Every finding on record at Bluebird Hospice

Upon patient record review, 3 of 19 (Patient #6, 9, 10) 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 Incomplete medications Patient #6 - Medication profile contained Restasis 0.5% 1 drop 2 x day - did not specify which eye or both eyes. Patient #9 - Medication profile contained Hydrocortisone 2.5% cream 1 inch as needed for rash - no frequency. Patient #10 - Medication profile contained Miralax 17gm as needed PRN constipation - no frequency.

Upon patient record review, 2 of 19 (Patient #10, 14) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual's attending physician, if any) • Changes that have taken place since the initial assessment • Information on the patient's progress toward desired outcomes • Reassessment of the patient's response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days. Patient #10 - RN comprehensive assessment on 01/31/24 then again on 02/20/24 - greater than 15 days. Patient #14 - RN comprehensive assessment on 01/09/24 then again on 01/30/24 - greater than 15 days.

Upon patient record review, 4 of 19 (Patient #8, 10, 16, 18) 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 #8 - POC dated 12/30/23 MSW visit frequency 2 PRN. Patient #10 - Order written on 02/11/24 "decrease MSW visit frequency to PRN" Patient #16 - POC dated 01/08/24 MSW visit frequency PRN Patient #18 - Order written 12/01/23 "decrease MSW visit frequency to PRN"

Upon patient record review, 2 of 19 (Patient #10, 13) 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. Incomplete medications. Patient #10 - Order written on 01/18/24 - Foley Catheter to be placed by hospice nurse - order did not contain foley/balloon size or frequency of catheter change. Patient #13 - Order written 02/01/24 Hospice nurse to drain Plural catheter per visit or as needed. Order did not specify parameters on limits of what can be drained, as needed did not contain modifier, no orders for dressing change procedure.

Upon patient record review, 2 of 19 (Patient #9, 15) 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 #9 - POC dated 01/24/24 did not include DME: walker or wheelchair. Patient #15 - POC dated 01/31/24 did not included DME: Hoyer Lift.

Upon client record review, 2 of 19 (Patient #6, 15) did not have evidence that the IDG in collaboration with the attending physician reviewed, revised and documents the individualized plan as frequently as the patient's condition requires but no less frequently then every 15 calendar days. Patient #6 - IDG documented on 01/31/24 then again on 02/21/24 - 21 days between IDGs. Patient #15 - IDG documented on 02/07/24 then again on 02/28/24 - 21 days between IDGs.

Upon client record review, 3 of 19 (Patient #11, 13, 19) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #11 - POC dated 01/05/24 SN visit frequency 1wk1, 2wk12 - only 1 visit made week 2. Patient #13 - SN drained plural catheter and changed dressing on 01/25/24 and 01/29/24 and no order for the plural dressing care. Patient #19 - POC dated 12/2/23 SC visit frequency 1m1, 4m1, 6m1 only 3 visit made month 2.

Upon patient record review, 3 of 19 (Patient #6, 10, 15) 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 #6 - Aide care plan contained bed bath and shower every visit but did not document that patient was cognitively and functionally able to make decision. Patient #10 - Aide care plan contained bed bath and shower every visit but did not document that patient was cognitively and functionally able to make decision. Patient #15 - Aide care plan contained bed bath and shower every visit but did not document that patient was cognitively and functionally able to make decision.

Upon patient record review 2 of 19 (Patient #14, 15) 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 Missed visits and providing care with no order Patient #14 - POC dated 01/13/24 Aide visit frequency 2wk 8 - only 1 visit made wk 6 - no missed visit documented. Patient #15 - POC dated 01/31/24 Aide visit frequency 1wk1, 2wk 12 - only 1 visit made wk 4 - no missed visit documented.

Upon patient record review 2 of 19 (Patient #10, 14) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs. Patient #10 - Aide supervisory visit made on 01/31/24 then again on 02/20/24 - greater then 14 days. Patient #14 - Aide supervisory visit made on 01/09/24 then again on 01/30/24 - greater then 14 days.

Upon personnel record review, 1 of 15 (Personnel #12) did not have evidence that a skills competency assessment, specific to each discipline had been conducted for all personnel including volunteers initially during orientation. Personnel #12 - Skills competency assessment was completed by the PT Manager.

Upon patient client record review, 2 of 19 (Patient #10, 13) 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 #10 - SN visit note on 01/19/24 documented "#18 catheter inserted" did not document balloon size, urine output or patient tolerance. SN visit note on 01/24/24 states patient has #16 foley catheter but patient has a #18 foley catheter. Patient #13 - SN visit note on 01/29/24 documented "replaced plural drainage dressing", visit note 02/02/24 "cleaned and redressed plural drainage site" no specific documentation of dressing procedure.

Upon client record review, 2 of 19 (Patient #4, 5) 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

Upon client record review, 1 of 19 (Patient #6) did not have evidence that a written hospice plan of care is established and maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided is in accordance with this hospice plan of care. Patient #6 - POC dated 01/26/24 MSW 1m1, 2m3 - only 1 visit made in February.

Upon client record review, 1 of 19 (Patient #14) did not have evidence that the hospice plan of care identifies the care and services that are needed and specifically identify which provider (nursing facility or hospice) is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care. Patient #14 - SN visit note on 01/30/24 "Patient bandage clean and dry" all care provided by facility. No orders on POC for wound care or who was to provide the wound care.