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

Upon patient record review 1 of 19 (Patient #4) 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 4 admitted 3/14/23, no evidence of an initial spiritual assessment.

Upon patient record review, 1 of 19 (Patient #10) 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 10 medication profile included Naloxone 4mg 1 spray as needed, no evidence of a frequency.

Upon patient record review, 5 of 19 (Patient #1, 2, 5, 6, 7) did not have evidence that each patient and family received education and training provided as appropriate to their responsibilities for the care and services identified in the plan of care. Patient 1 no evidence of education provided on the following medications: Tylenol, Levsin, lorazepam, and ondansetron. Patient 2 no evidence of education provided for tramadol. Patient 5 no evidence of education provided on the following medications: oxycodone, Bisacodyl, fleet enema, ondansetron, Compazine, and Seroquel. Patient 6 no evidence of education provided for mirtazapine. Patient 7 no evidence of education provided on the following medications: hydrocortisone, nystatin, Anbesol, lorazepam, Tamsulosin, Debrox, amlodipine, milk of magnesium, hyoscyamine, and ondansetron.

Upon patient record review, 4 of 19 (Patient #4, 5, 6, 8) 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 4 and 8 nursing documentation documents evidence of high risk for aspiration, no evidence of aspiration precautions. Patient 5 Nursing visits document N/V and medications for nausea and vomiting, no evidence of a care plan for nausea and vomiting. Patient 6 mechanical soft diet and nursing visits document high risk for aspiration. No evidence of aspiration precautions.

Upon patient record review, 2 of 19 (Patient #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 7 initial plan of care included order for 20fr foley with 10ml balloon, within the same care plan the interventions included 16-18fr foley with 10ml balloon. Order is not clear as to the size of the foley. Patient 10 order for Naloxone 4mg 1 spray as needed, no evidence of a frequency.

Upon patient record review, 1 of 19 (Patient #3) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient 3 initial plan of care included orders for oxygen DME and a care plan for oxygen however no orders for oxygen, the patient had refused the oxygen and the orders for the DME and care plan for oxygen were not needed.

Upon client record review, 2 of 19 (Patient #1, 12) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 1 initial plan of care included order to check pulse ox upon admission and at recertification. There is a pulse ox documented on 9/3/24. No evidence of a pulse ox documented for the 6/28/24 or 8/27/24 recertifications. Patient 12 admitted on 7/29/24. Initial plan of care included order for SW 1m1 eval, then order on 8/1/24 for SW frequency effective 8.2.24 of 1m1, 2m2 and 3prn. No evidence of a SW visit in July and SW visit completed on 8/1/24 without an order for this visit.

Upon patient record review, 6 of 19 (Patient #1, 3, 4, 9, 11, 12) 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, 3, 12 plan of care includes aspiration precautions, no evidence of aspiration precautions on the aide care plan. Patient 4 nursing documentation of aspiration risk, no evidence of aspiration precautions on the aide care plan. Patient 9 plan of care includes aspiration precautions and patient is on Eliquis, no evidence of aspiration or bleeding precautions on the aide care plan. Patient 11 plan of care includes aspiration and fall precautions, no evidence of aspiration or fall precautions on the aide care plan.

Upon patient record review 1 of 19 (Patient #2) 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 2 aide care plan 9/13/24 included bed bath weekly. Aide visits on September 10, 13, 17, 20, 24, 27, 30, and October 4, 8, 11 all document bed bath performed.

Upon patient record review, 4 of 13 (Patient #1, #2, #4 and #10) 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. Patient #1,2,10 initial and subsequent plans of care included Oxygen 2-5LPM. No evidence of a route of administration on medication profile. Patient #4 RN visit on 10/22/21 documented Tylenol for pain. No evidence of Tylenol on medication profile.

Upon patient record review, 7 of 13 (Patient #1, #2, #5, #6, #8, #10 and #13) did not have evidence that the plan of care included all problems identified in the initial and/or comprehensive assessments. Patient #1 initial plan of care included functional limitation of legally blind and patient on Aspirin as blood thinner for cardiac disease. No evidence of goals and interventions for problems identified associated with visual challenges and risk for bleeding on plan of care. Patient #2 initial plan of care included diagnosis of dysphagia. No evidence of aspiration precautions or goals and interventions for aspiration precautions. Patient #5 initial plan of care included diagnosis of dysphagia and heart failure. RN visit on 10/26/21 documented dysphagia and choking 1x/week, and 2 ER visits within the last 6 months due to chest pain and shortness of breath. No evidence of aspiration precautions or goals and interventions for aspiration precautions. No evidence of goals and interventions for identified cardiac disease. Patient #6 initial plan of care included Aspirin. No evidence of bleeding precautions or goals and interventions for identified bleeding risk. Patient #8 initial plan of care included cardiomegaly, hypertension with heart failure, atrial fib, and heart failure. No evidence of goals and interventions for identified cardiac conditions. Patient #10 initial plan of care included Aspirin. No evidence of bleeding precautions or goals and interventions for identified bleeding risk. Patient #13 initial plan of care included Aspirin and cardiac diagnoses of hypertension and cardiomyopathy. No evidence of bleeding precautions or goals and interventions for identified bleeding risk or cardiac conditions.

Upon patient record review, 4 of 13 (Patient #1, #2, #4 and #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 #1,2,10 initial and subsequent plans of care included Oxygen 2-5LPM. No evidence of route of administration. Patient #4 RN visit on 10/22/21 documented Tylenol for pain. No evidence of an order for Tylenol.

Upon client record review, 2 of 13 (Patient #3 and #5) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #3 order on 8/9/21 for Chaplain frequency effective 8/5/21 of 1 every2m2, 1m2, and 1prn. Chaplain visits made on 8/9/21 and 9/14/21. Patient #5 order on 9/9/21 for Social Work and Chaplain frequency effective 9/14/21 of 1m2, and 2prn. Social Work visit made on 10/13/21 and Chaplain visit made on 10/26/21. No evidence of Social Work or Chaplain visit in September or refusal of visit.

Upon patient record review, 7 of 12 applicable (Patient #1, #5, #6, #8, #9, #10 and #13) did not have evidence in the patient record that hospice aide assignments and duties include which tasks are to be provided and the frequency of those tasks. Patient #1 identified as high risk for aspiration and legally blind. No evidence of aspiration precautions or visual precautions on aide care plan. Patient #5 diagnosis of dysphagia. No evidence of aspiration precautions on aide care plan. Patient #6 on Aspirin as blood thinner. No evidence of bleeding precautions on aide care plan. Patient #8 on Aspirin as blood thinner and identified as high risk for falls. No evidence of bleeding or fall risk precautions on aide care plan. Patient #9 diagnosis of dysphagia. No evidence of aspiration precautions on aide care plan. Patient #10 on Aspirin as blood thinner and identified as high risk for falls. No evidence of bleeding or fall risk precautions on aide care plan. Patient #13 on Aspirin as blood thinner. No evidence of bleeding precautions on aide care plan.

Upon patient record review 3 of 12 applicable (Patient #5, #10 and #11) did not have evidence documentation in the patient record that a hospice aide provides services that are ordered by the IDG and included in the plan of care. Patient #5 aide care plan dated 10/19/21 included bathing bed bath every visit. Aide visit on 10/27/21 for bed bath documented chair bath. Aide visit on 10/29/21 for bed bath documented partial bath. No evidence of communication with RN to change care plan for these visits. Patient #10 aide care plan dated 7/21/21 included shampoo every visit. Aide visit on 8/12/21 for shampoo documented not needed this visit. No evidence of refusal or communication with RN. Patient #11 aide care plan dated 10/15/21 included bathing shower as every visit. Aide visit on 10/22/21 for bathing shower documented no - bed bath. No evidence of communication with RN.

Upon patient client record review, 1 of 13 (Patient #5) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Patient #5 RN visit on 10/5/21 documented Tylenol in use for pain. No evidence patient taking Tylenol or evidence of an order for Tylenol. When interviewing RN stated that was entered in error. RN documented clarifying note during survey.