Every finding on record at Destiny Hospice and Palliative Care Inc

Upon observation, there was no evidence the Emergency Plan communication plan includes all of the following: • Names and contact information for the following: • Hospice employees • Entities providing services under arrangement • Patients' physicians • Other hospices The communication plan did not include the entities providing services under arrangement or other hospices. Corrected on site.

Upon observation, there was no evidence the Emergency Plan communication plan must includes a primary and alternate means for communicating with hospice's employees and Federal, state, tribal, regional, and local emergency management agencies. The agency does not have an alternate means for communicating with their hospice employees in their communication plan. Corrected on site.

Upon patient record review, 5 of 5 (Patient #1,2,3,4,5) did not have evidence in the patient record that the comprehensive assessment takes into consideration the imminence of death.

Upon patient record review, 1 of 5 (Patient #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 3: Upon home visit finding, patient has a Trapeze on their bed. This was not included on the POC.

Upon client record review, 2 of 5 (Patient #1,3) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 1: On 3/5/24 SN documented "Assisted POA with hygiene care to the patient" There is no evidence the nurse provided the colostomy care that is ordered every visit and no documentation to support it was completed by caregiver or refused. On 3/26/24 there was no evidence that colostomy care was performed. It is ordered every visit and there was no evidence the POA performed the care or that it was refused. The medical record contains an order by the physician that the patient refused MSW and SC on 12/23/23. All of the IDG's since that date have that the MSW and SC are both still ordered once a month and 1 prn. There is no evidence visits were made beyond on their initial assessments. Patient 3: The POC contains an order for narcotic count every visit. There is no evidence of a narcotic count being done in the past 6 weeks of visits. There is evidence the patient has Ativan and Morphine in the home for symptom management.

Upon patient record review 1 of 5 (Patient #1) did not have evidence documentation in the patient record that a hospice aide provides services that are: Patient 1: The aide documented on 2/20/24 and 2/23/24 that a meal was prepared. This was not ordered on the aide POC.

Upon observation, there was no evidence the hospice documented the cost savings achieved through the use of volunteers. Documentation must include the following: • The identification of each position that is occupied by a volunteer • The work time spent by volunteers occupying those positions • Estimates of the dollar costs that the hospice would have incurred if paid employees occupied the positions identified in paragraph (d)(1) of CFR 418.78 for the amount of time specified in paragraph (d)(2) of CFR 418.78 The agency Volunteer Hours log does not list each position that is occupied by a volunteer or estimate the dollar costs that the hospice would have incurred if paid employees occupied the positions.

Upon patient client record review, 3 of 5 (Patient #1, 2, 3) 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: The SN documented on 2/27/24 "checked patient's stoma and changed dressing" there is no evidence the POC was followed as the documentation did not include specific details. SN documented 3/12/24 "changed colostomy" there is no evidence the POC was followed as the documentation did not include specific details. On 3/26/24 there was no evidence that colostomy care was performed. Patient 2: The medical record contains an order by the physician that patient refused MSW 3/19/24. The MSW has documented "Assess and instruct sleep interruptions and medication administration, improving" on every IDG since 3/19/24. There is no evidence the MSW saw the patient beyond the initial assessment. Patient 3: The SN documented on 3/27/24, 3/15/24,2/28/24 "performed wound care on patient's ischium". There is no evidence the SN followed the POC as the documentation did not include specific details.