Every finding on record at Alta Care Hospice and Palliative Care Inc

Upon patient record review, 4 of 19 (Patient #5, 7, 9, 15) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient #5, 7, 9, 15: Hospice Election Form section for choosing or not choosing physician is left blank. Neither "I do not choose or I acknowledge that my choice" is marked.

Upon patient record review, 4 of 19 (Patient #1, 3, 7, 10) 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: Admitted status post hospitalization for pneumonia and sepsis with continuous oxygen per initial comprehensive assessment. Initial IDG Care Plan did not include related problem, goals, interventions. . Patient #7: Patient admitted with order for oxygen. Has problem for cardiovascular disease, but there is no specific problem, goal or intervention related to oxygen and/or oxygen safety precautions. Patient #10: Patient with history of epilepsy, but no related problem, goals, interventions including seizure precautions. Patient #16: Patient admitted with (2) Stage 2 buttocks wounds requiring antibiotic for infection. There is no related problem, goal, intervention other than pain.

Upon patient record review, 2 of 19 (Patient #12, 16) 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 #12: POC orders for wound care "Per Facility Protocol" without specifying wound treatment and tracking any changes/updates in hospice POC. Physician admitting order also says per facility protocol. Patient #16: Wound care order does not specify location or specific frequency of wound care. Treatment order to clean with Normal Saline. Pat dry. Apply triple antibiotic ointment to wound bed. Cover with sterile gauze and ABD pad and secure with tape. Caregiver may change dressing when soiled or dislodged.

Upon patient record review, 3 of 19 (Patient #7, 16, 17) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient #7: Started on antibiotic Bactrim 8/29/24 for skin infection. No update to problems, goals, interventions Patient #16: Foley catheter inserted 6/9/24 with no update to problems, goals, interventions. Patient #17: Foley placed 6/10/24 with no update to problems, goals, interventions

Upon client record review, 2 of 19 (Patient #1, 15) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1: No documented physician order for PPD administered 8/23/24 and 9/5/24 for Step 1 and 2 respectively. Patient #15: No documented physician order for PPD administered 8/26/24. Also on 9/22/24 visit note states patient c/o abdominal distention and urinary retention. SN documented attempt to place Foley catheter #14, #16, Coude' without success. RN added that patient reported history of surgical placement of catheter. The only order was a standing order for 16fr Foley prn for urinary retention. There is no documented evidence of communication with physician related to difficulty passing and order for various catheter size/type attempts.

Upon patient record review, 6 of 14 (Patient #1, 2, 5, 7, 10, 11) 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, 5, 7, 11: Patient is on oxygen, but aide assignment does not include flow rate and/or O2 safety precautions. Patient #2: Patient experiencing multiple falls with no high risk fall /precautions. Patient #10: Patient with secondary diagnosis of Epilepsy. Aide assignment sheet does not include seizure precautions.

Upon patient client record review, 17 of 19 (Patient #1, 2, 3, 4, ,5, 6, 7, 8, 10, 11, 12, 13, 14, 15, 16, 17) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient #1, 2, 3, 4, ,5, 6, 7, 8, 10, 11, 12, 13, 14, 15, 16, 17: Patients requested Notification of Non-Covered Items, Services and Drugs. Medication profiles identified non-covered medications, but they are not listed and/or provided in Notification. Patient #5, 7, 9, 15: Hospice Election Form section for choosing or not choosing physician is left blank. Neither "I do not choose or I acknowledge that my choice" is marked.

Upon patient client record review, 18 of 19 (Patient #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 15, 16, 17, 18, 19) 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. Patients #1, 2, 3, 4, 5, 6, 8, 9, 10, 11, 12, 13, 15, 16, 17, 18, 19: Patient consent forms and EOB have one line for signature: Patient/Representative signature. There is no space to print patient name or responsible party's name. There is only one line shared for patient and/or responsible party/POA. There is no line to identify relationship. It is difficult to ascertain who actually signed the forms. Patients #2: 9/25/24 PRN SN visit - Documentation using SOAP Visit template utilized by agency. The template has triggers/prompt for subjective, objective and assessment, but rather than removing the template's guidance, (Generic verbiage remains unchanged) and replacing it with visit data, the agency does a narrative summary only in the Plan section of the note Patient #7: 10/2/24, 10/5/24 PRN SN visits. Documentation using SOAP Visit template utilized by agency. The template has triggers/prompt for subjective, objective and assessment, but rather than removing the template's guidance, (Generic verbiage remains unchanged) and replacing it with visit data, the agency does a narrative summary only in the Plan section of the note.

Upon client record review, 2 of 19 (Patient #15, 16) did not have evidence that if a patient revokes the election of hospice care or is discharged from hospice in accordance with §418.26, the hospice must forward to the patient's attending physician: • A copy of the hospice discharge summary • The patient's clinical record, if requested Patients #15, 16: There is no documented evidence that the discharge summary was forwarded to the attending physician.

Upon client record review, 2 of 19 (Patient #15, 16) did not have evidence that the discharge summary includes all required information. Patients #15, 16: Discharge summaries did not include a summary of patient's stay.

Upon patient record review, 11 of 11 (Patient #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11) did not have evidence that the hospice obtained the patient's or representative's signature confirming that they received a copy of the Patient's Rights and Responsibilities. Patient Records 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11: There is no signed copy of the Patient Rights in any of the records reviewed. There is no acknowledgement form that Patient Rights were received/discussed. There is no documentation in RN initial admission summary that Patient Rights were discussed or presented. The Patient Information Handbook that is reportedly used for initial discussion/education and left in home, does contain copy of patient rights.

Upon patient record review 1 of 11 (Patient #7) 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 #7: Patient admitted 11/12/20. MSW Psychosocial Assessment performed 11/23/20.

Upon patient record review 2 of 11 (Patient #2 and #4) 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 #2: No evidence that a spiritual assessment was completed as part of the comprehensive assessment. Patient #4: No evidence that a psychosocial assessment was completed as part of the comprehensive assessment.

Upon patient record review, 1 of 11 (Patient #2) 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 Record #2: There is no evidence of bereavement assessment.

Upon client record review, 6 of 11 (Patient #1, 2, 3, 5, 7, 8, did not have evidence that the IDG in collaboration with the attending physician reviewed, revised and documents the individualized plan as frequently as the patient's condition requires but no less frequently then every 15 calendar days. Patient Records 1, 2, 3, 5, 7, 8 have no documented evidence of IDG Review Meeting 2/23-3/23/22.

Upon client record review, 4 of 11 (Patient #1, 2, 4, 5) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient Record #1 Initial POC Order 2/17/22 SN 1/wk, 3 PRN. Visits provided 2x week (2/17/22, 2/18/22) (3/20/22. 3/26/22). Initial POC Order for MSW 1/wk. Visits were made monthly (2/22 and 3/21). SC 1/wk 3 prn. Visits were made monthly (2/22 and 3/11). Patient Record #2 Initial POC Order 2/15/22 includes MSW 1/WK. MSW visits on 2/19 and 3/17. POC includes SC 1/WK but there was no evidence of SC visits. Patient Record #4 Initial POC Order SN 2X/WK: Provided 1x/wk: 2/14, 2/20, 3/5, 3/12, 3/16, 3/22, 3/31/22 Patient Record #5: Initial POC Order SW 1/WK (provided 2/21, 3/23), SC 1/WK. (Visits 2/23, 3/09) Both MSW and SC visits provided 1x month.

Upon patient record review, 10 of 10 applicable records. (Patient #1, 2, 3, 4, 5, 7, 8, 9, 10, 11) 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 Records 1, 2, 3, 4, 5, 7, 8, 9, 10, 11 have assignments that include "as needed" tasks. Patient Record #1: As needed assignments include back rub massage, nail care, shave. Initial POC Order for HA was 5x/wk. Assignment sheet assigned frequency of 3x/wk. Patient Record #2: As needed assignments include change linen, housekeeping, make bed. Patient Record #3: As needed assignments include back rub massage, shave, change linen. Patient Record #4: As needed assignments include nail care, shave, change linen. Patient Record #5: As needed assignments include back rub, massage, change linen, shave. Patient Record #7: As needed assignments include change linen and light housekeeping. Patient Record #8: As needed assignment include shampoo hair, change linen, ROM. Patient Record #9: As needed assignments include back rub, massage, change linen and light housekeeping. Patient Record #10: As needed assignments include back rub, massage, nail care, shave. Patient Record #11: As needed assignments include back rub, massage, nail care, partial bath shower, shave.

Upon patient record review 3 of 10 applicable records (Patient #2, 4, 5) 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 Record #2: Assigned tasks include complete bed bath 3x/wk and Partial Bed Bath 2x/wk. Week of 2/21-2/25, HA documented provided complete bed bath all 5 days. Patient Record #4: Initial POC order includes HA visit frequency 2/wk. Aide visits provided 2/17/22, 2/18/22, 2/19/22, 2/21/22, 2/23/22, and 2/24/22. HA visits provided 5x/wk weeks of Feb 27-March 5th, 2022 (2/28, 4/1, 3/2, 3/3, 3/4) and March 6-12, 2022 (3/7, 3/8, 3/9, 3/10, 3/11). Patient Record # 5: Tasks of ROM and light housekeeping were assigned every visit. The HA documented "NA" for these tasks 2/24/22 visit.

Upon patient client record review, 11 of 11 (Patient #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient Records 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11: There is no signed copy of the Patient Rights in any of the records reviewed. There is no acknowledgement form that Patient Rights were received/discussed. There is no documentation in RN initial admission summary that Patient Rights were discussed or presented. The Patient Information Handbook that is reportedly used for initial discussion/education and left in home, does contain copy of patient rights. Patient Record #10: Patient Election Statement contains no effective date. The spaced for effective date is blank. The form was signed on 1/21/22.

Upon client record review, 2 of 2 applicable records (Patient #10, 11) did not have evidence that if a patient revokes the election of hospice care or is discharged from hospice in accordance with §418.26, the hospice must forward to the patient's attending physician: • A copy of the hospice discharge summary • The patient's clinical record, if requested Patient Records 10, 11: No documented evidence that the discharge summary was forwarded to physician.

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. Patient Records 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11: There is no documentation to confirm that the patient received copy of policies and procedures on the management and disposal of controlled drugs. Agency Policy PC-M60 Medication Use and Disposal of Controlled Substances requires “At the time when controlled substances are first ordered-the hospice nurse: provides copies….."

Upon observation, there was no evidence the hospice discussed the policies and procedures for managing the safe use and disposal of controlled drugs with the patient or representative and the family in a language and manner that they understand to ensure that these parties are educated regarding the safe use and disposal of controlled drugs. Patient Records 1, 2, 3, 4, 5, 6, 7, 8, 9, 10: There is no documentation to confirm that the staff discussed policies and procedures on the management and disposal of controlled drugs in Records 1-10. Patient Record 11 SN documentation during death visit included that CG was educated regarding disposal, consistent with Administrator's report of practice to educate at time of death.