Every finding on record at Ardor Care Hospice

Upon patient record review, 5 of 5 records (Patients #1,#2,#3,#4,#5) 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: The medical record contained nursing documentation upon admission identifying patient issue with dyspnea. There was no evidence of problems, goals, and interventions related to respiratory included in the plan of care. Corrected on site. Patient 2: The medical record contained nursing documentation upon admission identifying patient issue with dyspnea and bladder incontinence. There was no evidence of problems, goals, and interventions related to respiratory or bladder incontinence included in the plan of care. Corrected on site. Patient 3: The medical record contained nursing documentation upon admission identifying patient issue with dyspnea. There was no evidence of problems, goals, and interventions related to respiratory included in the plan of care. Corrected on site. Patient 4: The medical record contained nursing documentation upon admission identifying patient issue with oxygen use, dyspnea, and bladder incontinence. There was no evidence of problems, goals, and interventions related to respiratory, oxygen safety, and bladder incontinence included in the plan of care. Patient 5: The medical record contained nursing documentation upon admission identifying patient issues with bladder incontinence, high risk for skin breakdown, risk of aspiration, dysphagia, and endocrine dysfunction. There was no evidence of problems, goals, and interventions related to bladder incontinence, risk for skin impairment, risk of aspiration/dysphagia, and endocrine included in the plan of care.

Upon patient record review, 3 of 5 (Patient #1, 2, 3) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patients 1,2,3: The medical records contained nursing documentation that facility where all 3 patients reside declined aide and volunteer services due to fear of COVID two days after each patient and family initially elected the services upon admission. All patients started care 10-26-21. There was no evidence of a physician order to discontinue aide and volunteer frequencies. Corrected on site.

Upon patient record review, 2 of 5 records (Patients #2,#4) 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 2: The medical record contained nursing documentation upon admission identifying patient use of hospital bed, bedside table, and shower chair. During home visit, it was observed that hospital bed also had full bed rails. There was no evidence of the bed, rails, table, and shower chair included in the plan of care. Corrected on site. Patient 4: The medical record contained nursing documentation upon admission identifying patient use of hospital bed and shower chair. There was no evidence of the bed and shower chair included in the plan of care.

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. During observation throughout three home visits, the RN was witnessed removing gloves without disinfecting or washing hands and placing cleansed equipment on portion of barrier that previously contained the dirty equipment. All patients resided at same personal care home and were seen consecutively.

Upon patient record review, 1 of 2 applicable (Patient #5) did not have evidence in the patient record that hospice aide assignments and duties specify a frequency for completion. Patient 5: The medical record contained ordered aide frequency of twice weekly. The aide care plan did not define frequency for any of the tasks assigned.