Every finding on record at Clear Soul Hospice Inc

Upon patient record review, 1 of 14 (Patient #3) 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 #3, Upon home visit patient was laying in a hospital bed. No evidence of hospital bed documented on plan of care under DME.

Upon client record review, 1 of 14 (Patient #10) did not have evidence that the IDG in collaboration with the attending physician reviewed, revised and documents the individualized plan as frequently as the patient's condition requires but no less frequently then every 15 calendar days. Patient #10, There was no evidence of a signature for MSW on IDG meeting note dated 4/28/25. The discipline weas actively involved with the patient therefore there was no evidence of collaboration since there was no signature to validate participation.

Upon patient record review, 3 of 5 (Patient #1, #2 and #3) 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: This patient had a side rails on bed and bedside table. These items were not included on the Plan of Care. Patient #2: This patient had a bed with side rails. This item was not included on the Plan of Care. Patient #3: This patient had a bed side table. This item was not included on the Plan of Care.

Upon patient record review 3 of 5 (Patient #1, #4, #5) 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 1: On record review there was no evidence of a Spiritual assessment. Consultant later brought in copy for date of 3/11. Corrected on site. Patient 4: On Soc the SC assessment was started but incomplete. There was no evidence of a completed Spiritual care assessment. Patient 5: On Soc the SC assessment was started but incomplete. There was no evidence of a completed Spiritual care assessment.

Upon patient record review, 4 of 5 records (Patient #1, #3, #4, #5) 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: Order dated 3/9/2022 0900 am Oxygen inhalation a 2LPM via nc as needed for shortness of breath. 2nd order dated for 3/9/2022 0900am includes O2 2L continuous via NC for Shortness of breath. Per medication profile 3/9/2020 Oxygen 2L continuous via nc for SOB. In SOC nurses note includes O2 2LPM via NC for no more than 2 hours per day. There was no evidence of a clear order for O2. Corrected on site. Order 3/9/2022 Lidocaine 4% topical cream 3x day as needed for pain apply thin layer to affected area. There is no evidence of an affected area. Corrected on site. Patient 3: Order dated 3/9/2022 included Diclofenac Sodium 1% gel topical apply to painful areas as needed for generalized muscle pain. There was no evidence of frequency or site. Corrected on site. Order and Medication profile dated 3/9/2022 0900 included O2 2 L per min via n/c as needed for SOB. 2nd order dated 3/9/2022 0900 included O2 2L/min via nc as needed no more than 2h hours daily for SOB wheezing. There was no evidence of a clear O2 order. corrected on site. Patient 4: Order dated 1/12/2022 0900 includes O2 2L PM via nc as needed for SOB. 2nd order dated 1/12/2022 0900 included Oxygen 2-5 L/min via nc 2 hours a day as needed for SOB. The medication profile dated 1/12/2012 includes O2 2LPM via nc 2 hours a day as needed for SOB. There was no evidence of a clear O2 order. Patient 5: Order dated 1/11/2022 0900 O2 2L PM via nc as needed for SOB. No evidence of O2 on the medication profile.

Upon patient record review, 4 of 5 records (Patient #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 medications and treatments. Patient 1: Order dated 3/9/2022 0900 am Oxygen inhalation a 2LPM via nc as needed for shortness of breath. 2nd order dated for 3/9/2022 0900am includes O2 2L continuous via NC for Shortness of breath. Per medication profile 3/9/2020 Oxygen 2L continuous via nc for SOB. In SOC nurses note includes O2 2LPM via NC for no more than 2 hours per day. There was no evidence of a clear order for O2. Corrected on site. Order 3/9/2022 Lidocaine 4% topical cream 3x day as needed for pain apply thin layer to affected area. There is no evidence of an affected area. Corrected on site. Patient 3: Order dated 3/9/2022 included Diclofenac Sodium 1% gel topical apply to painful areas as needed for generalized muscle pain. There was no evidence of frequency or site. Corrected on site. Order and Medication profile dated 3/9/2022 0900 included O2 2 L per min via n/c as needed for SOB. 2nd order dated 3/9/2022 0900 included O2 2L/min via nc as needed no more than 2h hours daily for SOB wheezing. There was no evidence of a clear O2 order. corrected on site. Patient 4: Order dated 1/12/2022 09000 includes O2 2L PM via nc as needed for SOB. 2nd order dated 1/12/2022 0900 included Oxygen 2-5 L/min via nc 2 hours a day as needed for SOB. The medication profile dated 1/12/2012 includes O2 2LPM via nc 2 hours a day as needed for SOB. There was no evidence of a clear O2 order. Patient 5: Order dated 1/11/2022 0900 O2 2L PM via nc as needed for SOB. No evidence of O2 on the medication profile.

Condition of Participation: Core Services.

Upon personnel record review, 2 of 14 records (Personnel #9, #11) did not have evidence that the hospice routinely provide substantially all core services directly by hospice personnel (The hospice issues a W-2 form for the employee). These services including Medical Social Services and Nursing. Personnel 9: Found to be a contracted RN, assigned to Home visit with surveyor. Personnel 11: Found to be a contracted MSW, assigned to Home visit with surveyor. On arrival, the surveyor was given a list employees. When given list of Home visits and personnel the RN and MSW assigned were not on the employee list. The agency stated they were on call staff but were employees. After reviewing personnel file on day two, it was noted there was no W4s in the file. Agency then stated they were contracted staff.

Upon observation, there was no evidence a copy is provided of the hospice written policies and procedures on the management and disposal of controlled drugs to the patient or patient representative and family. The patient handbook describes written policies and procedures for disposal of controlled drugs. There is no evidence in the patients home folder or the patient record folder in office of a written policy, nor documentation that it was shared. There is no evidence the patient handbook with this information was shared with patients.

Upon observation, there was no evidence there is a copy of the CLIA certificate for the laboratory used for specimen testing. Corrected on site.