Every finding on record at All Saints Hospice Care, Inc

Upon patient record review, 1 of 11 (Patient #10) 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 #10 On 2/28/22, order for Oxygen @ 2 LPM as needed for shortness of breath/dyspnea. Oxygen was not documented on Medication profile.

Upon patient record review, 2 of 11 (Patient #5,11) 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 #5 No initial bereavement assessment completed. Patient #11 No initial bereavement assessment completed.

Upon patient record review, 1 of 11 (Patient #10) 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 #10 On 2/28/22, order for Oxygen @ 2 LPM as needed for shortness of breath/dyspnea. No route documented in the order for oxygen.

Upon client record review, 10 of 11(Patient #1,2,3,4,5,6,7,8,9,10) 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 order dated on 2/4/22, SN 2x/week. Week of 2/4/22, only 1 visit made by SN. Patient #2 SN order dated 3/25/22, SN 2x/week. Week of 3/25/22, only 1 visit made by SN. Patient #3 SN order dated 2/17/22, SN 2x/week. SN completed visits 1x/week instead of 2x/week. Patient #4 SN order dated 3/30/22, SN 2x/week. SN completed visits 1x/week instead of 2x/week. Patient #5 SN order dated 3/6/22, SN 1x/week. SN completed visits 2x/week during the weeks of 3/6/22, 4/17/22, 4/24/22. Patient #6 SN order dated 1/23/22, SN1x/week. SN completed visits on 1/23/22 and 1/25/22. Patient #7 SN order dated 1/9/22, SN 1x/week. SN completed visits 2x/week instead of 1x/week. Order for RN every 14 days. No RN visit between 3/20/22 and 4/17/22. Patient #8 SN order dated 3/28/22, SN 2x/week. SN completed visit 1x for the week of 4/7/22. Patient #9 No order for SN. RN every 14 days ordered on 6/7/21. Patient visits completed on 3/7/22, 3/9/22, 3/14/22, 3/16/22, 3/28/22, 3/30/22, 4/4/22, 4/6/22, 4/11/22, 4/13/22, 4/18/22, 4/20/22, 4/25/22, 4/27/22. Order was not updated or changed during IDG for SN visits. Patient #10 SN order on 11/20/21, SN 1x/week. SN completed visits on 4/4/22, 4/8/22, 4/11/22, 4/16/22.

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 during home visit SC was observed placing his clipboard down on table without providing a barrier between his clipboard and the table, as per policy.

Upon patient record review, 1 of 8 applicable (Patient #4) 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 #4 No parameters for vital signs on Aide care plan.

Upon patient record review 4 of 8 applicable (Patient #2, 4, 5 and 6) 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 Order for Aide dated on 3/25/22 2x/week, only 1 Aide visit during the first week. Patient #4 Order for Aide dated on 3/30/22 2x/week, only 1 Aide visit during the first week. Patient #5 Order for Aide dated on 3/6/22 1x/week, no Aide visit week of 4/10/22. Patient #6 Aide visits on 1/25/22 and 1/28/22 no evidence of the tasks that were completed and no signature. On 2/28/22 Aide CP order bed bath, brush hair, brush teeth, nails, peri care, no documentation that cares were completed.

Upon patient client record review, 2 of 11 (Patient #3, 11) did not have evidence that each patient record contains Physician certification and recertification of terminal illness. Patient #3 No signature on CTI for both Medical Director and Provider from 2/17/22. Patient #11 No signature on CTI for both Medical Director and Provider from 1/7/22.

Upon patient client record review, 2 of 11 (Patient #9 and 11) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient #9 IDG notes did not have evidence of signatures from MD, RN, SC on 4/19/22, and MD, RN, SC, MSW on 4/5/22, 3/8/22, 3/22/22, 2/22/22, 2/8/22. Patient #11 IDG notes did not have evidence of signatures from MD, SC, MSW on 3/22/22 and 2/22/22. No MD, SC signatures on 2/8/22 and 1/11/22.