #3: LVN after using all supplies, with dirty gloves on, cleaned all items and put back into clean bag. Patient #5: LVN draped stethoscope over neck prior to and after use with patient.

Upon patient record review, 4 of 14 (Patient #4, #10, #11, #12) 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 #4: Pt has orders for O2, The aide POC has no evidence of O2 precautions. Corrected on site. Patient #10: Patient history of Epilepsy, takes anti-seizure medication, also on Eloquis to thin blood. There was no evidence on the aide POC for bleeding or seizure precautions. Patient #11: Patient has order for O2, there was no evidence on the aide POC for 02 precautions. Patient #12: Patient has dysphagia as comorbidity in diagnosis. There was no evidence on the aide POC of aspiration risk.

Upon patient record review 2 of 14 (Patient #4, #12) 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 #4: SOC 8/16/2023, Aide visit frequency ordered 2x1, 3x 12, to start 8/16/2023. There were no visits or missed visits the week of 8/16/2023. Patient #12: SOC 10/27/2022 Aide visit frequency 2x 12. Weeks of 11/13/2022, 11/20/2022, 11/27/2022, 12/4/2022 and 12/11/2022 had one aide visit per week with no evidence of a missed visit for the 2nd ordered visit.

Upon patient client record review, 1 of 14 (Patient #3) 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 #3: SOC SN notes included "She is not aware of his surroundings, she requires maximum assist for all ADL's, he requires supervision at all times.

Upon client record review, 14 of 14 (Patient #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14) did not have evidence that the written policies and procedures for managing controlled drugs was provided and discussed. Patient #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14: there was documentation that medication disposal was discussed and policy TX 22 Medication Disposal was provided in admit package. There was no evidence that the written policies and procedures for managing controlled drugs was provided and discussed. There also exist a policy TX 22 Controlled Drugs- Safe Use and Disposal that was not provided.