Every finding on record at Caring One Hospice LLC

Upon patient record review, 1 of 6 (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. Patient #3 SOC date 03/14/25. Initial Bereavement Risk Assessment dated 03/24/25.

Upon patient record review, 1 of 5 (Patient #2) 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 Patient 2: Upon review of the medication profile, the hospice has patient with calmoseptine topical ointment 0.44%, the patient medication profile did not list this medication.

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

Upon patient record review, 3 of 5 (Patients #2, #3, #5) 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: Upon admission, nurse charts that patient has noted dyspnea and dysphagia on a mechanical soft diet, there are no problems, goals, or interventions to manage findings. Patient 3: Upon admission, nurse charts that patient needs to be on aspiration precautions, there are no problems, goals, or interventions to manage findings. Patient 5: Upon admission, nurse charts in the narrative that patient has pain rating 6/10, in the pain section of the assessment, it is charted that patient has no pain. There are no problems, goals, or interventions to manage findings.

Upon patient record review, 3 of 5 (Patients #1, #3, #5) 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: Nurse charts in admission assessment that patient is using supplemental oxygen, there is no order for oxygen. Patient 3: Nurse charts in admission assessment that patient is using supplemental oxygen, there is no order for oxygen. Patient 5: Nurse charts in admission narrative that patient has Norco 5 on order for pain management, there is no order written for Norco.

Upon patient record review, 4 of 5 (Patients #1, #3, #4, #5) 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 1: Patient has oxygen concentrator, nebulizer, and walker in home, there are no orders for listed medical equipment. Patient 3: Patient has air mattress, oxygen concentrator and Emergency tanks, there are no orders for listed medical equipment. Patient 4: Patient has walker and oxygen concentrator there are no orders for listed medical equipment. Patient 5: Patient has nebulizer, oxygen concentrator, and walker there are no orders listed for medical equipment.

Condition of Participation: Hospice Aide and Homemaker Services. L607

Upon personnel record review, 1 of 11 (Personnel # 5) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) ·Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff. ·Reading and recording temperature, pulse, and respiration ·Safe transfer techniques and ambulation. ·Normal range of motion and positioning ·Appropriate and safe techniques in personal hygiene and grooming that include-- ·(A) Bed bath ·(B) Sponge, tub, and shower bath ·(C) Shampoo, sink, tub, and bed ·(D) Nail and skin care ·(E) Oral hygiene ·(F) Toileting and elimination The other subject areas in this section may be evaluated through written examination, oral examination or after observation of a Hospice Aide with a patient. Personnel #5: There is no evidence of personnel having direct supervision performing tasks with a patient or pseudo patient.

Upon patient client record review, 1 of 5 (Patient #5) 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 5: On the admission note, the nurse charts that patient has no pain in the pain section of the assessment but in the narrative charts that patient has 6/10.