Every finding on record at Compassionate Care Hospice of Clifton, L.L.C.

Upon patient record review, 2 of 23 (Patient #7,#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 7:The medical record contains nursing documentation on 6/14/23 and 7/20/23 that the patient was given Ibuprofen for joint pain. There is no evidence of Ibuprofen on the patients medication profile. Corrected on site. Patient 10:The patient's medication profile includes an entry for oxygen to be delivered at 5-10 liters per minute vis nasal cannula as needed. There is nursing documentation on 7/5/23 that instruction on use of mask for oxygen delivery was provided. There is no evidence on the medication profile for delivery method of mask or titration instructions for oxygen. Corrected on site.

Upon patient record review, 1 of 23 (Patient #5) 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 5:The patient was admitted on 7/12/23. There is no evidence of a bereavement risk assessment completed until 7/19/23.

Upon patient record review, 2 of 23 (Patient #1,#23) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient 1:The medical record contains documentation by the nurse on 8/9/23 that the patient was hypertensive and had not received his morning medication. There is no indication of follow up and further assessment by the nurse. Patient 23:The medical record contains documentation by the nurse on 7/31/23 that the patient was complaining of abdominal pain and felt like she may need to have a bowel movement. The hospice nurse asked the facility nurse to give ordered Milk of Magnesia. There is no indication of follow up for pain or constipation until 8/7/23.

Upon patient record review, 3 of 23 (Patient #9,#10,#15) 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 9:The patients medical record contains an order on admission for oxygen via nasal cannula at 2-5 liters per minute via nasal cannula as needed. There is no evidence of care plan problems with goals and interventions related to management of oxygen use. Corrected on site. Patient 10:The medical record contains MSW documentation on 8/30/23 of PRN visit made to patient upon request of the patient due to decreasing finances and the need to move into home with son. There is no evidence of problems, goals and interventions to reflect the assessed needs of the patient and family. Corrected on site. Patient 15:The medical record contains nursing documentation of patient decline and transitioning on 5/5/23. There is no evidence of problems goals and interventions for imminence.

Upon patient record review, 4 of 23 (Patient #7,#9,#10,#18) 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:The medical record contains nursing documentation on 6/14/23 and 7/20/23 that the patient was given Ibuprofen for joint pain. There is no evidence of an order for Ibuprofen on the patients plan of care. Corrected on site. Patient 9:The patient's plan of care includes an order dated 9/18/23 for sacral wound to clean with normal saline, apply calmoseptine and cover with Opti foam. There is no evidence of the frequency of wound care or who is to perform care in the order. Corrected on site. Patient 10:The patient's plan of care includes an order for oxygen to be delivered at 5-10 liters per minute vis nasal cannula as needed. There is nursing documentation on 7/5/23 that instruction on use of mask for oxygen delivery was provided. There is no evidence in the plan of an order for use of mask for oxygen delivery or titration instructions for oxygen. Corrected on site. Patient 18:The patient's plan of care includes an order on 9/15/23 for wound care to right lower leg of cleanse with 1/4 Dakin's, rinse with normal saline, pat dry, apply Flagyl and cover with ABD pad and secure with gauze. There is no evidence in the plan of care for the frequency of wound care and who is to perform. Corrected on site.

Upon patient record review, 3 of 23 (Patient #1,#2,#7) 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:The medical record contained nursing documentation upon admission identifying use of walker. There is no evidence of walker included in the plan of care. Corrected on site. Patient 2:The medical record contained nursing documentation upon admission identifying use of bed rails and pressure relief mattress. There is no evidence of bed rails or pressure relief mattress included in the plan of care. Corrected on site. Patient 7:The medical record contained nursing documentation upon admission of Nebulizer equipment and supplies, walker and cane. There is no evidence that nebulization equipment and supplies, walker and cane are included in the plan of care. Corrected on site.

Upon client record review, 3 of 23 (Patient #4,#21,#22) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 4: The visit frequency for the chaplain was indicated as 4x/month. There is no evidence of 4 visits for 8/7/23 - 8/31/23. Patient 21:The visit frequency for the chaplain was indicated as 7x/month. There is no evidence of 7 visits from 6/16/23-6/30/23. The visit frequency for the medical social worker is indicated as 4x/month. There is no evidence of 4 visits from 6/16/23-6/30/23. Patient 22:The visit frequency for the chaplain is indicated as 5x/month. There is no evidence that 5 visits were completed from 7/1/23-7/31/23.

Upon patient record review, 2 of 23 (Patient #7,#21) 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 7:The aide plan of care did not include universal precautions. Corrected on site. Patient 21:The aide plan of care indicated the task of monthly weights. Patient is unable to stand or bear weight. This was documented as unable to perform and not updated on the aide care plan. Corrected on site.

Upon patient record review 3 of 23 (Patient #19,#20,#22) 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 19:The aide plan of care indicated the visit frequency of 5 visits per week. There is no evidence of documentation of visits for the week of 9/8/23. Patient 20:The aide plan of care indicates the aide visit frequency to be 1 visit on week 1 and 3 visits on week 2. There is no evidence of documented visits on week 1 and 2 visits documented on week 2. Patient 22:The aide plan of care indicated the visit frequency of 2 visits per week. There is documented visits on 7/6/23 and 7/14/23 but no other visits documented in record. Corrected on site.

Based on staff interviews, review of one (1) of five (5) medical records of patients with orders for oxygen (#1), and review of facility policy and procedure, it was determined the facility failed to provide oxygen in accordance with the patient's plan of care. Findings include: Reference: Facility policy titled, "Hospice Plan of Care," states, "... The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including the following: ... Medical supplies and appliances necessary to meet the needs of the patient." 1. Review of Medical Record #1 revealed the following: a. The patient was admitted to the facility on 9/7/21. The hospice certification period was from 9/7/2021 to 11/5/2021. b. The Physician Orders on 'The Hospice Certification and Plan of Treatment,' under the section titled, Orders of Discipline and Treatment, stated, "Hospice Nurse to instruct regarding oxygen management include administration at 2L (liters)/Min (minute) via nasal cannula (continuous/PRN), care of equipment and safety" c. The Physician Orders on 'The Hospice Certification and Plan of Treatment,' under the section titled, Medications, stated, "O2 - Oxygen 2 Liter O2 - PRN/PRN Start Date 9/8/2021 Reason: Dyspnea Instructions: Inhale 2 Liters of Oxygen for Dyspnea ..." d. The Visit Note Report, dated 9/7/21, under the section titled, Narrative, stated, "... DTR (daughter) agreed to ordering oxygen" e. The Visit Note Report, dated 9/14/21, under the section titled, Narrative, states, "... The oxygen arrived and patient was placed on oxygen at 2 liters ..." 2. The patient did not receive the oxygen until six (6) days after the oxygen was ordered. 3. The above findings were confirmed with Staff #1 and Staff #2 on 2/24/22 at 2:00 PM.