Every finding on record at Asj Enterprise Inc

Upon patient record review, 2 of 8 (Patient #2,#5) 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 #2: On admission, the patients medication administration record with entry of oxygen profiled to be delivered at 2-4 liters per minute via nasal cannula. There was no evidence that instructions for titration are included on the medication profile. Corrected on site Patient #5: On admission, the patients medication administration record with entry of oxygen profiled to be delivered at 2-4 liters per minute via nasal cannula. There was no evidence that instructions for titration are included on the medication profile. Corrected on site

Upon patient record review, 2 of 8 (Patient #3,#8) 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 #3: The patient's medical record contains documentation upon admission that the patient requires oxygen to be delivered at 2-4 liters per minute via nasal cannula as needed. The initial plan of care includes problems and goals related to oxygen safety with no interventions. Corrected on site. Patient #8: The patient's medical record contains documentation on 5/8/23 and 5/11/23 of increased difficulty with swallowing and diet change to chopped meats due to dysphagia. There is no evidence of updates to the plan of care to include problems, goals and interventions related to dysphagia. Corrected on site.

Upon patient record review, 2 of 8 (Patient #2,#5) 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 #2: Upon admission, the patient's plan of care includes order for oxygen at 2 - 4 liters per minute via nasal cannula. There is no evidence of instructions for titration. Corrected on site. Patient #5: Upon admission, the patient's plan of care includes order for oxygen at 2 - 4 liters per minute via nasal cannula. There is no evidence of instructions for titration. Corrected on site

Upon patient record review, 1 of 8 (Patient #1) 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: The aide plan of care dated 6/13/23 with assignment of tub bath and bed bath with the frequency of every visit. Corrected on site.

Upon patient record review 2 of 8 (Patient #2,#3) 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: The aide plan of care included tasks of oral care, change linens, dress patient and nail cleaning/filing assigned every visit. Aide documentation for visits on 6/27/23, 6/28/23, 6/30/23, 7/10/23, 7/12/23, and 7/14/23 did not indicate that those assignments were completed as assigned. Patient #3: The aide plan of care included tasks of oral care, change linens and nail cleaning/filing assigned every visit. Aide documentation for visits on 7/3/23, 7/5/23, 7/723, 7/10/23, 7/12/23, and 7/14/23 did not indicate that those assignments were completed as assigned.

Upon patient client record review, 1 of 8 (Patient #1) 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#1: On the initial nursing assessment 6/13/23 there is a write over for the date of the nurse signature with no documentation of date of correction or who completed the correction of the date.

Upon review of policy and procedure, EMERGENCY PREPAREDNESS AND IMPLEMENTATION, 558.256 did not define procedures to follow up with on duty staff and patients to determine services that are needed, in the event that there is an interruption in services during or due to an emergency. The hospice must inform state and local officials of any on-duty staff and patients that they are unable to contact.

Upon review of policy and procedure, EMERGENCY PREPAREDNESS AND IMPLEMENTATION, 558.256 did not include the development of arrangements with other hospices and other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to hospice patients.

Condition of Participation: Initial and Comprehensive Assessment of the Patient.

Upon patient record review 2 of 5 (Patient #2, #3) 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: There was no evidence the comprehensive assessed psychosocial, emotional, and spiritual needs. Patient #3: There was no evidence the comprehensive assessed spiritual needs.

Upon patient record review, 4 of 5 (Patient #1, #2, #3, #4) did not have evidence in the patient record that the comprehensive assessment takes into consideration the imminence of death. Patients #1-#4: There was no evidence that the comprehensive assessment took into consideration the imminence of death.

Upon patient record review, 4 of 5 (Patient #1, #2, #3, #4) 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 #1: The medication profile contained acetaminophen 325mg, take two tablets every 6 hours PRN pain, Norco 5/325mg every 8 hours PRN pain, and Tylenol 650mg suppository every 6 hours PRN pain/temp however, there was no evidence of maximum allowable dose. COS Patient #2: The medication profile contained acetaminophen 325mg, take one tablet daily, acetaminophen 325mg every 4 hours PRN pain/temp, and acetaminophen 650mg suppository every 6 hours PRN terminal fever however, there was no evidence of maximum allowable dose. COS Patient #3: The medication profile contained Tylenol ES 500mg take one tablet every 4 hours PRN pain and acetaminophen 650mg suppository every 6 hours PRN pain/temp however, there was no evidence of maximum allowable dose. COS Patient #4: The medication profile contained acetaminophen 500mg, take one tablet daily, and acetaminophen 650mg suppository every 6 hours PRN terminal fever however, there was no evidence of maximum allowable dose. COS

Upon patient record review, 1 of 5 (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 #2: Patient admitted on 02/20/2023 however, there was no evidence of a bereavement assessment completed.

Condition of Participation: Interdisciplinary Group, Care Planning, and Coordination of Services. L536

Upon patient record review, 1 of 5 (Patient #4) 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 #4: The plan of care indicated the patient was a full code however, there was evidence of a completed DNR in patient record. COS

Upon patient record review, 4 of 5 (Patient #1, #2, #3, #4) 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. Patient #1: The visit frequencies for nurse was 1/week and PRN, aide 3/week and PRN, social work monthly or as needed, spiritual care 1/month and as needed, and volunteer PRN. COS Patient #2: The visit frequencies for nurse was 1/week and PRN, aide 3/week and PRN, and volunteer PRN. COS Patient #3: The visit frequencies for nurse was 1/week and PRN. COS Patient #4: The visit frequencies for nurse was 1/week and PRN, social work monthly or as needed, spiritual care 1/month and as needed, and volunteer PRN. COS

Upon patient record review, 4 of 5 (Patient #1, #2, #3, #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 medications and treatments. Patient #1: The orders for acetaminophen 325mg, take two tablets every 6 hours PRN pain, Norco 5/325mg every 8 hours PRN pain, and Tylenol 650mg suppository every 6 hours PRN pain/temp did not contain evidence of maximum allowable dose. COS Patient #2: The orders for acetaminophen 325mg, take one tablet daily, acetaminophen 325mg every 4 hours PRN pain/temp, and acetaminophen 650mg suppository every 6 hours PRN terminal fever did not contain evidence of maximum allowable dose. COS Patient #3: The orders for Tylenol ES 500mg take one tablet every 4 hours PRN pain and acetaminophen 650mg suppository every 6 hours PRN pain/temp did not contain evidence of maximum allowable dose. COS Patient #4: The orders for acetaminophen 500mg, take one tablet daily, and acetaminophen 650mg suppository every 6 hours PRN terminal fever did not contain evidence of maximum allowable dose. COS

Upon patient record review, 4 of 5 (Patient #1, #2, #3, #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 #1: The nurse admission note listed patient using low air loss mattress, nebulizer, over bed table, and shower chair however, there was no evidence of these listed on plan of care. COS Patient #2: The nurse admission note listed patient using cane, walker, bedside commode, low air loss mattress, nebulizer, over bed table, and shower chair however, there was no evidence of these listed on plan of care. COS Patient #3: The nurse admission note listed patient using bedside commode, over bed table, nebulizer and shower chair however, there was no evidence of these listed on plan of care. COS Patient #4: The nurse admission note listed patient using low air loss mattress, nebulizer, over bed table, suction unit, and shower chair however, there was no evidence of these listed on plan of care. COS

Upon client record review, 1 of 5 (Patient #2) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #2: The nurse visit frequency was 1/week and PRN however, there was evidence of visits on 04/17, 04/19, 05/02, and 05/03/2023 and there was no documentation that any of these were PRN.

Condition of Participation: Hospice Aide and Homemaker Services. L607

Upon patient record review, 4 of 5 (Patient #1, #2, #3, #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 Patients #1-#4: There was no evidence that written patient care instructions were prepared by a registered nurse, no aide care plan. COS

Upon review of policy and procedure, AGENCY CLOSURE AND VOLUNTARY SUSPENSTION OF OPERATIONS, 558.217 did not include that if the hospice discontinues operation, hospice policies and procedures must provide for retention and storage of clinical records. The hospice must inform its State Agency and its CMS Regional Office where such clinical records will be stored and how they may be accessed.

Upon personnel record review, 1 of 11 (Personnel #10) did not have evidence that all personnel have been fully vaccinated for COVID-19. The agency was unable to obtain proof of COVID vaccination or an approved exemption for contracted OT.