Every finding on record at Anew Hospice Ft Wayne LLC

Upon observation, there was no evidence the Emergency Plan communication plan must includes an alternate means for communicating with hospice's employees. Corrected on site.

Upon patient record review, 1 of 10 (Patient #3) 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: SN SOC identified pt. on O2 4L via NC continuous. There was no evidence on the medication profile for O2. Medication profile dated 8/25/2024 for Morphine Sulfate solution 20mg/ml, admin 0.25ml SL Q 4 hours PRN SOB or severe pain. Dated 8/27/2024 Oxycodone 5mg 2 tablets PO Q 4 hrs. PRN mild, moderate of severe pain. No evidence of clear parameters of which med to give and when. During home visit medication reconciliation found Hospice medication profile had Tylenol suppository, Hyoscyamine and Phenergan on it- they were added in error and not intended nor with a Dr Order. All corrected on site.

Upon patient record review, 1 of 10 (Patient #3) 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: SN SOC identified pat as on O2 4L via NC continuous. There was no evidence of an order for O2. Dated 8/25/2024 order for Morphine Sulfate solution 20mg/ml, admin 0.25ml SL Q 4 hours PRN SOB or severe pain. Dated 8/27/2024 Oxycodone 5mg 2 tablets PO Q 4 hrs. PRN mild, moderate of severe pain. No evidence of clear parameters of which med to give and when. Corrected on site.

Upon patient record review, 3 of 10 (Patient #2,#8,#10) 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: SN on SOC assessment identified pt. at risk of falls, score of 9>4. No evidence on the aide POC/assignment sheet of pt. at risk for falls. Corrected on site. Patient #8: SN on SOC assessment found pt. to be at risk of aspiration and is using Oxygen. No evidence on the aide POC/assignment sheet of pt. at risk for aspiration or Oxygen precautions. Patient #10: SN on SOC assessment identified pt. at risk of falls, score of 9>4. No evidence on the aide POC/assignment sheet of pt. at risk for falls.

Upon client record review, 1 of 10 (Patient #6) 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 #6: Patient revoked to go to hospital, no have evidence the hospice forwarded to the required information to the patient's attending physician (or hospital).

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. Patients signed consent that this was discussed and SN documented on SOC that the policy was discussed and provided. There was no copy in the admit packs of this policy and the Administrator agrees the policy was not provided.