Every finding on record at Care Solution Hospice, Inc.

Upon patient record review, 3 of 14 (Patient #6,7,9) 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 6: On medical record review, it was observed that LVN documented during visit made on 06/18/2024: “patient is on PRN oxygen therapy. Increased liter flow to 4 lpm due to desaturation, instructed pcg on oxygen safety measures.” There is no evidence of oxygen orders on the medication profile. Patient 7: Patient has order for diclofenac 1 percent topical gel. Order instructions are to apply every six hours for mild pain. There is no evidence of application site on the medication profile. Patient 9: Patient has order for Humulin N insulin. There is no evidence of instruction to rotate injection sites on the medication profile.

Upon patient record review, 1 of 14 (Patient #3) did not have evidence in the patient record that the comprehensive assessment includes 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.

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

Upon patient record review, 10 of 14 (Patient #1,2,3,4,5,6,7,8,9,10) 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 1: The following precautions are documented in the record: infection. There is no evidence of any of this care plan in the medical record. Patient 2: The following precautions are documented in the record: skin, diabetic, infection. Patient also has a diagnosis of depression. There is no evidence of any of these care plans in the medical record. Patient 3: There is documentation of bleeding and infection precautions. There is no evidence of bleeding or infection care plans in the medical record. Patient 4: The following precautions are document in the record: bleeding, aspiration, infection. There is also documented weakness. There is no evidence of any of these care plans in the medical record. Patient 5: The following precautions are documented in the record: aspiration, infection, diabetic, bleeding. There is no evidence of any of these care plans in the medical record. Patient 6: The following precautions are documented in the record: bleeding, skin, infection. There is no evidence of these care plans in the medical record. Patient 7: The following precautions are documented in the record: bleeding, infection. There is no evidence of these care plans in the medical record. Patient 8: The following precautions are documented in the record: infection. There is also documented anxiety. There is no evidence of these care plans in the medical record. Patient 9: The following precautions are documented in the record: skin. There is also documented depression and caregiver anxiety. There is no evidence of these care plans in the medical record. Patient 10: The following precautions are documented in the record: bleeding. There is also documented caregiver anxiety. There is no evidence of these care plans in the medical record.

Upon patient record review, 3 of 14 (Patient #6,7,9) 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 6: On medical record review, it was observed that LVN documented during visit made on 06/18/2024: “patient is on PRN oxygen therapy. Increased liter flow to 4 lpm due to desaturation, instructed pcg on oxygen safety measures.” There is no evidence of physician's orders for oxygen in the medical record. Patient 7: Patient has order for diclofenac 1 percent topical gel. Order instructions are to apply every six hours for mild pain. There is no evidence of application site in the physician's order. Patient 9: Patient has order for Humulin N insulin. There is no evidence of instruction to rotate injection sites in the physician's order.

Upon patient record review, 1 of 14 (Patient #6) 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 6: On medical record review, it was observed that LVN documented during visit made on 06/18/2024: “patient is on PRN oxygen therapy. Increased liter flow to 4 lpm due to desaturation, instructed pcg on oxygen safety measures.” There is no evidence of oxygen orders in the patient’s plan of care.

Upon client record review, 7 of 14 (Patient #1,2,3,5,6,7,8) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 1: Physician’s order for RN visit frequency is every 14 days. There is documentation of visit dates: 5/22/24, 6/3/24, 6/16/24, 6/24/24 which is outside the ordered frequency. Patient 2: Physician’s order for RN visit frequency is every 14 days. There is documentation of visit dates: 6/7/24 and 6/18/24, which is outside the ordered frequency. Physician’s order for MSW visit is monthly. Order written 6/10/24. There is no evidence of MSW visit 6/12/24-6/30/24. Patient 3: Physician’s order for MSW visit is monthly. Order written 6/26/24. There is no evidence of MSW visit 6/26/24-6/30/24. Patient 5: Physician’s order for MSW visit is monthly. Order written 6/10/24. There is no evidence of MSW visit 6/10/24-6/30/24. Patient 6: Physician’s order for MSW visit is monthly. Order written 5/16/24. There is no evidence of MSW visit 5/16/24-5/31/24. In addition, It was observed that LVN documented during visit made on 06/18/2024: “patient is on PRN oxygen therapy. Increased liter flow to 4 lpm due to desaturation, instructed pcg on oxygen safety measures.” There is no evidence of physician's orders for oxygen in the medical record and LVN performed not in accordance to the plan of care. Patient 7: Physician’s order for MSW visit is monthly. Order written 5/16/24. There is no evidence of MSW visit 5/16/24-5/31/24. Patient 8: Physician’s order for MSW visit is monthly. Order written 5/16/24. There is no evidence of MSW visit 5/16/24-5/31/24.

Upon patient record review 1 of 14 (Patient #9) did not have evidence that the IDG ensures that the care and services provided are based on all assessments of the patient and family needs. Patient 9: During admission assessment, RN documented need for referral to physical therapy. There is no evidence in the medical record that this referral was made.

Upon observation, there was no evidence the hospice is in compliance with accepted professional standards and principles for all core services which includes nursing services, medical social services and counseling services. Upon personnel record review, 1 of 16 (Personnel #1) did not have evidence that personnel credentialing activities are conducted to verify qualifications of all credentialed/licensed personnel in the positions they hold at the time of hire, at renewal or in accordance with specific state practice act requirements. There is not evidence that this personnel member has completed education as a qualified social worker to meet the requirements of the core services of hospice.

Upon patient record review, 9 of 14 (Patient #1,2,4,5,6,7,8,9,10) 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: aide care plan without evidence of frequency for the following tasks: chair to bed; 2 bed rails up; turn and reposition; record bowel movements. Aide care plan also without evidence of following precautions: aspiration and infection. Patient 2: aide care plan without evidence of frequency for the following tasks: chair to bed; record bowel movements; all housekeeping tasks. Aide care plan also without evidence of following precautions: aspiration, bleeding and infection. Patient 4: aide care plan without evidence of frequency for the following tasks: chair to bed; 2 bed rails up; record bowel movements; turn and reposition; adult diapers; upper dentures; all housekeeping tasks. Aide care plan also without evidence of following precautions: aspiration. Patient 5: aide care plan without evidence of frequency for the following tasks: record bowel movements; all housekeeping tasks. Aide care plan also without evidence of following precautions: aspiration, bleeding, diabetic, and infection. Patient 6: aide care plan without evidence of frequency for the following tasks: change linen; record bowel movements. Aide care plan also without evidence of following precautions: bleeding, skin. Patient 7: aide care plan without evidence of frequency for the following tasks: chair to bed; turn and reposition; record bowel movements; change linen. Aide care plan also without evidence of following precautions: aspiration, bleeding, seizure, skin. Patient 8: aide care plan without evidence of frequency for the following tasks: chair to bed; turn and reposition; record bowel movements; dentures; change linen. Aide care plan also without evidence of following precautions: bleeding, skin, aspiration. Patient 9: aide care plan without evidence of frequency for the following tasks: chair to bed; record bowel movements; change linen. Aide care plan also without evidence of following precautions: aspiration, diabetic. Patient 10: aide care plan without evidence of frequency for the following tasks: record bowel movements; change linen. Aide care plan also without evidence of following precautions: aspiration.

Upon patient record review 3 of 14 (Patient #2,5,6) 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 2: Physician’s order for aide visit frequency twice weekly. Order written on 6/7/24. There is no evidence of aide visits before 6/9/24. During visit on 7/11/24, there is no evidence that aide performed task: bed low position. Patient 5: Physician’s order for aide visit frequency twice weekly. Order written on 6/5/24. There is no evidence of aide visits before 6/12/24. Patient 6: Physician’s order for aide visit frequency twice weekly. Order written on 5/11/24. There is no evidence of aide visits before 5/12/24.

Upon patient record review 2 of 14 (Patient #6,7) 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 6: There is no evidence of aide supervisory visit between dates: 5/25/24 and 6/10/24. Patient 7: There is no evidence of aide supervisory visit between dates: 6/6/24 and 7/4/24.

Condition of Participation: Organization and Administration of Services.

Upon observation, there was no evidence the hospice is directed by a Board of Directors/governing body which assumes full legal authority and responsibility for the operation of the hospice. The governing body did not assume responsibility in ensuring that personnel were qualified to provide core services for the hospice program as evidenced by not having a qualified social worker for medical social services.

Upon patient client record review, 6 of 14 (Patient #1,9,10,12,13,14) 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 1: No evidence of credentials with staff signature on the informed consents. Staff signature not legible. Patient 9, 10, 12, 13: No evidence of credentials with staff signature on consents. Patient 14: No evidence of credentials with staff signature on the informed consents. No evidence of patient choice re: receipt of non-covered items, services, drugs.

Upon personnel record review, 1 of 16 (Personnel #1) did not have evidence that all Medical Social Services are provided by a qualified Medical Social Worker in accordance with the state's Social Work Practice Act, the hospice's policies and procedures and/or job descriptions.