Every finding on record at Cowboy Cares, Inc.

Upon patient record review 1 of 13 (Patient #8) 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. Patient 8: There was no evidence the comprehensive assessment included the required spiritual assessment elements. The only spiritual assessment completed by RN upon admission was brief identifying patient religion and need for spiritual care visit. Chaplain visited 9/6/22 and completed the comprehensive assessment, but it was after the 5 day requirement as the admission date was 7/29/22.

Upon patient record review, 3 of 13 (Patient #4, #9, #13) 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: There was no evidence the comprehensive assessment included the required spiritual assessment elements. The only spiritual assessment completed by RN upon admission was brief identifying patient religion and need for spiritual care visit. Patient 9: There was no evidence the comprehensive assessment included the required spiritual assessment elements. The only spiritual assessment completed by RN upon admission was brief identifying patient religion and need for spiritual care visit. Patient 13: There was no evidence the comprehensive assessment included the required spiritual assessment elements. The only spiritual assessment completed by RN upon admission was brief identifying patient religion and need for spiritual care visit. Chaplain contacted 10/17/22 with admission date of 10/3/22.

Upon patient record review, 6 of 13 records (Patients #1,#2,#3,#4,#7,#13) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications. Patient 1: The medication profile contained ciclopirox gel 7.7mg/g strength with no dose defined, PRN frequency with no parameters for how often it can be applied, and no indication for PRN use. The medication profile contained morphine solution with strength of 20mg/5ml with no dose defined and PRN frequency with no parameters for how often morphine can be administered. The medication profile also contained ativan PRN for frequency with no parameters for how often ativan can be administered. Corrected on site. Patient 2: The medical record contained nursing documentation upon admission identifying patient use of oxygen. There was no evidence of the oxygen listed on the medication profile. Patient 3: The medical record contained nursing documentation upon admission identifying patient use of oxygen. There was no evidence of oxygen listed on the medication profile. Patient 4: The medical record contained nursing documentation 7/27/22 identifying patient use of IV for morphine administration. There was no evidence of morphine listed on the medication profile. Patient 7: The medical record contained nursing documentation upon admission identifying patient use of oxygen. There was no evidence of oxygen listed on the medication profile. Patient 13: The medication profile contained miralax oral powder with no instructions for a diluent. The profile also contained duplicative listing of fentanyl patches, one scheduled upon admission and one with increased dose listed as PRN. Nursing leadership verified the PRN was error and initial listing should have been discontinued.

Upon patient record review, 3 of 13 records (Patient #4,#8,#13) 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: The medical record contained nursing documentation 7/27/22 identifying patient had two IVs. There was no evidence of problems, goals, and interventions related to IV use and maintenance. Patient 8: The patient was on hospice service for heart failure. There was no evidence of problems, goals, and interventions related to cardiac dysfunction. Patient 13: The medical record contained nursing documentation upon admission identifying patient use of CPAP. There was no evidence of problems, goals, and interventions related to CPAP use or respiratory dysfunction.

Upon patient record review, 5 of 13 records (Patients #1,#2,#8,#9,#13,) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient 1: The medical record contained an order for social work frequency for evaluation upon admission and four PRNs for ongoing support, and an order for spiritual care frequency for evaluation upon admission and five PRNs for ongoing support. There was no evidence of updated orders on the care plan after the initial assessment for anticipated ongoing needs. Corrected on site. Patient 2: The medical record contained orders for social work and spiritual care frequencies of five PRNs. There was no evidence of updated orders on the care plan for anticipated ongoing needs. Patient 8: The medical record contained an order for social work frequency for evaluation upon admission and four PRNs for ongoing support, and an order for spiritual care frequency for evaluation upon admission and five PRNs for ongoing support. There was no evidence of updated orders on the care plan after the initial assessment for anticipated ongoing needs. Patient 9: The medical record contained an order for social work frequency for evaluation upon admission and four PRNs for ongoing support, and an order for spiritual care frequency for evaluation upon admission and five PRNs for ongoing support. There was no evidence of updated orders on the care plan after the initial assessment for anticipated ongoing needs. Patient 13: The medical record contained an order for social work frequency for evaluation upon admission and four PRNs for ongoing support, and an order for spiritual care frequency for evaluation upon admission and five PRNs for ongoing support. There was no evidence of updated orders on the care plan after the initial assessment for anticipated ongoing needs.

Upon patient record review, 7 of 13 records (Patients #1,#2,#3,#4,#7,#11,#13) 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: The medical profile contained an order for ciclopirox gel 7.7mg/g strength with no dose defined, PRN frequency with no parameters for how often it can be applied, and no indication for PRN use. The medical profile contained an order for morphine solution with strength of 20mg/5ml with no dose defined and PRN frequency with no parameters for how often morphine can be administered. The medical profile also contained an order for ativan PRN for frequency with no parameters for how often ativan can be administered. Corrected on site. Patient 2: The medical record contained nursing documentation upon admission identifying patient use of oxygen. There was no evidence of an order for oxygen in the medical record. Patient 3: The medical record contained nursing documentation upon admission identifying patient use of oxygen. There was no evidence of an order for oxygen in the medical record. The record also contained an order for catheter change frequency. There was no evidence of an order for catheter size, type, and maintenance in the medical record. Patient 4: The medical record contained nursing documentation 7/27/22 identifying facility RN stated IV present for morphine as needed. There was no evidence of an order for morphine in the medical record. Patient 7: The medical record contained nursing documentation upon admission identifying patient use of oxygen. There was no evidence of an oxygen order in the medical record. Patient 11: The plan of care contained documented use of a foley catheter. There was no evidence of an order for catheter type, size, and maintenance. Patient 13: The medical record contained an order for miralax oral powder with no instructions for a diluent. The record also contained an order for a fentanyl patch listed as PRN.

Upon patient record review, 7 of 13 records (Patients #1,#3,#4,#6,#7,#12,#13) 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: Upon observation during home visit, there was identified use of a motorized scooter for ambulation. There was no evidence of the scooter included as DME on the plan of care. Corrected on site. Patient 3: The medical record contained nursing documentation upon admission identifying patient use of over bed table, wheelchair, geri-chair/recliner, nebulizer. There was no evidence of the table, wheelchair, geri-chair/recliner, and nebulizer included as DME and supplies on the plan of care. Patient 4: The medical record contained nursing documentation upon admission identifying patient use of air mattress, bed, table, bedpan, egg crate, and wheelchair. There was no evidence of the mattress, bed, table, and bedpan included as DME and supplies on the plan of care. Patient 6: The medical record contained nursing documentation upon admission identifying patient use of cane and walker. There was no evidence of the cane and walker included as DME on the plan of care. Patient 7: The medical record contained nursing documentation upon admission identifying patient use of a shower chair and oxygen. There was no evidence of a shower chair and oxygen included as DME on the plan of care. Patient 12: The medical record contained nursing documentation upon admission identifying patient use of a walker. There was no evidence of the walker included as DME on the plan of care. Patient 13: The medical record contained nursing documentation upon admission identifying patient use of a cane and CPAP. There was no evidence of the cane and CPAP included as DME on the plan of care.

Upon patient record review, 5 of 13 records (Patients #2,#5,#9,#10,#12) did not have evidence in the patient record that hospice aide assignments and duties are: • 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 2: The aide care plan contained tasks for toileting, transfer, ambulation, dressing, feeding, and bathing with frequencies PRN. Patient 5: The aide care plan contained tasks for toileting, transfer, dressing, feeding, and bathing with frequencies PRN. Patient 9: The aide care plan contained tasks for ambulation, toileting, and transfer with no frequency, and task of feeding and housekeeping with frequencies PRN. Patient 10: The aide care plan contained task of ambulation with no frequency and task of feeding PRN. Patient 12: The aide care plan contained tasks for ambulation, toileting, transfer, dressing, feeding, and bathing with frequencies PRN.

Upon patient record review, 1 of 13 records (Patient #3) did not have evidence that the medical director or physician designee provides written certification that it is anticipated that the patient's life expectancy is 6 months or less if the illness runs its normal course. Patient 10: The medical director signed the CTI 5/11/22 with patient admission 5/5/22. There was no evidence of a timely verbal certification received.

Upon patient client record review, 2 of 13 records (Patients #4, #6) 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. Patient 4: The medical record contains two different forms for election of benefit, one containing right to receive notice of hospice non-covered items, and one without. One form states patient has primary but declines to utilize and elects the hospice medical director for ongoing needs while the other form identifies a physician at the hospital as their elected attending physician. Patient 6: The medical record contained transfer documentation to another hospice agency signed 6/29/22. The documentation did not contain when the discharge was to occur. Discharge was documented as occurring 6/30/22. Documentation was not clear on the date of discharge.