Every finding on record at By Your Side Hospice Care LLC

Upon patient record review, 3 of 5 records (Patient #1,#4,#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 #1: The medication profile indicated Oxygen 1-5L/min prn to maintain O2 Sat 88-92%. There was not evidence of a route. In addition, on 11/26/24, the record indicated an order for Loperamide 4mg q6h prn. There was not evidence that this was on the medication profile. Patient #4: The medication profile contained lidocaine 40mg/ml cream q2h prn for joint pain without evidence of a specific location. Patient #5: The medication profile contained NTG 0.4 SL Q5 min prn without evidence of how many doses to administer and what the next course of action should be if doses are ineffective. Also, Triamcinolone cream, moderate amount prn BID to rash with no specific location. In addition, Nystatin 100u/mg topical powder BID without evidence of a specific location.

Upon patient record review, 1 of 5 records (Patient #4) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient that reflects 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 record indicated that the patient was on ASA 325 mg daily and Plavix 75 mg 1 tab daily. There was not evidence that bleeding precautions were on the plan of care.

Upon patient record review, 3 of 5 records (Patient #1,#4,#5) did not have evidence the plan of care includes all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #1: The record indicated an order for Oxygen 1-5L/min prn to maintain O2 Sat 88-92%. There was not evidence of a route. Patient #4: The record contained an order for lidocaine 40mg/ml cream q2h prn for joint pain without evidence of a specific location. Patient #5: The record contained an order for NTG 0.4 SL Q5 min prn without evidence of how many doses to administer and what course of action to take if doses are ineffective. Also, Triamcinolone cream, moderate amount prn BID to rash with no specific location. In addition, Nystatin 100u/mg topical powder BID without evidence of a specific location.

Upon patient record review 1 of 5 records (Patient #5) 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 Patient #5: The aide plan of care dated 11/11/24 and 12/3/24 indicated to shower and shampoo weekly. The aide visit frequency was 2x/week. From 11/25/24-12/10/24 (3 weeks), there was not evidence that these tasks were performed and no explanation as to why they were not completed.

Upon patient record review, 4 of 14 (Patient #2, 3, 4, 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: The patient has orders for Acetaminophen Supp. 650mg every 4 hours prn as well as Acetaminophen 325mg 2 tablets q 4 hours prn. There is no max dose of Acetaminophen in 24 hours listed. Patient #3: The patient has 2 orders for Acetaminophen Supp. 650mg every 6 hours prn that are active, as well as Acetaminophen 325mg 2 tablets 4 times daily. There is no max dose of Acetaminophen in 24 hours listed. The patient is prescribed polyethylene glycol and the order does not include reconstitution instructions. Patient #4: The patient has an order for Acetaminophen Supp. 650mg every 6 hours prn that are active, as well as Acetaminophen 325mg 2 tablets q 4 hours prn. There is no max dose of Acetaminophen in 24 hours listed. The patient is prescribed polyethylene glycol and the order does not include reconstitution instructions. Patient #5: The patient has an order for Acetaminophen Supp. 650mg every 6 hours prn that are active, as well as Acetaminophen 325mg 2 tablets q 6 hours prn, and a third order for Acetaminophen 500mg three times daily. There is no max dose of Acetaminophen in 24 hours listed. The patient is prescribed polyethylene glycol and the order does not include reconstitution instructions.

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

Upon patient record review, 4 of 14 (Patient #1, 3, 7, 10) 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 #1: There is an order on 09/10/24 for wound care. There is no assessment of a wound, nor is there mention of the wound found in nursing assessments. The nursing visit on 09/18/24 contains documentation of a right shin skin tear. There is no documentation of wound assessment or of care provided. Patient #3: Admission visit on 09/27/24 states that there is a stage 1 bilateral buttock pressure injury. There is not a wound assessment with measurements of that wound. The nursing visit mentions this stage 1 on the follow up nursing visit, though there is still not a wound assessment. The next mention of any wound is on the nursing visit on 10/14/24 when the RN case manager charts that there is a "stage 3 pressure injury to her coccyx and there will be wound changes 3 times weekly until healed." The order written the same day states "Stage 2 bilateral buttock pressure injury, cleanse wound with soap and water, apply xeroform, cover with ABD pads, change 3 times weekly and prn." There have been no follow up wound assessments or measurements obtained. POC states wound to be assessed weekly. Patient #7: Patient was admitted with a stage 3 wound to the coccyx on 4/6/24. This wound was assessed and measured on 4/9/24. The next wound assessment was completed on 04/19/24. The wound care order states from admission "Medi honey on bordered foam change 3 times weekly. per wound RN at facility" There is a second wound noted on 05/24/24 as a Rt. Sacral stage 2 pressure ulcer. There was no change in orders or POC. The next wound assessment was on 07/24/24 when a third wound was noted on left heel. On 08/19/24 patient found with bruising on bilateral shins, L middle finger and hand. There is no follow up visit or phone call until 08/23/24. Patient #10: Patient facility staff called on 11/01/24 and PRN visit made for "multiple bouts of vomiting and diarrhea. No follow up call or visit made as of 11/05/24.

Upon patient record review, 5 of 14 (Patient #3, 4, 5, 9, 10) 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: Patient is on service for Systolic heart failure. There are no interventions or goals in the POC for her primary diagnosis. Patient #4: Patient is on service for senile degeneration of the brain, there are no interventions or goals for neuro on her POC. She has Oxygen, though no interventions or goals for oxygen on her POC. Patient #5: Patient on service for senile degeneration of the brain, there is no POC for primary diagnosis of neuro disturbance. The patient has increased anxiety and agitation, though no interventions or goals are found for these on the POC. Patient #9: Patient is on service with primary diagnosis of Protein calorie malnutrition. There is not a nutrition POC with interventions or goals. Patient is on oxygen, but still actively smoking. There are no interventions or goals for smoking within the Oxygen pathway. Patient #10: Patient on service for senile degeneration of the brain, there is no POC for primary diagnosis of neuro disturbance.

Upon patient record review, 3 of 14 (Patient #1, 3, 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 #1: Patient has wound order written 09/09/24 that states, "Clean area with normal saline, pat dry, and cover with bordered dressing. Hospice to change 3x per week until healed." This does not delineate the location or type of wound. The visit on 09/20/24 states that skin tear is healed - there is no order to discontinue wound care. Patient #3: Patient has a pressure wound order dated 10/14/24 that reads, "Stage 2 bilateral buttock pressure injury, cleanse wound with soap and water, apply xeroform, cover with ABD pads, change 3 times weekly and prn." The order does not delineate who will change the dressing or an indication for prn. Patient #7: This patient had 3 different wound and wound locations. There is only one treatment order dated 04/06/24 that states, " Medi Honey on bordered foam change 3 times a week. This order does not include location or type of wound. It also does not state who is responsible for dressing changes.

Upon patient record review, 6 of 14 (Patient #1, 3, 5, 6, 9, 10) 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. Patients 1,3,5,6,9,10: The Plan of care does not include coordination of care with ALF.

Upon observation, there was no evidence the hospice ensures that non-core services are provided to hospice patients and their families according to applicable laws and regulations. Non-core services include Physical Therapy, Occupational Therapy and Speech-Language Pathology. The hospice did not ensure that non core services are available for Occupational and Speech-Language pathology.

Upon patient record review, 4 of 14 (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 Patient #1: The POC lists patient uses w/c and walker - this needs to be one or the other. The POC states "safety precautions assigned" but does not state what they are. This patient requires bleeding precautions as well as fall precautions. Patient #2: The aide POC indicates the following tasks: Assist with dressing, trim nails, shave, oral care, incontinence care, and clean patient area/equipment, however, no frequency listed for these tasks. The aide is ordered to assist with feeding but the Aide POC does not list patient diet or frequency of assistance with feeding. Safety precautions are "assigned" but not specified on POC. Patient #3: Tasks for Assist with dressing, social and emotional support, clean patient area are listed as q shift, though patient seen only twice weekly. No safety precautions listed. Patient #4: Range of Motion is ordered as tolerated. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable. No safety precautions are specified despite the POC stating they are assigned.

Upon client record review, 1 of 14 (Patient #12) did not have evidence that the discharge summary includes all required information. Patient #12: the patient revoked services to seek aggressive treatment at local emergency department. There is no evidence in the record of the receiving agency being provided with a summary of the patient's stay, current POC, or current physician orders.

Upon client record review, 4 of 14 (Patient #2, 4, 7, 8) 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. Patients 2,4,7,8: The Plan of care does not include coordination of care with SNF

Condition of Participation: Personnel Qualifications.

Upon personnel record review, 1 of 12 (Personnel #7) did not have evidence that all Speech Therapy Services are provided by a qualified licensed Speech-Language Pathologist (SLP) or Audiologist in accordance with the state's Speech-Language Pathology Practice Act and the hospice's policies and procedures and/or job descriptions. The agency does not have an active contract that include Speech and Language Therapy

Upon personnel record review, 1 of 12 (Personnel #6) did not have evidence all Occupational Therapy Services are provided by a qualified licensed Occupational Therapist (OT) in accordance with the state's Occupational Therapy Practice Act and the hospice's policies and procedures and/or job descriptions. The agency currently does not have an active contract for OT services.

Upon personnel record review, 2 of 12 (Personnel #6,7 ) did not have evidence the hospice obtained a criminal background check on all contracted individuals who have direct patient care and access to patient records. No HR files available as no contract for OT/SLP services.

Upon client record review, 2 of 8 (Patient #6, 8) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #6: SW ordered 2x mo on POC dated 10/28/22. Visits performed 10/29. No second visit for the month of October. No evidence of missed visit nor order to correct frequency. Patient #8: SW ordered 1x mo on POC dated 10/20/22. SW performed visits on 10/22, 10/26, 11/3 and 11/10. This exceeded number of orders visits and no evidence of order to correct frequency.

Upon patient record review 3 of 8 (Patient #4, 6, 7) 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 #4: Aide ordered 1x wk effect 11/9-11/23. No visits performed, no evidence of missed visit or order to correct frequency. Patient #6: Aide ordered 2xwk on POC dated 10/28. No evidence of second visit for first week. No evidence of a missed visit. Patient #7: Aide ordered 2xwk beginning 11/11/22. Visits did not begin until 11/25/22. No visits performed between 11/11 and 11/25/22. No evidence of missed visits or order to correct frequency.