Every finding on record at A-Z Hospice Care 366d 247

Upon patient record review 1 of 14 (Patient #4) 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 #4: The start of care was on 01/11/25, the psychosocial comprehensive assessment was completed on 0/18/25, this was not completed within 5 days from the start of care.

Upon patient record review 8 of 14 records reviewed (Patient #1-8) 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 #1-8: There was no spiritual comprehensive assessment completed at the time of the survey. Patient #1, #5, #6, #7: There was no psychosocial comprehensive assessment completed at the time of the survey.

Upon patient record review, 2 of 14 records reviewed (Patient #2,#7) 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: The medication profile indicated Ergocalciferol 1.25mg capsule po once a day, the prescription was labeled for the frequency to be once a week. COS. Patient #7: The medication profile had erythromycin 0.5% small amount ophthalmic once a day. There was no direction on which eye or eye(s) to administer this medication. COS.

Upon patient record review, 3 of 14 records reviewed (Patient #1, #5, #6) 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, #5, #6: There was no initial bereavement assessment completed at the time of the survey.

Upon patient record review, 7 of 14 records reviewed (Patient #2, #3, #4, #5, #6, #7, #8) 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 #2: The patient was a full code on admission. There was no developed individualized plan of care that reflected the patient/family goals and interventions regarding this code status. COS. Patient #3: The patient was taking Eliquis 5mg po BID. There was no developed individualized plan of care that reflected the patient/family goals and interventions regarding bleeding precautions. COS. Patient #4: The patient was a full code on admission. There was no developed individualized plan of care that reflected the patient/family goals and interventions regarding this code status. COS. Patient #5: The patient was a full code on admission. There was no developed individualized plan of care that reflected the patient/family goals and interventions regarding this code status. COS. Patient #6: The patient was a full code on admission. There was no developed individualized plan of care that reflected the patient/family goals and interventions regarding this code status. COS. Patient #7: The patient was a full code on admission. There was no developed individualized plan of care that reflected the patient/family goals and interventions regarding this code status. COS. Patient #8: The patient was a full code on admission. There was no developed individualized plan of care that reflected the patient/family goals and interventions regarding this code status. COS.

Upon patient record review, 6 of 14 (Patient #1,#2,#3,#4,#5,#7) 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 #1: The record indicated the social worker and spiritual care visits were ordered prn and at recert, there was no defined frequency for the social worker and or chaplain. COS. Patient #2: The record indicated the social worker and spiritual care visits were ordered prn and at recert, there was no defined frequency for the social worker and or chaplain. COS. Patient #3: The record indicated the social worker and spiritual care visits were ordered prn and at recert, there was no defined frequency for the social worker and or chaplain. COS. Patient #4: The record indicated the social worker and spiritual care visits were ordered prn and at recert, there was no defined frequency for the social worker and or chaplain. COS. Patient #5: The record indicated the social worker and spiritual care visits were ordered prn and at recert, there was no defined frequency for the social worker and or chaplain. COS. Patient #7: The record indicated the social worker and spiritual care visits were ordered prn and at recertification there was no defined frequency for the social worker and or chaplain. COS.

Upon patient record review, 1 of 14 records reviewed (Patient #7) 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 #7: The orders read erythromycin 0.5% small amount ophthalmic once a day. There was no direction on which eye or eye(s) to administer this medication. COS.

Upon patient record review, 3 of 14 records reviewed (Patient #1, #2, #5) 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 record indicated the patient had shower chair and walker. These DME items were not listed in the Plan of Care. COS. Patient #2: The record indicated the patient had a BP cuff. This DME item was not listed in the Plan of Care. COS. Patient #5: The record indicated the patient has a walker and bedside table. These DME items were not listed in the Plan of Care. COS.

Upon client record review, 1 of 14 (Patient #3) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #3: There was no order for the initial visit made by the social worker on 11/27/24. COS.

Upon patient record review, 1 of 14 records reviewed (Patient #9) did not have evidence that the IDG documents the sharing of information between all disciplines providing care and services in all settings, whether the care and services are provided directly or under arrangement. Patient #9: The record indicated the Spiritual Assessment completed on 11/19/24, the patient reported a pain level of "6" the RN documented the Self Identified Threshold to be "5" earlier on the same day, the Chaplain did not report this pain level to the nurse.

Upon patient record review 2 of 14 (Patient #6,#8) 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 #6: There was no Hospice Aide visits ordered. The Hospice Aide made visits on 2/25/25, 2/27/25, 3/3/25, 3/18/25 and on 3/20/25. Patient #8: The hospice aide visits were order 2 X W. There was a visit made on 3/3/25 and no second visit was made during that week.

Upon patient record review 4 of 14 records reviewed (Patient #1, #6, #7, #8) 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 #1: The hospice aide supervision was done by the RN on 03/10/25, there was no supervision completed on the RN visit made on 03/24/25. Patient #6: The record indicated the RN had supervisory visits schedule on 02/24/25, 03/03/25, 03/12/25 and 03/19/25 there were no supervision for the aide documented during any of these visits. Patient #7: The RN had a supervisory visit due for the Hospice Aide on 02/08/25, there was no supervisory completed. Patient #8: The RN had a supervisory visit due for the Hospice Aide on 02/22/25, there was no supervisory completed.

Upon patient client record review, 1 of 14 records reviewed (Patient #1) did not evidence that each patient record contains physician orders. Patient #1: There were no diet orders on the chart at the time of the survey. COS.

Upon personnel record review, 1 of 1 applicable (Personnel # 4) did not have evidence in the personnel file that the competency assessment included assessment of all required tasks. Personnel #4 - The competency assessment form currently utilized by the agency lists only shampoo. There is no specification for the competency to include: Shampoo, sink, tub and bath.

Upon personnel record review, 1 of 1 applicable records (Personnel #2 ) did not have evidence the alternate administrator's personnel record verifies that: • There is a signed job description for this role The Administrator designee had a signed job descriptions for Admin/DPCS. It did not designate that the employee was the designee although aware of actual role as designees.

Upon patient client record review, 5 of 5 (Patient #1, 2, 3, 4, 5,) did not have evidence that each patient record contains Physician certification of terminal illness. The agency was completing a Face to Face form that indicated the patient's name and a review of symptoms, current body system assessment, pain level, Karnofsky, PPS and FAST assessments and a life expectancy, but did not include the benefit period, attestation statement, etc. that is required to be included on the Certification of Terminal Illness.