Every finding on record at Crestline Hospice, Inc

Upon patient record review, 1 of 14 (Patient #5) 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 #5: Patient admitted 12/8/23 with metastatic rectal cancer. He had indwelling Foley Catheter 14 Fr, 10cc balloon. He had colostomy (Nov 2023). There were no related problems, goals interventions included in IDG Plan of Care.

Upon patient record review, 3 of 14 (Patient #2, 9, 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 #2: 12/05/23: Initial orders included Stage 3 coccyx - Cleanse with wound cleanser and pat dry. Apply calcium alginate. Cover with hydrocolloid wound dressing. Wound care 3x/week OR as needed without qualifying reason for PRN. 12/17/23 wound care order for Right rectal Stage #2 wound. Hospice SN will clean area with wound spray, pat dry. Apply zinc oxide based ointment liberally. Change diaper if needed TWO times a week and as needed which is an unclear frequency. 12/17/23 Sacrum stage #2. Hospice SN will clean TWO a week and as needed with wound spray pat dry which is an unclear frequency. Patient #9: 11/27/23 Cleanse wounds to skin tear left forearm with wound cleanser, pat dry, apply alginate, then cover with dry dressing. Change every 7 days or as needed if dressing becomes soiled or dislodged ("or" should be and. Alginate should be specific). Patient #10: 10/26/23 order. New wound care order. Cleanse stage II pressure ulcer to coccyx area with NS or wound cleanser, pat dry. Apply alginate and cover with bordered dressing. Change every 3 day or as needed if dressing become soiled or dislodged. May be performed by SN or CG ("or" should be and. Alginate should be specific).

Upon client record review, 4 of 14 (Patient #2, 5, 6, 10) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #2: 12/14/23 physician order for ST evaluation r/t dysphagia. Evaluation performed 12/29/23. There was a follow-up/discharge visit 1/10/24, however there was no evidence of a physician order for the follow up visit. Patient #5: Patient had Foley catheter change 12/27/23. Foley catheter changed during visit with clear yellow urine return. Tolerated well. 16 Fr. There is no order for Foley catheter changes. Patient #6: 12/21/23 physician order for PT Evaluation. Another order 1/5/24 PT order received from Dr. Greer for evaluation to determine if treatment is warranted. There was no evidence these were completed. Patient #10: Patient record includes volunteer visit notes for Sept., Oct. and Nov, 2023. There were no notes beyond November. There is no physician order to start volunteer and no physician order to discontinue.

Upon patient record review 1 of 14 (Patient #1) did not have evidence that the IDG ensures that the care and services provided are based on all assessments of the patient and family needs. Patient #1: MSW 12/19/23 assessment noted need for volunteer and emailed VC who left message for family. There was no evidence of follow up, refusal documented or an order.

Upon patient record review, 1 of 14 (Patient #1) 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: SOC 12/11/23. Patient had history of fall resulting in fracture, hospitalization and rehab. HA assignment included task for shower. POC/MD Orders included DME of shower chair, walker, bedside commode. The assistive devices were not specified in assignment for HA.

Upon personnel record review, 2 of 14 (Personnel #12, 14) did not have evidence the hospice employees and contract employees have received orientation on the hospice philosophy. Personnel #12, 14, (contracted staff who had performed visits) had no documented evidence of orientation to hospice philosophy.

Upon patient client record review, 3 of 14 (Patient #1, 3, 8) 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 #1: HA documented visit type as ALF 12/26/23, 1/23/24 and as home 1/25/24. Patient resides in home setting. 12/18/23 PT Evaluation. PT summary notes that patient is admitted to home health. Addresses homebound status. Patient #3: MSW visit 12/28/23 includes in summary that patient was admitted with terminal illness of colon cancer. All other documentation references admitting diagnosis of Alzheimer's. Staff interview clarifies MSW made error and made late entry documentation to correct. Patient #8: F2F 12/12/23 NP documents patient is a 95 year old female admitted to hospice. Physician's 12/18/23 CTI says patient is 81 year old female admitted to hospice for protein calorie malnutrition.

Upon observation, there was no evidence the organizational chart matches the hospice's information submitted to CMS and/or State licensing agencies for ownership and management personnel. The agency reports that new administrator was appointed administrator January 2023 and new DPCS August 2023. By end of survey, the agency had not presented evidence reporting changes in organizational chart to CMS and/or state licensing.