Every finding on record at Arcadia Hospice, LLC

Based on record reviews and interview, the hospice's Emergency Preparedness Plan (EPP) had the incorrect hospice name listed. The findings are: On 4/28/2022 at 9:51 AM, review of the hospice's EPP revealed the plan was titled with the incorrect hospice's name. The finding was verified by the Administrator at 11:06 AM on 4/28/2022.

Based on record reviews and interview, the hospice failed to provide documentation that its volunteer program provided Emergency Preparedness Plan (EPP) training for one of one volunteer (Volunteer #1). The findings are: On 4/27/2022 at 1:42 PM, review of the hospice's volunteer file for Volunteer #1 revealed there was no documentation that Volunteer #1 had training on the hospice's EPP. The finding was verified by the Volunteer Coordinator at 1:52 PM on 4/27/2022.

Based on review of the hospice's admission packet and interview, the hospice failed to provide the patient's a hospice admission packet with accurate information for the name of the hospice. The findings are: On 4/27/2022 at 9:22 AM, review of the hospice's Admission Booklet given to patients and caregivers upon admission revealed the name for the hospice on the admission packet is not accurate. The patient consents (Admission Consent and Consent for Election of Medicare Hospice Benefit) were titled with an inaccurate name for the hospice. The finding was verified by the Administrator at 4:08 PM on 4/27/2022.

Based on record reviews and interview, the hospice Interdisciplinary Group (IDG) did not ensure the patient's Plan Of Care (POC) contained measurable goals for 11 of 11 patient charts reviewed. (Patient #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, and #11) The findings are: Patient #1 On 4/26/2022 at 4:19 PM, review of Patient #1's chart revealed the patient's POC did not have measurable goals: "nursing plan of care will be established, verbalize understanding of managing cardiopulmonary symptoms, a chaplain plan of care, a medical social worker plan of care, medications will be managed and demonstrate compliance with medication regimen". The finding was verified by the Administrator 2:49 PM 4/27/2022. Patient #2 On 4/25/2022 at 12:55 PM, review of Patient #2's chart revealed the patient's POC did not have measurable goals: "nursing plan of care will be established, pain will be managed, demonstrate safe wound care, verbalize understanding of signs of imminent death, social worker plan of care, chaplain plan of care, and assistance with personal care". The finding was verified by the Administrator at 3:07 PM on 4/27/2022. Patient #3 On 4/26/2022 at 12:15 PM, review of Patient #3's chart revealed the patient's POC did not have measurable goals: "nursing plan, medications will be managed, oxygen safety, inhalation therapy, pain management, social worker care plan, and personal care". The finding was verified by the Administrator at 3:14 PM on 4/27/2022. Patient #4 On 4/26/2022 at 12:10 PM, review of Patient #4's chart revealed the patient's POC did not have measurable goals: "nursing plan of care, manage skin breakdown, managing cardiopulmonary symptoms, anorexia and dehydration, food offering, social worker plan of care, and a chaplain plan of care". The finding was verified by the Administrator at 3:16 PM on 4/27/2022. Patient #5 On 4/26/2022 at 11:47 AM, review of Patient #5's chart revealed the patient's POC did not have measurable goals: "nursing plan of care, manage skin breakdown, neurological status, pain, oxygen safety, social worker plan of care, chaplain plan of care, personal care, and volunteer plan". The finding was verified by the Administrator at 3:17 PM on 4/27/2022. Patient #6 On 4/25/2022 at 2:10 PM, review of Patient #6's chart revealed the patient's POC did not have measurable goals: "nursing plan of care, safety needs, social worker plan of care, oxygen safety, anorexia/dehydration, food offering, and medication management". The finding was verified by the Administrator at 3:22 PM on 4/27/2022. . Patient #7 On 5/25/2022 at 1:54 PM, review of Patient #7's chart revealed the patient's POC did not have measurable goals: "nursing plan of care, medications, pain, dementia, social worker plan of care, chaplain plan of care, and assistance with personal care". The finding was verified by the Administrator at 3:23 PM on 4/25/2022. Patient #8 On 4/26/2022 at 2:02 PM, review of Patient #8's chart revealed the patient's POC did not have measurable goals: "nursing plan of care, medications, compliance with medications, pain, social worker plan of care, and personal care" . The finding was verified by the Administrator at 3:33 PM on 4/27/2022. Patient #9 On 4/26/2022 at 2:16 PM, review of Patient #9's chart revealed the patient's POC did not have measurable goals: "nursing plan of care, medications, compliance with medications, pain, social worker plan of care, chaplain plan of care, and nausea/vomiting". The finding was verified by the Administrator at 3:38 PM on 4/27/2022. Patient #10 On 4/26/2022 at 2:45 PM, review of Patient #10's chart revealed the patient's POC did not have measurable goals: "nursing plan of care, pain, neurological status, safety needs, chaplain plan of care, and social worker plan of care". The finding was verified by the Administrator at 3:39 PM on 4/27/2022. Patient #11 On 4/26/2022 at 3:11 PM, review of Patient #11's chart revealed the patient's POC did not have measurable goals: "neurological status, skin breakdown, chaplain plan of care, social worker plan of care, fear/anxiety, personal affairs, and spiritual concerns". The finding was verified by the Administrator at 3:42 PM on 4/27/2022.

Based on record reviews and interview, the hospice Interdisciplinary Group (IDG) failed to update the patient's Plan Of Care (POC) to the patient's status for 5 of 9 patient charts reviewed. (Patient #1, #2, #4, #5, and #6) The findings are: Patient #1 On 4/26/2022 at 4:19 PM, review of Patient #1's chart revealed the patient's POC was not updated to the patient's present health status re: "patient is nearly fully blind, incontinent of bowel and bladder, fatigue, and a fall risk. Patient is taking medication for a Urinary Tract Infection and the patient began Aide services on 1/10/2022 for maximum assistance with activities of daily living (ADL)." The finding was verified by the Administrator at 2:29 PM on 4/27/2022. Patient #2 On 4/25/2022 at 12:55 PM, review of Patient #2's chart revealed the patient's POC was not updated to the patient's current health status re "patient is a fall risk, has constipation, problems swallowing, and a nutritional concern." On 4/27/2022 at 12:15 PM, review of Patient #2's medication record as compared to the hospice medication profile revealed the hospice medication profile did not match the patient's medication list. The finding was verified by the Administrator at 3:07 PM on 4/27/2022. Patient #4 On 4/26/2022 at 12:10 PM, review of Patient #4's chart revealed the patient's POC was not updated to the patient's current health status. Patient #4 had expressive aphasia, incontinent of bowel and bladder, and poor mobility with a fall risk. The finding was verified by the Administrator at 3:16 PM on 4/27/2022. Patient #5 On 4/26/2022 from 10:10 AM to 10:46 AM, observations during a home visit with Patient #5 revealed RN#1 did not review the patient's medications during the visit. The finding was verified at 10:46 AM on 4/26/2022. On 4/26/2022 at 11:47 AM, review of Patient #5's chart revealed the IDG meeting dated 4/13/2022 listed the patient's current problems, but omitted "chronic constipation, difficulty swallowing, and anxiety/agitation." The problem list was not updated to the patient's current health status. The finding was verified by the Administrator at 3:17 PM on 4/27/2022. Patient #6 On 4/26/2022 from 9:22 AM to 9:55 AM, an observation during a home visit with Patient #6 revealed RN #1 did not review the patient's medications during the visit. The finding was verified at 10:46 AM on 4/26/2022 with RN #1.

Based on observations and interview, 1 of 1 Hospice Aide observed in the provision of patient care failed to use accepted principles for infection control. (Hospice Aide #1) The findings are: On 4/25/2022 from 3:06 PM to 3:35 PM, observations of Hospice Aide #1 in the provision of care for a patient who resides in a facility revealed Hospice Aide #1 failed to perform hand hygiene after glove removal. The finding was verified by Aide #1 at 3:35 PM on 4/25/2022.

Based on record reviews and interview, the hospice failed to provide documentation of a dietary contract/agreement. The findings are: On 4/27/2022 at 11:20 AM, review of the hospice's agreements/contracts revealed the hospice had no dietary contact/agreement for patient nutritional support if warranted. The finding was verified by the Administrator at 3:56 PM on 4/27/2022.

Based on review of hospice forms and materials and interview, the governing body has not ensured the hospice leadership has instituted the use of the hospice's name on its formal documents that includes but is not limited to the hospice patient admission packet, Quality Assessment and Performance Improvement (QAPI) forms and data, and the forms used for the governing body meeting minutes. All of the formal data and information had another name on all of the hospice forms and materials. The findings are: On 4/27/2022 at 9:22 AM, review of the hospice's Admission Booklet given to patients and caregivers upon admission does not have the hospice's business name. Patient consent forms for Admission Consent and Consent for Election of Medicare Hospice Benefit are not titled with the hospice's business name. The finding was verified by the Administrator at 4:08 PM on 4/27/2022. On 4/28/2022 at 9:16 AM, review of the hospice's Quality Assessment and Performance Improvement (QAPI) plan revealed the QAPI forms do not have the business name for the hospice on the forms. The finding was verified by the Administrator at 11:03 AM on 4/28/2022. On 4/28/2022 at 9:22 AM, review of the Governing Body minutes revealed the minutes did not have the formal business name of the hospice on the forms. The finding was verified by the Administrator at 11:04 AM on 4/28/2022. On 4/28/2022 at 10:16 AM, review of the hospice's agreements/contracts revealed the hospice contracts with a Pharmacy and Durable Medical Equipment (DME) did not have the hospice's business name. The finding was verified by the Administrator at 11:02 AM on 4/28/2022. On 4/28/2022 at 11:36 AM, review of hospice policies and procedures for Volunteer Services, Improving Organizational Performance, On-Call and Weekend Services, The Plan of Care, Interdisciplinary Group Plan of Care, and Patient Bill of Rights did not have the hospice's business name on any of the documents. The finding was verified by the Administrator at 4:06 PM on 4/27/2022.