Every finding on record at Acacia Hospice Care of Lake Havasu

Upon observation, there was not evidence that the Emergency Preparedness Plan included strategies for addressing those emergency events identified by the risk assessment for which the Hospice identified themselves to be at highest risk.

Upon patient record review, 1 of 8 (Patient #7) did not contain evidence of a current/comprehensive Medication Profile, and/or that a review had been completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. Patient #7: A verbal order was obtained on 11/03/21 for Oxygen 3 lpm continuous. Oxygen was not added to the med profile.

Upon client record review, 1 of 8 (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: The 08/12/21 IDG Plan of Care referenced a skin tear to right lower leg, red, warm, possibly cellulitis, with further reference to an ATB order and dressing change order. The intervention of dressing change was again documented on 08/26/21 as the nurse writes, "removed old dressing." There was no wound order located within the Hospice Plan of Care, as having been obtained from the Physician.

Upon patient record review, 2 of 2 applicable (Patients #7 and 8) did not contain evidence that the Hospice develops a Bereavement Plan of Care that notes the kind of bereavement services to be offered, and the frequency of such service delivery. There was evidence of various bereavement activities but no plan of care the outlined which bereavement services were to be provided and the frequency of those activities.

Upon personnel record review, 1 of 1 applicable (Personnel #8) did not contain evidence that the Skills Competency Assessment conducted by the RN on 01/21/22 included the tasks of nail and skin care.

Upon patient record review, 2 of 6 applicable (Patients #1, 2) did not contain evidence that the Hospice Aide Plan of Care assignments/duties include the task to be provided and the frequency of those tasks. Patient #1: The Aide POC dated 01/14/22 assigned Change linen, Light housekeeping and Make bed as needed. Patient #2: The Aide POC dated 01/07/22 assigned Change linen and Assist ambulation as needed. As of 01/25/22, the aide POC continued to assign Foley care, however, the patient's Foley had been removed on 01/14/22.

Upon patient record review, 2 of 6 applicable (Patients #1 and 5) did not contain evidence that the Hospice Aide provided care/services that were ordered by the IDG and included in the plan of care. Patient #1: The last Aide visit frequency update, to the Hospice IDG Plan of Care, was 10/08/21 ordering the Aide to make 2x per week home visits. During the weeks from 10/24/21 to 12/05/21, the Aide made only 1 visit per week. Patient #5: The Aide POC dated 8/31/21 assigned aide twice weekly and the following tasks: Back rub/massage, Change linen, Light Housekeeping, Make bed and Range of Motion to be provided 2x per week. These tasks were not provided for the 09/03 and 09/07/21 Aide visits. Additionally, aide visits 9/3 and 9/7 were the only visits made. Missing evidence of an order to discontinue aide services.

Upon patient record review, 3 of 3 applicable live discharges (Patients #4, 5 and 6) did not contain a DC Summary which included all CMS-required content, as follows: • A summary of the patient's stay, including treatments, symptoms and pain management • The patient's current plan of care • The patient's latest physician orders

Upon inpatient contract review, 1 of 1 applicable (HHLH) did not include the CMS requirement that a copy of the Discharge Summary will be provided to the Hospice at the time of discharge from GIP or Respite care/services.