Every finding on record at Blue River Hospice, Inc.

Upon patient record review, 1 of 5 (Patient #1) 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 Patent #1: Physician’s order for SC/MSW visit frequency is "1x then PRN". Additionally, Physician’s order for SN visit frequency "2x week + PRN" There is no evidence of the number of PRN visits for SC/MSW/SN. Corrected on Site.

Upon patient record review, 3 of 5 (Patients #2,4,5) 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 equipment and supply needs. Patients #2,4,5: The record reflected that this patient had a oxygen concentrator. This item was not included on the Plan of Care. Corrected on Site.

Upon patient record review, 4 of 14 (Patients #2, 3, 5, 7) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient #2: The patient has multiple wounds. There is no evidence of continuous assessment and management of wounds by hospice RN. On 01/05/24, Caregiver called, reporting symptoms of UTI. Cipro was ordered over phone. No follow up call or visit until 01/09/24. Patient #3: On 07/11/24, patient caregiver called with complaints of anxiety and agitation. Ativan ordered for 2mg at bedtime. No follow up call or visit until 07/15/24. On 08/14/24, call from caregiver with reports of nausea and vomiting. Approval for comfort kit received but no nurse assessment done. Next visit was 08/17/24. On 09/11/24, caregiver called with complaints of anxiety and agitation. Seroquel was ordered , 50mg at bedtime. No nurse assessment completed. No follow up call or visit for 6 days on 09/17/24. Patient #5: On 11/04/24, caregiver called with complaints of pain. Order given for Motrin. No nursing assessment done. No follow up call or visit until 11/11/24. On 11/18/24, caregiver called requesting cough syrup as patient had complaints of cough. orders received for Robitussin DM. No follow up call or nursing visit done until 11/25/24. Patient #7:The patient has wounds on bilateral legs. There is no evidence of continuous assessment and management of wounds by hospice RN.

Upon patient record review, 3 of 14 (Patient #2, 4, 7) 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: Current wound order for patient states, "Left Anterior Breast: cleanse the wound with cleanser and pat dry with gauze. Apply tetracyte to the wound bed, followed by alginate. Cover with foam with silicone bordered dressing 3x weekly and PRN for soiled or loose dressing." as well as a second wound order that reads, "Sacro-coccyx: cleanse with NS, pat dry with gauze, apply thin layer of triple antibiotic and cover with bordered gauze, daily and as needed when soiled." Neither order specifies who will change the dressing. It does not specify frequency of hospice RN dressing changes. Patient #4: Patient has a diagnosis of seizures and is currently on seizure medications. There are no interventions or goals for seizures. Patient #7: Current wound order for patient reads, "BLE wounds: Cleanse wound with Hypochlorous acid spray or wound cleanser like Anasept if available and pat dry, apply Mupirocin ointment to wound beds, until refill is available use Medihoney, apply adaptic to secure ointment in beds, cover with ABD, and secure with Kerlix and ace wrap or Coban. 5x/week and as needed if soiled or dislodged." This order does not specify who is to change dressing and frequency that hospice RN will change dressing.

Upon patient record review, 5 of 14 (Patients #1, 3, 5, 6, 10) 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: During home visit, it was noted that the patient has a fall mat, mechanical lift, wheelchair, grab assist bar, elbow and heel protectors that are not included in the plan of care. Patient #3: The patient's plan of care does not have any DME listed. The patient has an over bed table, Nebulizer, oxygen concentrator, E-tank, and suction machine that were discussed in initial RN assessment. Patient #5: The patient has a nebulizer to use with her Duoneb. She also has a walker. These items are not listed on the plan of care. Patient #6: The patient has an oxygen concentrator, e-tank, and nebulizer ordered on initial RN assessment. There are no DME items included on the plan of care. Patient #10: The patient's plan of care does not include the provided DME or supplies. Patient was assessed at initial RN assessment and the following were ordered: Walker, wheelchair, hospital bed.

Upon patient record review 2 of 14 (Patient #3,10) did not have evidence that the IDG ensures that the care and services provided are based on all assessments of the patient and family needs. Patient #3: on 08/01/24, it is documented that patient was referred for MSW visit. No visit ever completed. Patient #10. On February 12, 2024 the Case manager contact MSW for an "asap visit in person." Then on February 29, 2024, the case manager contacted MSW to update on patient and visit needs. No visit made until March 19, 2024. On June 17, 2024, the caregiver called to request MSW visit to patient. The MSW did not see the patient until July 15, 2024.

Upon patient record review, 2 of 14 (Patients #2, 7) did not have evidence that the IDG shares information on a on-going basis with non-hospice healthcare providers furnishing services unrelated to the terminal illness and related conditions. Patients #2 and #7: Both patients are receiving care related to their plan of care from an outside company for wound care. The IDG meetings for each patient do not reflect discussion regarding wounds from the medical director or registered nurse. There is no collaboration through IDG of care for patient's wounds.

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. Patient #2: During RN visit, RN did not clean dirty equipment prior to returning it to his bag. Patient #3: During aide visit, aide did not place a bag barrier and returned her equipment to the bag without cleaning it.

Upon observation, there was no evidence the hospice is in compliance with accepted professional standards and principles for all core services which includes nursing services, medical social services and counseling services. The agency has a contract for wound care with California wound Docs. They are sending wound care to at least 1 patient at least weekly. The wound company is doing all full assessments of wounds. These wounds are part of the hospice plan of care. The Hospice medical director is writing orders for the dressing changes. This does not ensure that nursing is providing all core services when providing care that is related to the patient's plan of care. The agency was using services frequently from Wound Pros. They did not have a contract, though secured one during on site survey on day 3. This contracted agency was providing services that should have been provided by the core nursing services of the hospice as it was not highly specialized care.

Upon observation, there was no evidence the hospice is in compliance with accepted professional standards and principles for all non-core services which includes physical therapy, occupational therapy and speech-language pathology. Patient #2: During home visit with RN to a patient with extensive wounds, the RN asked when the dressing had been changed. The caregiver responded, "the shower nurse did it this morning". Interview with aide revealed that the aide was in fact putting the new dressing on after showers. This is outside the aides scope of practice.

Upon patient record review 1 of 14 (Patient #2) 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: During home visit with RN to a patient with extensive wounds, the RN asked when the dressing had been changed. The caregiver responded, "the shower nurse did it this morning". Interview with aide revealed that the aide was in fact putting the new dressing on after showers. This is not on the aide plan of care.

Upon contract review, 1 of 6 (Wound Pros contract) did not have evidence the agreement to furnish any services under arrangement included that the hospice must retain administrative and financial management, and oversight of staff and services for all arranged services, to ensure the provision of quality care. Arranged care/services are supported by written contract/agreement that requires all care/services are: • Authorized by the hospice • Furnished in a safe and effective manner by qualified personnel • Delivered in accordance with the patient's plan of care The agency did not have a contract with this wound management agency until day of survey exit. The contract did not reference hospice having administrative and financial oversight. In addition, the agency was using contract staff to provide services that were not highly specialized nursing services and no evidence of documentation that wounds were not related.

Upon patient record review, 1 of 5 (Patient #2) 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. Client Record #2: Patient revoked hospice participation effective 7/6/21. IDG Meeting POC Update dated 7/7/21 did not identify patient as discharged from services, but rather documented to "continue current plan of care."

Upon personnel record review, 1 of 1 (Personnel # 4) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) Appropriate and safe techniques in personal hygiene and grooming that include-- (C) Shampoo, sink, tub, and bed Personnel File #4: The competency checklist utilized for hospice aide, does not differentiate types of shampoo demonstrated for competency.

Upon patient record review, 5 of 5 (Patient #1, 2, 3, 4, 5) did not have evidence that the medical director or physician designee provides written certification that it is anticipated that the patient's life expectancy is 6 months or less if the illness runs its normal course. The physician must consider the following when making this determination: • The primary terminal condition • Related diagnosis • Current subjective and objective medical findings • Current medication and treatment orders • Information about the medical management of any of the patient's conditions unrelated to the terminal illness Client Records 1, 2, 3, 4, 5: The CTI form utilized by the agency for 5 of 5 patients includes the standard statement for certification of 6 month prognosis followed by a brief narrative. Immediately following the narrative, is the RN's signature. Interview with agency admin/DPCS validated that the narrative is composed by the RN. Following the narrative and the RN's signature and date of verbal order, there are (2) attestation statements, each signed respectively by the Medical Director or Designee and the attending physician (both being the same)