Every finding on record at Caring Partners Hospice

Upon patient record review, 1 of 14 (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: Patient #1: The medication reconciliation with Assisted Living (ALF) record and hospice medication record did not match. The ALF had Maxtussin 20mL, Milk of Magnesia 30mL and Robitussin 10mL all as PRN. The Hospice did not have these medications listed on their profile. The hospice had ordered Mucinex 20mL near the same time Maxtussin was added at the ALF profile. Agency contacted MD and Pharmacy to clarify orders. The ALF did receive Mucinex not Maxtussin from pharmacy, MD discontinued Robitussin, Maxtussin and Milk of Magnesia and Hospice provided ALF with clarification orders. Corrected on Site.

Upon patient record review, 1 of 14 (Patient #5) 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 #5: No Initial Bereavement Assessment has been completed to date.

Upon personnel record review, 1 of 10 (Personnel #7) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: ·Normal range of motion and positioning

Upon patient record review, 1 of 14 (Patient #6) did not have evidence that each patient record contains: • Signed election statement in accordance with 418.24 Patient #6: The election statement did not include contact information for BFCC-QIO (Livanta).

Upon patient record review, 1 of 14 (Patient #8) 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 #8: The record indicated that patient has music therapy in nursing narrative. Per agency, they do not provide this service and this was a typo. Additionally, the record indicated this patient has an Infusion Pump. This patient does not have any infusions ordered. Per agency, this was also a typo.

Upon patient record review, 2 of 14 (Patients #10, 11) did not have evidence that the discharge summary includes all required information. Patients #10: Did not have all CMS required elements as follows: • A summary of the patient's stay, including treatments, symptoms and pain management • The patient's current plan of care Patient #11: Did not have all CMS required elements as follows: • The patient's current plan of care

Upon patient record review 1 of 11 (Patient #1) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient #1- The patient was admitted 11/23/21 and initially declined Chaplain services. The spiritual assessment was not performed by the RN or Social Worker. The Chaplain did not perform the spiritual assessment until 12/01/21.

Upon patient record review, 1 of 11 (Patient #2) did not evidence the plan of care was accurate for all medications. Patient #2-The plan of care 02/05/22 includes Heparin 5000 units/ml Inject 50,000 units sq q 12h. Upon interview, this is an error as the patient was never prescribed heparin injections.

Upon patient record review, 1 of 9 applicable (Patient # 1) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient #1- The IDT/Plan of care update for 3/10/22 is blank and does not include information from the patient's updated comprehensive assessment to note the patient's progress towards outcome/goals from the plan of care. The update only includes the signatures of those in attendance.

Upon patient record review, 1 of 5 applicable (Patient #1) did not have evidence that before the recertification period for each patient, the medical director or physician designee must review the patient's clinical information and provide written documentation that it is anticipated that the patient's life expectancy is 6 months or less. Patient #1- The recertification CTI on record written 02/17/21 from the medical director does not include a physician's brief narrative explanation of the clinical findings that supports a life expectancy of 6 months. The narrative on record is lengthy nursing visit documentation with findings from the admission assessment.

Upon patient record review, 1 of 11 (Patient #3) did not have evidence that each patient record contains: • A Signed election statement in accordance with 418.24 Patient #3- The election statement on record does not include the date of election. This section was left blank on the form. The election statement also did not include the relationship of the responsible party who signed the form.

Upon patient record review, 11 of 11 (Patient #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11) did not have evidence that all entries are legible, clear, complete, accurate and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Patient #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11-The records did not contain dates for the electronic signatures on records. Patient #1- On 02/25/22 the LVN documented the patient had a left heel pressure ulcer. Upon interview, this was a documentation error as the patient did not have a heel wound. Patient #7-On the 11/30/21 death visit note the nurse documented the date of the patients death as 11/01/21. The correct date of death was 11/30/21.

Upon patient record review, 1 of 1 applicable (Patient #7) did not have evidence that the hospice plan of care identifies the care and services that are needed and specifically identify which provider (nursing facility or hospice) is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care. Patient #7-The patient resides in a SNF. On 11/04/21 an order was received for a stage 2 coccyx wound to be cleansed with saline, patted dry, and apply zinc oxide to the wound daily. The order does not specify whether the facility nurse and/or the hospice nurse is responsible for the wound care.