Every finding on record at Adequate Care Hospice, Inc

Upon patient record review, 2 of 5(Patient #2 and #5) 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 listed Arnicare topical gel without evidence of specific area for use. COS Patient #5: The medication profile listed capsaicin topical without evidence of specific area for use. COS

Upon patient record review, 1 of 5 (Patient #4) 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 #4: The plan of care did not have problems/interventions/goals for volunteer services. COS

Upon patient record review, 2 of 5 (Patient #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 medications and treatments. Patient #2: The order listed Arnicare topical gel without evidence of specific area for use. COS Patient #5: The order listed capsaicin topical without evidence of specific area for use. COS

Upon patient record review, 4 of 5 (Patient , #1, #2, #3, #4) 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 initial assessment noted patient has a wheelchair however, this was not listed on plan of care. The plan of care did not include supplies (bedpan and chux pads). COS Patient #2: The initial assessment noted patient has a wheelchair however, this was not listed on plan of care. COS Patient #3: The initial assessment noted patient has a shower chair however, this was not listed on plan of care. COS Patient #4: The initial assessment indicated patient has an E tank however, this was not listed on plan of care. COS

Upon client record review, 2 of 5 (Patient #2, #4) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #2: The nurse visit frequency was ordered RN 2/week and LVN 1/week and 2 PRN however, the week of 05/14 there was only two visits completed on 05/15-RN and 05/16-LVN. COS Patient #4: The nurse visit frequency was ordered each RN and LVN at 1/week and 2 PRN, however the week of 05/07/2023 there was evidence of 3 visits on 05/09-RN, 05/10-LVN, and 05/11-LVN without any noted as PRN. In addition, the week of 05/14 there was evidence of only one visit on 05/18-RN. COS

Upon patient record review 1 of 5 (Patient #2) 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 #2: The aide visit frequency was ordered on start of care at 2/week however, each week there was only evidence of one visit the week of 05/07, which was on 05/12. COS

Upon observation, there was no evidence a copy is provided of the hospice written policies and procedures on the management and disposal of controlled drugs to the patient or patient representative and family COS

Condition of Participation: Initial and Comprehensive Assessment of the Patient.

Upon patient record review 1 of 19 (Patient #2) 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 #2: The patient was admitted on 9/30/22. The spiritual care assessment was completed on 10/7/22.

Upon patient record review 1 of 19 (Patient #16) 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 #16: The patient was admitted on 1/11/23. There was no evidence of a completed spiritual care assessment.

Upon patient record review, 2 of 19 (Patient #3, #4) 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: Documentation revealed in the initial nurse's note the patient had a fleets enema. Fleets enema was not included on the medication profile. Patient #4: Documentation 3/3/23 nursing note revealed the patient is taking MS Contin 15 mg BID. The medication profile was not updated to reflect the current medication regimen. Upon home observation, the patient is not taking hydrocodone, Benadryl, and Xanax. The medication profile was not updated to reflect the current medication regimen.

Upon patient record review, 6 of 19 (Patient #3, #6, #12, #17, #18, #19) 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 #3:The patient was admitted on 12/2/21. There was no evidence of a bereavement risk assessment at the time of survey. Patient #6: The patient was admitted on 1/29/23. There was no evidence of a bereavement risk assessment at the time of survey. Patient #12: The patient was admitted on 4/22/22. There was no evidence of a bereavement risk assessment at the time of survey. Patient #17: The patient was admitted on 5/11/22. There was no evidence of a bereavement risk assessment at the time of survey. Patient #18: The patient was admitted on 5/14/21. There was no evidence of a bereavement risk assessment at the time of survey. Patient #19: The patient was admitted on 11/15/22. There was no evidence of a bereavement risk assessment at the time of survey.

Condition of Participation: Interdisciplinary Group, Care Planning, and Coordination of Services. L536

Upon patient record review, 3 of 19 (Patient #2, #3, #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 nurse's documentation on 4/7/23 indicated that the patient had symptoms of constipation. There was not evidence of problems, goals, and interventions related to constipation included on the plan of care. Patient #3: The nurse's documentation on 3/3/23 and subsequent nursing visits indicate the patient had symptoms of constipation. There was not evidence of problems, goals, and interventions related to constipation included on the plan of care. Patient #8: The nurse's documentation on 2/21/23 and subsequent nursing visits indicate the patient had symptoms of constipation. There was not evidence of problems, goals, and interventions related to constipation included on the plan of care.

Upon patient record review, 4 of 19 (Patient #2, #4, #6, #8) 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 #2: Each plan of care contained orders for "Chaplain PRN only". Patient #4: Each plan of care contained orders for "Social Worker PRN only". Patient #6: The plan of care 1/31/23 and subsequent POCs ordered SW PRN visits without a quantity for those visits. Patient #8: Each plan of care contained orders for Social Worker and Chaplain "PRN only".

Upon patient record review, 2 of 19 (Patient #3, #4) 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 #3:The initial nursing note indicated that the patient had a fleets enema. There was no evidence of an order for a fleets enema. Patient #4: There is documentation in the nursing note 3/3/23the patient is taking MS Contin 15 mg BID. There is no order written to update the plan of care. Upon home observation, the patient is not taking hydrocodone, Benadryl, and Xanax. There is no order written to update the plan of care.

Upon patient record review, 3 of 19 (Patient #3, #5, #8) 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 #3: The agency plan of care does not include equipment and supply needs. According to the nurses initial assessment on 12/2/21 the patient needs a rollator. Patient #5: The agency plan of care does not include equipment and supply needs. According to the nurses initial assessment on 11/18/22 the patient needs a walker, cane, and briefs. Patient #8: The agency plan of care does not include equipment and supply needs. According to the nurses initial assessment on 12/6/21 the patient needs briefs and incontinence supplies.

Upon client record review, 1 of 19 (Patient #6) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #6: The social work visit frequency was indicated at "1x mo and prn to meet the needs identified". There was no evidence of any visits at the time of survey.

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 #2, Aide: The staff member was observed sitting her bag down on the patient's overbed table without a barrier and providing patient care without hand washing or use of hand sanitizer.

Upon patient record review, 2 of 19 (Patient #18, #19) did not have evidence the hospice offers bereavement counseling that includes: • Making bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. Bereavement counseling also extends to residents of a SNF/NF or ICF/IID when appropriate and identified in the bereavement plan of care • Ensuring that bereavement services reflect the needs of the bereaved • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery Patient #18: The medical record included a bereavement plan of care. There was no evidence any of the interventions on the plan of care were completed. Patient #19: The medical record included a bereavement plan of care. There was no evidence the 30 day and 90 day interventions on the plan of care were completed. The nurse's documentation indicates "identified concerns coming to terms with patients death" and the family request visits by the social worker and chaplain. There was no evidence visits were made by social work and spiritual care.

Upon patient record review, 4 of 19 (Patient #2, #3, #6, #9) 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 #2: The aide care plan dated 4/11/23 included complete dependence. There aide care plan contained no evidence indicating the amount of people it takes to transfer the patient safely. Patient #3: The nursing visit note dated 2/24/23 indicates the patient requires maximum assistance. The aide care plan dated 10/17/22 indicates that the patient's dependence is minimal. There was no evidence of an update to the aide care plan. Patient #6: The nursing note dated 4/3/23 indicates the patient requires 2 people to transfer. The aide care plan indicates patient is a 1 person transfer. There was no evidence that the aide care plan was updated. Patient #9: The visit frequency on the aide plan of care was indicated at 3x/week and 1 prn.

Upon patient record review, 19 of 19 (Patient #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19) did not have evidence that the medical director or physician designee provides written certification that it is anticipated that the patient's life expectancy is 6 months or less if the illness runs its normal course. The physician must consider the following when making this determination: • The primary terminal condition • Related diagnosis • Current subjective and objective medical findings • Current medication and treatment orders • Information about the medical management of any of the patient's conditions unrelated to the terminal illness Patients #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19: The CTI narrative written by the medical director or physician designee states "the patient has a prognosis of 6 months or less if the illness runs its normal course". The CTI narrative does not contain evidence of consideration for subjective and objective medical findings, medication and treatment orders, and information about the medical management of any of the patient's conditions unrelated to the terminal illness. The CTI included a nursing narrative and the NP F2F visit scanned and attached to the CTI.

Upon patient record review, 13 of 19 (Patient #1, #2, #3, #4, #5, #8, #9, #11, #12, #13, #14, #17, #18) did not have evidence that before the recertification period for each patient, the medical director or physician designee must review the patient's clinical information and provide written documentation that it is anticipated that the patient's life expectancy is 6 months or less. Patients #1, #2, #3, #4, #5, #8, #9, #11, #12, #13, #14, #17, #18: The recertification of terminal illness does not contain evidence the medical director or physician designee reviewed the patient's clinical information or the patient's individual clinical circumstances to compose a brief clinical justification narrative. The CTI included a nursing narrative and the NP F2F visit scanned and attached to the CTI.

Upon personnel record review, 1 of 15 (Personnel #14) did not have evidence that all Speech Therapy Services are provided by a qualified licensed Speech-Language Pathologist (SLP) or Audiologist in accordance with the state's Speech-Language Pathology Practice Act and the hospice's policies and procedures and/or job descriptions.

Upon personnel record review, 1 of 15 (Personnel #15) did not have evidence all Occupational Therapy Services are provided by a qualified licensed Occupational Therapist (OT) in accordance with the state's Occupational Therapy Practice Act and the hospice's policies and procedures and/or job descriptions.

Upon personnel record review, 1 of 15 (Personnel #13) did not have evidence all Physical Therapy Services are provided by a qualified licensed Physical Therapist (PT) in accordance with the state's Physical Therapy Practice Act and the hospice's policies and procedures and/or job descriptions.

Upon personnel record review, 3 of 15 (Personnel #13, 14, 15) did not have evidence the hospice obtained a criminal background check on all contracted individuals who have direct patient care and access to patient records.

Upon personnel record review, 2 of 15 (Personnel #8, #11) did not have evidence of criminal background checks being obtained in accordance with state requirements. In the absence of state requirements, criminal background checks are obtained within three months of the date of employment for all states that the individual has lived or worked in the past 3 years. Personnel #8: The personnel record did not contain evidence of criminal background checks being obtained within 3 months of the date of employment. Personnel #11: The personnel record did not contain evidence of criminal background checks being obtained within 3 months of the date of employment.

Upon personnel record review, 3 of 15 (Personnel #13, 14, 15) did not have evidence that all personnel have been fully vaccinated for COVID-19 or had an approved exemption.