Every finding on record at Canestro Care Hospice Inc.

Upon patient record review, 1 of 5 (Patient #1) 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: There is evidence of an order for Nitroglycerine 0.4 mg SL po PRN chest pain, with instructions to repeat q 5 min. Do not take more than 3 tablets in 15 min. There is not information what to do after 15 minutes. Additionally, O2 2L via NC PRN shortness of breath is entered as a treatment and does not appear on the medication list. Both were corrected on site.

Upon patient record review, 2 of 5 (Patient #1,2) 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 #1: There is evidence the patient is on Plavix 75 mg daily for anticoagulation. There is not a Problem/Intervention/Goal for bleeding precautions on the plan of care. Patient #2: There is evidence in the initial nursing assessment 3/17/25, the patient had weight loss in past 6 months and is on aspiration precaution. There is not a Problem/Intervention/Goal for nutrition with weight loss and aspiration precautions. (Corrected on site)

Upon patient record review, 1 of 5 (Patient #1) 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: There is evidence of an order for Nitroglycerine 0.4 mg SL po PRN chest pain, with instructions to repeat q 5 min. Do not take more than 3 tablets in 15 min. There is not information what to do after 15 minutes.

Upon observation, there was no evidence the organization follows their policies and procedures to maintain the the patient's clinical record in confidential manner. There is evidence complete records of five discharged patients were not retained by the agency therefore confidentiality of these records was not maintained.

There is evidence all patient records are retained for a minimum of six years from the date of the most recent discharge or the death of the patient, unless state law stipulates a longer period of time. There is evidence complete records of five discharged patients were not retained by the agency.

Upon observation, there was no evidence the Emergency Preparedness plan includes a process for cooperation and collaboration with local, tribal, regional, state, and federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. Corrected on site and was added to Emergency Preparedness Binder local, tribal, regional, state and federal contact information.

Upon patient record review, 1 of 5 (Patient #3) 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 #3 RN initial assessment of 4/11 stated that the patient is on Oxygen continuous at 2L/min but oxygen not listed under medication on the POC. Oxygen concentrator listed under DME in the plan of care.

Upon patient record review, 1 of 5 (Patient #2) 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 #2 RN initial assessment of 4/5 stated that patient has shower chair but not listed in the plan of care.

Upon patient record review, 1 of 5 (Patient #5) did not have evidence the hospice offers bereavement counseling that includes: • Making bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. Bereavement counseling also extends to residents of a SNF/NF or ICF/IID when appropriate and identified in the bereavement plan of care • Ensuring that bereavement services reflect the needs of the bereaved • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery Patient #5. There was no evidence that there is a individualized bereavement plan of care that note the kind of bereavement services to be offered and frequency of service delivery.

Upon patient client record review, 3 of 5 (Patient #1, #2, #3) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient #1, #2, #3 Signed Election of Benefit documents did not contain a start of care date.

Condition of Participation: Patient’s Rights. L500

Upon patient record review, 4 of 5 (Patient #2, 3, 4, 5) did not have evidence that the hospice obtained the patient's or representative's signature confirming that they received a copy of the Patient's Rights and Responsibilities. No evidence of signed consents for these patients.

Upon patient record review, 4 of 5 (Patient #2, 3, 4, 5) did not have evidence that if a state court has not adjudged a patient incompetent, any legal representative designated by the patient in accordance with state law may exercise the patient's rights to the extent allowed by state law. No evidence of signed consents for these patients.

Upon patient record review, 4 of 5 (Patient #2, 3, 4, 5) did not have evidence that the patient chooses a health care provider, including an attending physician. No evidence of signed consents for these patients.

Upon patient record review, 4 of 5 (Patient #2, 3, 4, 5) did not have evidence of the appropriate documentation for release of confidential information. No evidence of signed consents for these patients. No evidence of signed consents for these patients.

Upon patient record review, 4 of 5 (Patient #2, 3, 4, 5) did not have evidence that the patient received information about the services covered under the hospice benefit. No evidence of signed consents for these patients.

Upon patient record review, 4 of 5 (Patient #2, 3, 4, 5) did not have evidence that the patient received information about the scope of services that the hospice will provide and specific limitations on those services. No evidence of signed consents for these patients.

Upon patient record review, 5 of 5 (Patient 1,2,3,4,5) did not have evidence in the patient record that the comprehensive assessment takes into consideration the imminence of death. Patient 1-5: The comprehensive assessment did not document imminence of death. No entries in this area of the comprehensive assessment form by admission RN.

Upon patient client record review, 4 of 5 (Patient 2, 3, 4, 5) did not have evidence that each patient record contains: • Signed election statement in accordance with 418.24 Patient 2, 3, 4, 5: No evidence of patient or designated representative signatures on the election statement that is present in the records.

Upon client record review, 2 of 5 (Patient 4,5) did not have evidence that the discharge summary includes all required information. Patient 4: The discharge summary did not include a summary of the patient's stay,including treatments, symptoms and pain management. Patient 5: The discharge summary did not include a summary of the patient's stay,including treatments, symptoms and pain management.

Upon client record review, 4 of 5 (Patient #2, 3, 4, 5) did not have evidence that the written policies and procedures for managing controlled drugs was provided and discussed.