Every finding on record at Crowning Comfort Hospice Inc.

Upon patient record review 1 of 5 (Patient #1) 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 #1 There is no evidence in the patient record of a psychosocial assessment completed at the time of admit on 10/31/22 or to date.

Upon patient record review, 1 of 5 (Patient #1) 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 #1 The comprehensive assessment identifies the use of oxygen, 2-5L prn, that is not included in the medication profile.

Upon patient record review, 2 of 5 (Patient #1, 3) 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 #1 and 3 There is no evidence in the patient record of an initial bereavement assessment completed within 5 days of admit or to date.

Upon patient record review, 1 of 5 (Patient #1) 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 patient uses Oxygen 2-5L prn for shortness of breath that is not included in the plan of care.

Upon patient record review, 3 of 5 (Patient #1, 2, 3) 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 documentation the patient is utilizing Oxygen, walker wheelchair, nebulizer, incontinence supplies, no evidence these were included in the plan of care. Patient #2 documentation the patient is utilizing hospital bed, walker, incontinence supplies, no evidence these were included in the plan of care. Patient #3 documentation the patient is utilizing walker, and incontinence supplies, no evidence these were included in the plan of care.

Upon personnel record review, 1 of 11 (Personnel #5) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) ·Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff. ·Reading and recording temperature, pulse, and respiration ·Safe transfer techniques and ambulation. ·Normal range of motion and positioning ·Appropriate and safe techniques in personal hygiene and grooming that include-- ·(A) Bed bath ·(B) Sponge, tub, and shower bath ·(C) Shampoo, sink, tub, and bed ·(D) Nail and skin care ·(E) Oral hygiene ·(F) Toileting and elimination The other subject areas in this section may be evaluated through written examination, oral examination or after observation of a Hospice Aide with a patient. Personnel #5 The Hospice Aide evaluation of skills does not include evidence of competency for shampooing at the sink, tub, or bed.