Every finding on record at Capital Hospice, Inc.

Upon patient record review, 14 of 14 (Patient #1,2,3,4,5,6,7,8,9,10,11,12,13,14) did not have evidence in the patient record that the comprehensive assessment takes into consideration the imminence of death.

Upon patient record review, 1 of 14 (Patient #3) 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: Patient 3: The medication profile contains an order for Vitamin 25mcg po daily. Upon home visit finding this order should have been written as Vitamin D2 25mcg po daily. Corrected on site.

Upon patient record review, 1 of 14 (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: The POC 10/1/23 contains an order for Vitamin 25mcg po daily. Upon home visit finding this order should have been written as Vitamin D2 25mcg po daily.

Upon patient record review, 1 of 14 (Patient #2) did not have evidence in the patient record that hospice aide assignments and duties are: Patient 2: The Aide POC 9/6/23 and 11/5/23 contain orders for toileting and diaper change with no frequency. Corrected on site.

Upon patient record review 1 of 14 (Patient #3) did not have evidence documentation in the patient record that a hospice aide provides services that are: Patient 3: Upon home visit aide was observed transferring pt from bed to w/c using a walker and 2 assists. There are no orders for transferring pt on the aide POC. The aide stated she is applying Calmoseptine and A&D ointment to the pt's buttocks each visit. This is not ordered on the aide POC.

Upon patient client record review, 1 of 14 (Patient #12) did not have evidence that each patient record contains Physician certification and recertification of terminal illness. Patient 12: The medical record does not contain a physician certification completed by the patient's chosen attending physician.

Based on interview and record review, the hospice agency failed to ensure one of two sampled patients (Patient 1) and family member or caregiver, were informed of their rights in a preferred language (Spanish), that they could understand, both verbally and in writing. This failure resulted in Patient 1 not understanding hospice care, miscommunication, and poor provision of care. --- During a review of the agency's document titled, "Patient Rights and Responsibilities," undated, the document indicated, "...As a [name of agency] patient, you have the right to: 1. Be informed of your rights and responsibilities in a language and manner, which you understand..." During a review of Patient 1s ";Patient Intake," dated 9/19/22, the document indicated, Patient was a 95-year-old, admitted onto hospice service on 9/19/22 with a diagnosis of heart disease and a language preference of Spanish. During a review of the ";Complaint/Incident Intake Report," dated 4/26/23, the report indicated, Patient 1's Family Member (FM) reported Patient is Spanish speaking only and the agency has been communicating with Patient and family only in English. During an interview on 5/4/23, at 10:26 a.m., with FM, FM verbalized, the agency staff had Patient 1 signed the consent for Hospice service in English. FM, further verbalized, patient has very limited in English skills and even reading skills in Spanish are very limited. During a concurrent interview and record review, on 6/7/23 at 3:17 p.m., Patient 1's clinical record (CR) was reviewed with the Director of Patient Care Services (DPCS). The CR indicated, the written copies of documents signed by Patient 1, including notice of rights, were provided in English and no professional translator was provided for hospice-patient communications. DPCS verbalized and confirmed, the non-English forms were not available for the agency staff to use for the year 2022 and were only made available in 2023, and no translator was used.