Every finding on record at Catholic Community Hospice of Northeast Ks LLC

Upon patient record review, 7 of 14 (Patients #1,#2,#4,#6,#7,#8,#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 1: The medication profile contained duplicative Miralax. Corrected on site. Patient 2,4,6,8,9: The medication profiles contained Miralax oral powder with no instructions for a diluent. Corrected on site. Patient 7: The medication profile contained atropine for secretions with an ophthalmic route. Corrected on site.

Upon patient record review, 3 of 14 (Patients #1,#4,#9) 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 medical record contained nursing documentation upon admission identifying patient is insulin dependent requiring blood glucose monitoring. There was no evidence of problems, goals, and interventions related to endocrine dysfunction. Corrected on site. Patient 4: The medical record contained physician documentation on the current benefit period identifying patient has dysphagia requiring a pureed diet and is a high risk for skin impairment. There was no evidence of problems, goals, and interventions related to dysphagia, a modified diet, and risk for skin impairment. Corrected on site. Patient 9: The medical record contained an order 11/21/23 for a pureed diet with honey thick liquids. There was no evidence of problems, goals, and interventions related to a diet modification. Corrected on site.

Upon patient record review, 1 of 14 (Patient #4) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient 4: The medical record contained an order for spiritual care frequency PRN only. Corrected on site.

Upon patient record review, 6 of 14 (Patients #2,#4,#6,#7,#8,#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 2,4,6,8,9: The medical records contained orders for Miralax oral powder with no instructions for a diluent. Corrected on site. Patient 7: The medical records contained orders for Miralax oral powder with no instructions for a diluent and atropine for secretions with an ophthalmic route. Corrected on site.

Upon patient record review, 1 of 16 (Patient #12) did not have evidence the hospice offers bereavement counseling that includes: • Making bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. Bereavement counseling also extends to residents of a SNF/NF or ICF/IID when appropriate and identified in the bereavement plan of care • Ensuring that bereavement services reflect the needs of the bereaved • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery Patient 12: The bereavement care plan did not contain the tasks for mailings or phone calls that have been conducted.

Upon patient record review, 2 of 14 (Patients #1,#9) 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: The aide care plan did not include bath task but had instructions for the aide to remove wound dressing for shower and notify facility nurse to reapply. Corrected on site. Patient 9: The medical record contained nursing documentation identifying patient required a transfer assist of two however, there were no instructions for transfer included in the aide care plan. Corrected on site.

Upon personnel record review, 13 of 16 (Personnel #1,#2,#3,#4,#5,#6,#7,#8,#9,#10,#11,#12,#13) did not have evidence that the hospice employees have received orientation on their specific job requirements. There was no evidence of orientation received upon hire in the personnel files.

Upon personnel record review, 1 of 16 (Personnel #3) did not have evidence that a skills competency assessment, specific to each discipline had been conducted for all personnel including volunteers initially during orientation. Personnel 3: There was no evidence of a skills competency assessment for role as an RN.

Upon patient client 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 medical record contained an election form identifying the patient representative elected to received the Notification of Non-Covered Items upon admission 6/21/22. The notification was not furnished until 7/5/22.

Upon patient client record review, 1 of 16 (Patient #1) did not have evidence that each patient record contains Advance Directives. Patient 1: The DNR in the medical record was not signed by a physician. Corrected on site.