Every finding on record at Ace Home Health Care & Hospice Inc.

Upon patient record review, 5 of 19 (Patients #3, 5, 6, 10, 11) 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 #3: Patient is prescribed Acetaminophen 650mg suppositories 1 every 6 hours prn fever and 650mg po every 6 hours prn pain. Neither order states maximum dose in 24 hours. Patient is prescribed Miralax. The order does not include instructions for reconstitution. Patient #5: Patient is prescribed Acetaminophen 650mg suppositories 1 every 6 hours prn fever and 650mg po every 6 hours prn pain. Neither order states maximum dose in 24 hours. Patient #6: Patient is prescribed Acetaminophen 650mg suppositories 1 every 6 hours prn fever; Norco 10/325mg 1 every 6 hours prn pain; Norco 10/325mg 1 tablet twice daily; Norco 10/325mg prn prior to wound care. The orders do not contain 24 hour max dose. Patient #10: Patient is prescribed Acetaminophen 650mg suppositories 1 every 6 hours prn fever and 650mg po every 6 hours prn pain, as well as Norco 5/325mg 1 every 8 hours prn. The orders do not include the 24 hour max dose. Patient #11: Patient is prescribed Acetaminophen 650mg suppositories 1 every 6 hours prn fever and 650mg po every 6 hours prn pain. Neither order states maximum dose in 24 hours. Patient is prescribed Miralax. The order does not include instructions for reconstitution.

Upon patient record review, 5 of 19 (Patients #1, 7, 8, 11, 12) 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: The patient is on anti seizure medications for history of epilepsy. There are no goals or interventions for seizure on the POC. Patient #7: The patient is on anti seizure medications for history of seizures. There are no goals or interventions for seizures on the POC. Patient #8: The patient is on Pradaxa, an anti coagulant. There are no interventions or goals for anticoagulation and bleeding precautions on the POC. The patient is on hospice with a primary diagnosis of Colon Cancer. There are no interventions or goals for Cancer on the POC. Patient #11: The patient is on Plavix, an anticoagulant. There are no interventions or goals for anti coagulant use or bleeding precautions on the POC. Patient #12: The patient is on Aspirin, an anti coagulant. There are no interventions or goals for anti coagulant use or bleeding precautions on the POC.

Upon personnel record review, 1 of 14 (Personnel #12) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) ·Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff. ·Reading and recording temperature, pulse, and respiration ·Safe transfer techniques and ambulation. ·Normal range of motion and positioning ·Appropriate and safe techniques in personal hygiene and grooming that include-- ·(A) Bed bath ·(B) Sponge, tub, and shower bath ·(C) Shampoo, sink, tub, and bed ·(D) Nail and skin care ·(E) Oral hygiene ·(F) Toileting and elimination The other subject areas in this section may be evaluated through written examination, oral examination or after observation of a Hospice Aide with a patient. Personnel #12: There is not evidence on competency evaluations that all required tasks were done with a pseudo or actual patient, including Temperature, Pulse, Respirations, Positioning and Range of motion

Upon patient record review, 5 of 19 (Patients #1, 7, 8, 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 #1: The patient has history of Epilepsy, Seizure precautions are not included in the Aide POC. Patient #7: The patient has history of seizures. Seizure precautions are not included in the Aide POC. Patient #8: The patient is on anticoagulants. Bleeding precautions are not included in the Aide POC. Patient #11: The patient is on anticoagulants. Bleeding precautions are not included in the Aide POC. Patient #12: The patient is on anticoagulants. Bleeding precautions are not included in the Aide POC.

Upon observation, there was no evidence the annual report documents the use of volunteers providing day to day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract personnel.

Observed in Record Review. In 13 of 13 patient records reviewed, the written plan of care was not based on the patient’s goals and the time frames, settings, and services required to meet those goals in the charts for all charts reviewed. Examples included: In the chart for HSHV#1, the patient's initial plan of care did not include the time frame anticipated to meet the majority of the goals of care, except for ongoing. This included pain management, understanding of fall precaution teaching and medication management teaching. In addition, some goals were not measurable nor individualized to this confused patient. E.g. Patient will verbalize that symptoms of decreased cardiac output are adequately managed within limits of disease process.. In the chart for HSHV#3, this patient with a hospice diagnosis of Senility and dementia, the pain goal of Patient will report pain using a standardized pain scale, and report/demonstrate that pain is managed at or below the SIG was on-going which was not individualized to the patient who was unable to utilize a standardized pain scale, nor an acceptable time frame for symptom management. Additionally, the goal of Caregiver will verbalize understanding of non-verbal pain cues is on-going and did not have a target date appropriate to a symptom management goal. In the chart for HSRR#1, the goal Caregiver will demonstrate effective wound care. - Completed By: Ongoing on the initial plan of care was not an appropriate goal when the hospice expected the caregivers to be providing the wound care. In the chart for HSRR#2, goals had not been individualized/appropriate/measurable for this patient with Alzheimer's Patient will have acute confusion/ behaviors reduced to manageable level within the limits of the disease. - Completed By: Ongoing. Additionally, there was not an anticipated time frame for achievement for the pressure ulcer risk goal of Patient/caregiver will verbalize a plan for preventing impaired skin integrity. other than on-going. In the chart for HSRR#4, the patient with pain as an active problem had the anticipated time frame for pain at or below his self-identified threshold as on-going and not prioritized as to be met within minutes/hours/days of med administration, etc. as would be expected of this symptom related goal with active interventions. Additionally, there was no target date for the safety goal of patient and caregiver will verbalize oxygen safety and use of equipment which was on-going. In the chart for HSRR#5, the patient for whom pain was a major problem and for whom the pain medication was increased at the admission visit, had no anticipated time frame for achievement of his pain management goal. In the chart for HSRR#6, the patient with seizure activity, the goal of Patient/caregiver will verbalize when to call hospice for seizure activity was on-going rather than prioritized early in the care of the patient. Additionally, this patient had dementia, so was not individualized to the patient. This was discussed with the Hospice Director.

Observed in Record Review. In 6 of 13 patient records reviewed, the plan of care (POC) did not include all services needed for palliation and management of the terminal illness and related conditions. In the chart for HSHV#1, the order for oxygen stated both continuously and prn. Additionally, the patient had orders for wound care to a skin tear upon admission. This order was missing the frequency of treatment. In the chart for HSRR#4, the patient had CPAP identified during an EMS visit and later again during an SN visit. This treatment was not included on the patient's hospice POC. In the chart for HSRR#6, the patient had multiple pressure ulcers. The POC included instruction of the caregiver to change the dressings as well as pre-medicating with pain medication prior to care, however the order for wound care had not been included in the Hospice POC. Additionally, the SN visit notes indicate the patient is using oxygen. The POC included no orders for oxygen. In the charts for HSRR#7 and HSRR#10 the dressing change order was missing the frequency of the treatment. In the chart for HSRR#5, volunteer services were added. The POC was not updated to include this service. This was confirmed with the Hospice Director.

Observed in Record Review. In 2 of 13 patient records reviewed, the organization had not provided care according to the patient's individualized plan of care. In the chart for HSHV#1, the initial wound care order for a skin tear did not include application of a medication. During the second SN visit, the nurse applied petroleum jelly to the wound. In the chart for HSRR#4, during the second SN visit, the nurse documented the patient's oxygen was at 2lpm. The order was for 5lpm. There was no documentation this was addressed with the patient nor the physician informed. Additionally, the initial plan of care indicated the patient was to have wound care provided to his coccyx wound and for the SN to teach the caregiver the wound care. There was no wound care documented for this patient in any of the first four nursing visits, nor documentation that the caregiver had been taught and was providing the care. This was confirmed with the Hospice Director.

Observed in Record Review. In 1 of 2 patient records reviewed, the hospice had not developed a bereavement plan of care that specified the type of bereavement services to be offered and the frequency of service delivery. In the chart for BR#1, the bereavement plan of care included the counseling services which were added due to the bereavement risk, however did not include the standard bereavement interventions that were planned such as the standard mailings sent at pre-determined time points over the 13 month bereavement episode. This was discussed with the Hospice Director.

Observed in HR File Review. The hospice had not defined roles for hospice volunteers as confirmed with the HR Manager.

Observed in Record Review. In 2 of 13 patient records reviewed, the patient's record did not contain information that reflected the patient's care. In the chart for HSRR#4, on the second SN visit, the nurse documented that the patient had no wounds, yet she obtained revised wound care orders that same date for a pressure ulcer on the coccyx. Additionally, during the fourth SN visit - the nurse documented SN administered morphine as needed per pt request. without indicating the dose nor route. In the chart for HSRR#6, the SN documented wound care rendered. without elaboration as to the details of the care provided. This was discussed with the Hospice Director.

Observed in Record Review. In 1 of 2 patient records reviewed, in which a patient was discharged alive, the organization had not completed a discharge summary. In the chart for HSRR#1, the patient revoked the hospice benefit. The RN informed and facilitated continued care by the Skilled Nursing facility, however the discharge summary present in the patient's chart did not include a summary of the patient's stay, including treatments, symptoms and pain management, the current plan of care, the latest physician orders, etc. This was discussed with the Hospice Director.

Observed in Record Review. In 1 of 13 patient records reviewed, at the time when controlled medications were first ordered, the hospice had not documented that it provided a copy of its written policies and procedures on the management and disposal of controlled medications to the patient or the patient’s representative and family. This documentation was missing in the record for HSHV#2. The information was present in the informational folder in the patient's home. This was discussed with the Hospice Director.

Observed in Record Review. In 1 of 3 patient records reviewed, for a patient residing in a SNF, the hospice plan of care did not identify which provider was responsible for performing the functions that have been agreed upon and included in the plan of care. In the chart for HSHV#1, the hospice plan of care included wound care, yet did not indicate which provider was to perform the wound care. This was confirmed with the Hospice Director.

Observed in HR File Review. In 2 of 4 HR files reviewed, the organization had not verified credentials of care providers using the primary source at the time of hire and/or renewal. In the file for the Hospice Director, the Nursing license which expired in August 2019 was not verified as renewed until July 2020. In the file for the RN who was hired in April 2020, the initial license verification was completed in June 2020; the renewal for the license which expired in June 2020, was verified in April 2021. This was discussed with the HR Manager.

Observed in HR File Review. In 1 of 9 HR files reviewed, the organization had not obtained a criminal background check as required by law and regulation within three months of hire for the Hospice Volunteer as confirmed with the HR Manager. The criminal background check was completed during the survey.