Every finding on record at Caring Hands Palliative & Hospice Inc.

Upon patient record review, 5 of 14 (Patient #2,9,10,11,12) 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 Orders dated 11/1/24 for Diclofenac 1% cream does not indicate a specific location to apply the cream. Patient #9 Orders dated for 10/2/24 for Bacitracin Ointment does not indicate a specific location to apply the ointment. Patient #10 Orders dated 1/20/25 "Hold all oral meds except comfort meds" and orders remain on medication profile for Lipitor, Quetiapine, Fluticasone, Narcan, Fentanyl, Atrovent and Omeprazole. Orders dated 9/24/24 for Nitroglycerin to be admin every 5 min x3 without indication of PRN use. Patient #11Orders dated 9/27/24 for Santyl ointment to be applied "as directed" with no indication of location or amount to be applied on medication profile. Patient #12 Orders dated 5/6/24 for Lotrisone 1% cream without indication of specific location on medication profile.

Upon patient record review, 3 of 14 (Patient #2,9,10) 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 #2 1/28/25 Orders for Aspirin, no bleeding precautions in place. Patient #9, #10 11/7/23 Orders for Oxygen without oxygen precautions in place.

Upon patient record review, 5 of 14 (Patient #2,9,10,11,12) 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 # 2 11/1/24 Orders for Diclofenac 1% with no indication of specific location to be applied. Patient # 9 10/2/24 orders for Bacitracin Ointment without indication of specific location. Patient # 10 Orders dated 1/20/25 "Hold all oral meds except comfort meds" and orders remain on medication profile for Lipitor, Quetiapine, Fluticasone, Narcan, Fentanyl, Atrovent and Omeprazole. Orders dated 9/24/24 for Nitroglycerin to be admin every 5 min x3 without indication of PRN use. Patient # 11 Orders dated 9/27/24 for Santyl ointment to be applied "as directed" with no indication of location. Patient # 12 Orders dated 5/6/24 for Lotrisone 1% cream without indication of specific location.

Upon patient record review, 6 of 14(Patient #2,4,8,11,12,14) 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 Oxygen, Wheelchair and Suction in use, no orders for DME in place. 11/1/24 Nurse note states "Patient ambulatory with walker", no orders for DME on POC. Patient # 4 POC states patient utilizes walker and wheelchair for mobility, no orders for DME on POC. Patient # 8, #11, #12, #14 Oxygen in use, no DME orders on POC.

Upon client record review, 2 of 14 (Patient #2,3) did not have evidence that the IDG in collaboration with the attending physician reviewed, revised and documents the individualized plan as frequently as the patient's condition requires but no less frequently then every 15 calendar days. Patient # 2 and #3 IDG was completed on 11/7/24 and the next IDG was completed 12/5/24

Upon client record review, 2 of 14 (Patient #2,11) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient # 2 SN frequency is ordered 1x/week, SN visits made 1/5/25 and 1/6/25 which is greater than the ordered frequency. Patient # 11 SC orders in place for 1x/month and no visits were made the month of September 2024.

Upon patient record review, 2 of 14 (Patient #2, #3) 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 #2 1/28/25 Aide care plan does not have oxygen precautions in place. Patient #3 12/9/24 Aide care plan does not have oxygen precautions in place

Upon patient record review 6 of 14 (Patient #3,4,5,6,7,9) 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 #3 1/31/25 Tasks for Record BM, Shampoo and Brush Teeth were marked "Task Incomplete" and not completed per the aide care plan. Patient #4 1/31/25 Tasks for Record BM was marked "Task Incomplete" and not completed per the aide care plan. Patient #5 Aide visit frequency ordered as 3x/week effective 1/26/25 and visits made only 2x/week on 1/27/25 and 1/29/25. Patient #6 Aide visit frequency ordered as 3x/week effective 12/15/24 and visits made only 2x/week on 1/27/25 and 1/29/25. Patient #7 Aide visit frequency ordered as 3x/week on 12/19/24 and only one visit was made on 12/20/24 for the week. On 1/18/25 there are 2 fully documented aide visits. Patient #9 2/3/25 Tasks for Urinary was marked "Task Incomplete" and not completed per the aide care plan.

Upon patient record review 5 of 14 (Patient #2,3,6,8,10) 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 #2 Aide supervisory visits were completed on 12/9/24 and 1/5/25 and 1/19/25 and 2/2/25 no evidence of a supervisory visit being completed between those visits. Patient #3 Aide supervisory visit completed 11/25/24, no evidence of supervisory visit completed again until 12/23/24. Patient #6 Aide visits started 12/13/24 and no evidence of a supervisory visit completed until 12/30/24. Patient #8 Aide supervisory visit completed 12/25/24, no evidence of supervisory visit completed again until 1/22/25. Patient #10 Aide supervisory visit completed 12/3/24, no evidence of supervisory visit completed again until 12/31/24.

Upon patient client record review, 1 of 14 (Patient #9) did not have evidence that each patient record contains Advance Directives. Patient #9 8/15/24, Son signed consents as POA, no evidence of POA paperwork on file.

Observed in Patient Home. In 6 of 6 patient records reviewed, it was noted by the nurse surveyor that for HV#1/RR#1, HV#2/RR#2, HV#3/RR#3, RR#4, RR#5, and RR#6 the goals were not measurable. Examples of goals were Patient will verbalize understanding of cardiovascular status changes is expected with the disease progression,” and Patient's episodes of respiratory crisis will be managed with hospice intervention as expressed by verbalized by pt/PCG during care. Additionally, there were no short-term goals at start of care to address issues of immediate needs such as understanding medication management, symptom management, pain management, mobility, or safety, the end of the certification period was the time frame for completion for all goals. Findings were verified by the Director of Patient Care Services.

Observed in Patient Home. In 1 of 3 home visits conducted, it was observed by the Nurse Surveyor that the organization did not implement the infection prevention and control activities it had planned. HV#1 with the licensed practical nurse. The nurse washed her hands with soap and water at the beginning of the visit prior to donning gloves. During the course of the visit she changed her gloves five times without hand sanitizing between glove changes per agency policy. Findings were verified by the Director of Patient Care Services who was present on the visits.