Every finding on record at Conway Hospital Inc

Upon patient record review 1 of 14 (Patient #4) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Pt #4 - Admitted to hospice services 4/11/24. Spiritual care assessment completed on 4/18/24 - day 7.

Upon patient record review 1 of 14 (Patient #2) 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 Pt #2 - Spiritual care participated in a Military recognition ceremony presentation of a certificate, etc. Spiritual care escorted group taking patient back to room. Documentation states "patient non responsive. SCC will reach out to PCG for more information." No evidence that spiritual care needs were assessed or addressed.

Upon patient record review, 4 of 14 (Patient #1,2,3,6) 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 Pt's 1,2 - Oxygen therapy not included on medication profile (Corrected on site) Pt #2 - During home visit noted PCG giving patient Baby ASA 81 mg q HS not noted on medication list. Pt # 3 - Facility patient medication chart showed orders 3/27/24 to include Barrier cream to buttock q shift and Dulcolax 10 mg. 1 rectal suppository q 72 hours prn constipation. These are not listed on medication list. Pt # 6 - On home visit med review with pts husband stated that patient was on Baby ASA 81 mg. QD. Not on medication list

Upon patient record review, 3 of 14 (Patient #3, 4, 5) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual's attending physician, if any) • Changes that have taken place since the initial assessment • Information on the patient's progress toward desired outcomes • Reassessment of the patient's response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days Pt #3, 4, 5 - no evidence that the IDG notes discussed progression towards outcomes and response. 4/18/24 -Area IDG mtg notes : goals met, continue present goals, and revise goals along with Pt/PCG plan for providing care and issues for next IDG meeting all left blank. (Corrected on site)

Upon patient record review, 1 of 14 (Patient #1) 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. Pt #1- Pt had a foley catheter. No evidence of problems/goals/interventions related to catheter on plan of care. (Corrected on site) Pt had skin care needs on assessment - no identified problems/goals/interventions on care plan related to alteration in skin care (Corrected on site)

Upon patient record review, 4 of 14 (Patient #1,2,3,6) 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. Pt's #1, 2 - No evidence of an order for oxygen. (Corrected on site) Pt #1 - no evidence of order for a foley catheter (corrected on site) Pt #2 -During home visit noted PCG giving patient Baby ASA 81 mg q HS not noted order. Pt # 3 - Facility patient medication chart showed orders 3/27/24 to include Barrier cream to buttock q shift and Dulcolax 10 mg. 1 rectal suppository q 72 hours prn constipation. These did not have evidence of orders. Pt # 6 - On home visit med review with pts husband stated that patient was on Baby ASA 81 mg. QD. No evidence of orders.

Upon client record review, 2 of 14 (Patient #2,8) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Pt #2 - RN documented on AV "Pt had a double lumen picc line to right upper arm that this RN removed." No order noted in EMR for PICC line removal (corrected on site). Pt #8 - No evidence of physician orders for RN, SW, or SCC visits.

Upon patient record review, 2 of 14 (Patient #6,14) 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 Pt 6, - Aide assignments are not specific to patient but generic and are assigned for (M,T,W,Th,F,S,Su)on all tasks (Corrected on site) Pt 14 - Aide assignments are not specific to patient but generic and are assigned for (M,T,W,Th,F,S,Su)on all tasks

Upon patient record review 10 of 14(Patient #1,2,3,6,8,9,10,11,12,14) 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 Pt # 1,2,3,8,9,10,11,12,14 - Tasks ordered for (M,T,W,Th,F,S,Su) Being cared for in residential hospice care, aide services were BID. Patients # 1,2,3,6,8,9,10,11,12,14. When a task was not completed no description of why task not completed nor that nurse was notified. Example: Document BM q shift; Document Output q shift; Perineal care with each incontinent episode; etc.... (M,T,W,Th,F,S,Su) Contact sheet checked off acknowledged; box for completed was blank with no comment in the comment section. Pt #6 - no order for aide services. 3/28/24 -Aide was seeing patient 2x week. (Corrected on site) In addition, Home care patient - aide service tasks ordered for (M,T,W,Th,F,S,Su) when seen 2 x week Pt #9 - aide visit order was 3xweek and 2 prn Visits made 1/30, 2/2, 2/6, 2/13, 2/20, 2/22, 2/26, 3/1 - 2 x week visits made

Upon observation, there was no evidence BOD/governing body minutes reflect the involvement in the hospice's management and administration of its resources to provide hospice services to patients and families. Agency is under the CMC umbrella and has clear lines of responsibility for it's hospice program however, there was not evidence presented of governing body meetings but rather staff meetings.

Upon patient client record review, 1 of 14 (Patient #4) 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. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Pt #4 - No documentation in patient record for 4/18/24 for SW visit that the RN and SCC all went together on this visit. Documented big discussion between patient and PCG with SW, SCC, and RN. Agency ED states policy is documentation is required to be completed within 24 hours. (Corrected on site)