Every finding on record at Briargate Healthcare Services Inc

Upon observation, there was no evidence that the Emergency Preparedness Plan included strategies for addressing those emergency events, as identified per the Hazard Vulnerability Risk Assessment, to be most likely to occur; in order to best prepare for and manage the consequences of power failures, natural disasters, and other emergencies that would affect the Hospice's ability to provide care.

Upon patient record review, 4 of 12 (Patients #1, 2, 6, and 11) did not contain a current/comprehensive Medication Profile. Patient #1 The Plan of Care dated 04/18/21 - 07/16/21 included Oxygen 2-4 l.p.m. prn NC. Whereas, the Medication Profile listed, ""Oxygen 2 lpm prn NC." Patient #2, 6, and 11 clinical record(s) reflected that these patients were on Oxygen. Their Oxygen was not included on their Medication Profile.

Upon patient record review, 1 of 12 (Patient #5) did not contain evidence that the comprehensive assessment included 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.

Upon patient record review, 1 of 12 (Patient #12) did not contain evidence that a Registered Nurse was designated to ensure continuous assessment of the patient and family's needs, and ensure follow-up on all areas of patient concern. A verbal order was obtained on 11/05/2021 for, "Cleanse wound with Normal Saline flush, apply Santyl Ointment, then Tegaderm. By SN 1x per week. Unna boot should be worn at all times". There was no reference to the patient's compliance with the physician-ordered Unna Boot in any of the 11/09/21, 11/16/21, and 11/23/21 nursing visit notes.

Upon patient record review, 1 of 12 (Patient #12) did not contain evidence that the Plan of Care included all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. A verbal order was obtained on 11/05/2021 for, "Cleanse wound with Normal Saline flush, apply Santyl Ointment, then Tegaderm. By SN 1x per week. Unna boot should be worn at all times". This is not a complete order, as it is not evident as to where on the patient's body this wound is located.

Upon patient record review, 2 of 12 (Patients #1 and 7) did not contain evidence that the Plan of Care included all services necessary for the palliation and management of the terminal illness and related conditions; specifically all DME and Supply needs: Patient #1: During Surveyor-attended home visit on 04/21/22 it was noted that the patient had a hospital bed. This was not on the Plan of Care. Patient #7: The SN SOC Assessment visit report noted that the patient had a: 1) Bed; 2) Cane; 3) Nebulizer; and 4) Oxygen Concentrator. These were not included on the Plan of Care.

Upon observation, there was not evidence that the Board of Directors/Governing Body had approved the frequency and detail of the 2022 QAPI data collection plan.

Upon patient record review, 5 of 11 applicable (Patients #1, 3, 4, 6, 7) did not contain evidence that the Hospice Aide POC was individualized, including all pertinent assignments, and other pertinent details: Patient #1: The Aide POC dated 04/18/22 assigned both a Bed Bath and a Shower. Patients #3, 4, 6, 7: For each of these patients, they had evidence of a D.N.R. order within their clinical record. This pertinent Advance Directive information was not included on these patients' Aide Plan(s) of Care.

Upon patient record review, 1 of 1 applicable (Patient #3), transferred to another Hospice, did not contain documented evidence that the Hospice had forwarded a completed Transfer Summary, and a copy of the patient record, if requested, to the receiving Hospice. Patient #3 was transferred to another Hospice on 01/07/2022. The Clinical Manager was not able to locate evidence of such Transfer Summary having been forwarded to the receiving Hospice.

Upon patient record review, 2 of 2 applicable (Patients #4 and 5) live discharges, did not contain evidence that if a patient revokes their Election of Hospice benefit, or is discharged from Hospice in accordance with §418.26, that the Hospice must complete, and forward to the patient's Attending physician, if any: • A copy of the hospice Discharge Summary • The patient's clinical record, if requested Patient #4 and 5 there was no evidence of a DC Summary having been established.