Every finding on record at Adya Hospice & Palliative Care, LLC

Upon patient record review 2 of 14 (Patient #6,11) 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 #6, Psychosocial assessment completed on 12/26/23, patient admitted on 12/20/23. Patient #11, Psychosocial assessment completed on 11/24/23, patient admitted on 11/18/23

Upon patient record review, 2 of 14 (Patient #2,7) 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, No evidence of initial care plan for MSW or SC was completed for IDG on 2/2/24. MSW visit made 1/25/24, SC visit made on 1/29/24. Patient #7, No evidence of wound care individualized on care plan.

Upon patient record review, 1 of 14 (Patient #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 #5, Shower chair was identified on nursing assessment as patient has. Shower chair was not included in DME on POC.

Upon client record review, 13 of 14 (Patient #1,2,3,4,5,6,7,8,9,10,11,13,14) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1, SN visit on 2/1/24, no evidence of order for SN visit. MSW visit 2/1/24, no evidence orders for MSW. SC visit on 1/31/24, no evidence for SC order. Orders for HA 1xw, MSW eval, SC 1x/m 2PRN, SN 2x/w 3PRN, obtained on 2/2/24 through initial IDG. Patient #2, SN visit on 1/26/24, 1/27/24, 1/29/24, 1/31/24, no evidence of order for SN visits. MSW visit 1/25/24, no evidence of order for MSW visit, SC visit on 1/29/24, no evidence of order for SC. Orders for HA 2x/w, MSW 1x/m 2PRN, SC 1x/m 2PRN, SN 2x/w 3PRN, obtained on 2/2/24 through initial IDG. Patient #3, SN visits 1/9/23, 1/11/23, 1/15/23, no evidence of order for SN visits. MSW visits 1/11/24, 1/26/24, no evidence of order for MSW. SC visits on 1/12/24, no evidence of order for SC. Orders obtained for HA 2x/w, MSW eval, SC eval, SN 2x/w 3PRN on 1/19/24 through initial IDG. Patient #4, SC completed telephone visit on 1/19/24, no evidence of telephone order for visit. Patient #5, SN visit on 1/17/24, 1/18/24, no evidence of SN order for visits. MSW visit 1/18/24, no evidence of order for MSW visit. Orders obtained for HA 1x/w, MSW eval, SC 1x/m 2PRN, SN 2x/w 3PRN on 1/19/24 through initial IDG. Patient #6, SN order on 12/22/23 for 3x/week, no evidence of visits until 1/3/24, 1/5/24. SC order on 12/22/23 as declined, visit made on 12/22/23 without order for visit. Patient #7, SN visit 12/13/23, 12/15/23, 12/18/23, no evidence of SN order for visits. MSW visit on 12/12/23, no evidence of order for MSW visit. SC visit on 12/15/23, no evidence of SC order for visit. Orders obtained on 12/22/23 for MSW 1x/m 2PRN, SC as needed, SN 2x/w 3PRN through initial IDG. Patient #8, SN visit on 9/3/23, 9/7/23, 9/11/23, 9/14/23, no evidence of SN order for visits, MSW visit on 9/5/23, no evidence of order for MSW visit, SC visit on 9/5/23, no evidence of SC order for visit. Orders obtained on 9/15/23 for HA 2x/w, MSW 1x/m 2PRN, SC 1x/m 2PRN, SN 2x/w 3 PRN through initial IDG. Patient #9, SN visit on 6/20/23, no evidence of order for SN visit, MSW visit made 6/20/23, no evidence of order for MSW visit. SC visit made 6/20/23, no evidence of order for SC visit. Orders obtained on 6/23/23 for HA 2x/w, MSW 1x/m 2 PRN, SC 1x/m 2PRN, SN 2x/w 3PRN, through initial IDG. SC missed visit for the month of July and made 2 visit in Aug on 8/2/23, 8/9/23. Patient #10, SN visit on 2/22/23, 2/24/23, 2/27/23, 3/2/23, no evidence of SN order. MSW visit made 2/24/23, no evidence of MSW order. SC visit on 2/24/23, 2/28/23, no evidence of SN order. Orders obtained on 3/3/23 for HA 2x/w, MSW 1x/m 2 PRN, SC 1x/m 2PRN, SN 2x/w 3 PRN through initial IDG. SC made tele visit on 2/24/23 without order for telephone visit. Patient #11, SN visit on 11/18/23, 11/20/23, 11/22/23, no evidence of SN order, SC visit on 11/22/23, no order for SC visit. Orders obtained on 11/24/23 for HA 2x/w, MSW eval, SC as needed, SN 3x/w 3 PRN, Vol 2x/m through initial IDG. Vol made no visits per order. MSW made visits on 11/24/23 and 11/25/23. Patient #13, SN visits on 8/28/23, 8/31/23, no evidence of order for SN visits. MSW visit on 8/29/23, no evidence of order for MSW, SC visit on 8/29/23, no evidence of order for SC visit. Orders obtained on 9/1/23 for MSW 1x/m 2PRN, SC 1x/m 2PRN, SN 2x/w 3PRN through initial IDG. Patient #14, SN visit on 3/29/23, no evidence of order for SN, MSW visit on 3/29/23 no evidence of order for MSW. Orders obtained on 3/31/23 for HA 2x/w, MSW 1x/2w 2PRN, SC 1x then PRN, SN 2x/w 3PRN through initial IDG. SC visit on 4/28/23 was telephone visit. No evidence of order for telephone visit.

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, LPN placed b/p, thermometer, stethoscope on clean area. LPN used thermometer and placed back on clean area without cleaning thermometer.

Upon patient record review 10 of 14 (Patient #1,2,3,5,7,8,9,10,11,14) 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 #1, Order on 2/2/24 for HA 1x/week then 2/16/24 orders for HA 3x/week. Patient was seen 2x/w for the 2nd and 3rd week. Aide care plan documents shower chair for type of bath. Aide gave bed bath. No evidence of discussion with RN. Patient #2, Visits on 1/26/24, 1/30/24, 2/1/24, 2/6/24, Order for HA were not obtained until 2/2/24 for 2x/w. Patient #3, Visits on 1/9/24, 1/12/24, 1/16/24. Order for HA were not obtained until 1/19/24. Patient #5, Order obtained on 1/19/24 for HA 1x/w then on 2/2/24 for 2x/week. Patient seen 2x/week prior to 2/2/24. Patient #7, Visit on 12/27/23, No order for HA visit. Patient #8, Visit on 9/8/23, 9/11/23, Order for HA were not obtained until 9/15/23. Aide care plan documents brush teeth. Aide did not complete on visit of 9/15/23. Patient #9, Visit on 6/20/23, Orders for HA were not obtained until 6/23/23. Aide care plan documents diet: mechanical soft. Aide did not document on visit of 7/14/23. Patient #10, Visit on 2/28/23, 3/2/23, Orders for HA were not obtained until 3/3/23. Patient #11, Visit on 11/20/23, Orders for HA were not obtained until 11/24/23. Patient #14, Visit on 3/29/23, Orders for HA were not obtained until 3/31/23.

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. Agency use of volunteers for 2023 was 2.54%

Upon client record review, 2 of 14 (Patient #8,10) did not have evidence that a written hospice plan of care is established and maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided is in accordance with this hospice plan of care. Patient #8, No evidence of care plan for alteration in skin. Patient has wound care since admission of 9/1/23. Patient #8,10, No evidence that a written hospice plan of care is established and maintained in consultation with SNF/NF.