Every finding on record at Community Home Care & Hospice, LLC

Upon patient record review 7 of 19 (Patients #1,#2,#3,#5,#8,#10,#14) 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: There was no evidence of a comprehensive spiritual assessment. Corrected on site. Patient 2: There was no evidence of a comprehensive spiritual assessment. Patient 3: There was no evidence of a comprehensive spiritual assessment. Patient 5: There was no evidence of a comprehensive spiritual assessment. Corrected on site. Patient 8: There was no evidence of a comprehensive spiritual assessment. Corrected on site. Patient 10: There was no evidence of a comprehensive spiritual assessment. Corrected on site. Patient 14: There was no evidence of a comprehensive spiritual assessment. Corrected on site.

Upon patient record review, 2 of 19 (Patients #11,#14) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications. Patient 11: The medical record contained nursing documentation 1/8/24 identifying patient use of oxygen. There was no evidence of oxygen included on the medication profile. Corrected on site. Patient 14: The medication profile contained oxygen with no delivery method. Corrected on site.

Upon patient record review, 4 of 19 (Patients #1,#2,#5#8) 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 1: The initial bereavement assessment was completed 11/17/23 with a start of care 11/10/23. Patient 2: The initial bereavement assessment was completed 2/7/24 with a start of care 2/1/24. Patient 5: The initial bereavement assessment was completed 2/7/24 with a start of care 2/1/24. Patient 8: The initial bereavement assessment was completed 11/6/23 with a start of care 10/31/23.

Upon patient record review, 4 of 19 (Patients #3,#4,#6,#14) 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 3: The medical record contained nursing documentation upon admission identifying patient is a high risk for falls. There was no evidence of problems, goals, and interventions related to fall safety. Patient 4: The medical record contained nursing documentation upon admission identifying patient is a high risk for falls. There was no evidence of problems, goals, and interventions related to fall safety. Corrected on site. Patient 6: The medical record contained nursing documentation upon admission identifying patient has dysphagia requiring a pureed diet and visits by speech pathologist. There was no evidence of problems, goals, and interventions related to dysphagia. Patient 14: The medical record contained nursing documentation upon admission identifying patient has a colostomy and is at high risk for falls. There was no evidence of problems, goals, and interventions related to colostomy care and fall safety. Corrected on site.

Upon patient record review, 3 of 19 (Patients #8,#11,#14) 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 8: The medical record contained a catheter order 1/31/24 that did not include instructions for change frequency and maintenance. Corrected on site. Patient 11: The medical record contained nursing documentation 1/8/24 identifying patient use of oxygen. There was no evidence of an order for oxygen dose, frequency, and delivery method. Corrected on site. Patient 14: The medical record contained an order for oxygen with no delivery method. Corrected on site.

Upon patient record review, 3 of 19 (Patients #5,#7,#12) 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 5: The medical record contained nursing documentation upon admission identifying patient use of a commode and wheelchair. There was no evidence of an order for the listed DME included in the plan of care. Corrected on site. Patient 7: 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 in the plan of care. Corrected on site. Patient 12: The medical record contained nursing documentation upon recertification 1/24/24 identifying patient use of a commode, bedside table, and nebulized medications. There was no evidence of an order for the listed DME included in the plan of care. Corrected on site.

Upon client record review, 4 of 19 (Patients #3,#5,#10,#13) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 3: The medical record contained an ordered nursing frequency of twice weekly. There was no evidence of a second visit completed the week of 1/28/24. Patient 5: The medical record contained an ordered nursing frequency of twice weekly. There was no evidence of a second visit completed the week of 1/28/24. Patient 10: The medical record contained an ordered nursing frequency of twice weekly. There was no evidence of a second visit completed the week of 1/21/24. Patient 13: The medical record contained an ordered nursing frequency of twice weekly. There was no evidence of second visits completed the weeks of 12/31/23 and 2/4/24.

Upon patient record review 2 of 19 (Patients #3,#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 3: The medical record contained an ordered aide frequency of three times weekly. There was no evidence of third visits completed the weeks of 12/31/23, 1/21/24, and 2/4/24. Patient 4: The medical record contained an ordered aide frequency of once weekly. There was evidence of three visits completed the week of 2/4/24.

Upon observation, there was no evidence the hospice documents and demonstrates viable and ongoing efforts to recruit and retain volunteers. There was no evidence of effort to recruit volunteers since February 2023.

Upon personnel record review, 1 of 12 (Personnel #2) did not have evidence the alternate administrator's personnel record verifies that: • The employee has appropriate education and experience requirements • There is a signed job description for this role • The employee has been orientated to this role Personnel 2: There was no evidence of signed job description and orientation to role of alternate administrator and alternate director of patient care.

Upon patient client record review, 2 of 19 (Patients #3,#4) did not have evidence that each patient record contains Advance Directives. Patient 3: The medical record identified the patient code status as DNR. There was no evidence of a copy of the DNR order in the medical record. Patient 4: The medical record identified the patient code status as DNR. There was no evidence of a copy of the DNR order in the medical record.

Upon patient client record review, 1 of 19 (Patient #18) did not evidence that each patient record contains physician orders. Patient 18: There was no evidence of an order to discharge patient for extended prognosis.

Upon client record review, 2 of 19 (Patients #8,#11) 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 8: The medical record contained an order for an indwelling catheter 1/31/24 that did not specify facility and hospice responsibilities for catheter changes and maintenance. Corrected on site. Patient 11: The medical record contained wound care orders 1/15/24 and 2/7/24 that did not specify facility and hospice responsibilities for care.