Every finding on record at Celestial Hospice Inc

Upon patient record review, 1 of 20 (Patient #13) 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 13: The patient was admitted for hospice services with a primary terminal diagnosis of Alzheimer's disease with confusion and safety concerns identified. There is no evidence of any care plans related to the patients cognitive status, the patient's safety, or the patient's self care deficits. (corrected onsite)

Upon client record review, 3 of 20 (Patient #6, 11, 14) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 6: SN visits are ordered with a frequency of 2 x weekly. There is evidence of a SN visit being made only once during the week of February 27, 2022, and no evidence of a missed visit notation. Patient 11: SN visits are ordered with a frequency of 2 x weekly; the patient has been seen by a SN only once weekly for the entirety for the hospice admission and no evidence of a visit the week of February 20, 2022. (corrected onsite). Patient 14: On 03.21.2022, a chaplain makes a home visit to provide SC services to the patient and family, without an order from the physician. (corrected onsite)

Upon observation and client record review, there was no evidence the hospice investigates all adverse events, incidents, accidents, variances or unusual occurrences that involve patient care and develops a plan of correction to prevent the same or similar event from occurring again. Patient 1: The patient record indicates ALF staff called the hospice on 03.24.2022 to notify that the patient had fallen and would be transported to the hospital for evaluation. However, the fall was not recorded in the hospice's incident tracking system.

Upon patient record review, 1 of 18 applicable (Patient #12) 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. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient 12: The HA care plan, dated 02.03.2022, indicates that linen should be changed if soiled, as needed. (corrected on site)

Upon patient record review 1 of 18 applicable (Patient #4) 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 4: HA visits are ordered with a frequency of 1 x weekly. There is no evidence of a HA visit being made during the weeks of February 20, 2022, or February 27, 2022, and no evidence of a missed visit notation.

Upon client record review, 1 of 1 applicable (Patient #18) did not have evidence that if a patient revokes the election of hospice care or is discharged from hospice in accordance with §418.26, the hospice must forward to the patient's attending physician: • A copy of the hospice discharge summary • The patient's clinical record, if requested Patient 18: There was no evidence of a completed discharge summary.