Every finding on record at Cedar Valley Hospice, LLC

Upon patient record review, 1 of 14 (Patient #4) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient 4: The medical record contained an election form identifying the patient representative chose an attending physician. The record profile at time of discharge states the attending is a nurse practitioner. There was no evidence of a change in physician form signed by the patient representative.

Upon patient record review 1 of 14 (Patient #8) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient 8: There was no evidence of a comprehensive spiritual assessment.

Upon patient record review, 3 of 14 (Patients #5,#6,#7) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications. Patient 5: The medication profile contained atropine drops ordered for increased secretions with ophthalmic route instead of oral/sublingual. Patient 6: The medication profile contained polyethylene glycol oral powder with no instructions for a diluent. Patient 7: The medication profile contained lidocaine topical patch with no area defined for administration.

Upon patient record review, 5 of 14 (Patients #1,#5,#6,#7,#10) 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: The medical record contained a wound care order 1/3/24 with no location identified. Patient 5: The medical record contained an order for atropine drops to treat increased secretions with ophthalmic route instead of oral/sublingual. Patient 6: The medical record contained an order for polyethylene glycol oral powder with no instructions for a diluent. Patient 7: The medical record contained an order for a lidocaine topical patch with no area defined for administration. Patient 10: The medical record contained nursing documentation starting 10/27/23 identifying patient use of an indwelling catheter. There was no evidence of an order for catheter type, size, and maintenance.

Upon patient record review, 4 of 14 (Patients #4,#5,#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 equipment and supply needs. Patient 4: The medical record contained an order for nebulized albuterol. There was no evidence of an order for nebulizer included as DME in the plan of care. Paitent 5: The medical record contained nursing documentation 11/9/23 identifying patient use of a hospital bed and wheelchair, and documentation 12/4/23 identifying use of a walker. There was no evidence of orders for the listed DME included in the plan of care. Patient 8: The medical record contained nursing documentation upon recertification 8/23/23 identifying patient use of bedrails. There was no evidence of an order for the rails included in the plan of care. Patient 9: The medical record contained nursing documentation upon admission identifying patient use of a nebulizer. There was no evidence of an order for the nebulizer included as DME in the plan of care.

Upon client record review, 1 of 14 (Patient #1) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 1: The medical record contained an order 12/27/23 stating social worker not needed. There was evidence of social work visits completed 1/4/24 and 2/5/24.

Upon patient record review, 3 of 14 (Patients #2,#4,#8) did not have evidence in the patient record that hospice aide assignments and duties are: • 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. Patient 2: The medical record contained nursing documentation 1/23/24 identifying patient resulted an injury during transfer to Broda chair. The aide care plan contains task to shower with no task for dressing, utilizing Broda chair, or instructions for assistance needed with transfer. Corrected on site. Patient 4: The medical record contained an order for a Broda chair 10/3/23 and nursing documentation 11/28/23 identifying patient is a assist of 2 with transfers. The aide care plan contained a task to shower with no instructions to utilize Broda chair or instructions for assistance needed with transfer. Patient 8: The aide care plan contained tasks to obtain weight, shower every other visit and sponge bathe every other visit. There were no tasks for dressing, transfer, or ambulation needs.

Upon patient record review 1 of 14 (Patient #8) 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 8: The medical record contained aide documentation for all visits stating both sponge bath and shower were given every visit. Task was to complete each bathing type every other visit.

Upon patient record review, 2 of 14 (Patients #4,#9) 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 4: The medical record contained a CTI with no narrative for benefit period 8 starting 12/17/23. Patient discharge date was 1/5/24. Agency verified patient was not billed for since 9/30/23. Patient 9: no narrative and signature for benefit period 3 starting 11/29/23. Agency confirmed patient was not billed from 9/30/23.

Upon patient client record review, 3 of 14 (Patients #4,#5,#6) did not evidence that each patient record contains physician orders. Patient 4: The medical record contained orders to discharge patient on 12/7/23 and 12/13/23 followed by an order to continue services through appeal 12/18/23. There was no evidence of an order to discharge after the appeal process. Patient discharged 1/5/24. Patient 5: The medical record contained signed transfer forms for discharge. There was no evidence of an order to discharge from hospice services. Patient 6: The medical record contained documentation identifying patient discharged due to move out of service area with admission to non-contracted hospital. There was no evidence of an order to discharge from hospice services.

Upon client record review, 1 of 14 (Patient #9) did not have evidence that a written hospice plan of care is established and maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided is in accordance with this hospice plan of care. Patient 9: The medical record contained an order for spiritual care once weekly. There was no evidence of a spiritual care visit completed the weeks of 10/8/23 and 11/12/23.

Upon patient record review, 1 of 14 (Patient #3) did not have evidence that the hospice provided the following information: • The most recent hospice plan of care specific to each patient • Hospice election form and any Advance Directives specific to each patient • Physician certification and recertification of the terminal illness specific to each patient • Names and contact information for hospice personnel involved in hospice care of each patient • Instructions on how to access the hospice's 24-hour on-call system • Hospice medication information specific to each patient • Hospice physician and attending physician (if any) orders specific to each patient Patient 3: There was no evidence of the hospice election form or names of hospice personnel in the patient's hospice binder at the facility.