Every finding on record at Devotion Hospice Care Inc

Upon patient record review, 1 of 15 (Patient #1) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient 1: During home visit, the family stated they were not given the choice of an attending physician.

Upon patient record review, 3 of 15 (Patient #1,3,10) did not have evidence in the patient record that the comprehensive assessment takes into consideration the imminence of death. Patient 1,3,10: In the RN comprehensive assessment, the RN does not take into consideration the imminence of death.

Upon patient record review, 2 of 15 (Patient #1,2) 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: Upon visiting the patient home, pt. is taking Amlodipine 5mg tablet, there is no evidence it is on the medication profile. Pt.'s family and caregiver stated pt. is taking Tylenol daily for pain 8/10 and it is not on the medication profile. Simvastatin oral at bedtime is ordered and is not in the patients home. Patient 2: During a home visit with the patient, " Losartan 50mg 1 tablet daily is on the medication profile but is not in the patient home. Furosemide 20 MG and 80 mg tablets are not in the home.

Upon patient record review, 4 of 15 (Patient #4,7,8,10) 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 4,7,8,10: On the initial bereavement assessment there is no evidence that the assessment includes the needs of the patient's family/caregivers, no one is named as the primary bereaved.

Upon patient record review, 6 of 15 (Patient #1,4,5,6,7,11) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient 1: On the POC 1/24/25 there is a pain assessment "5/10 pain" , the assessment does not include where the pain is or interventions for the pain.  Patient 4: On 5/26/25 the RN assessment there is documentation“ Complains 4/10 leg pain. Encouraged verbalization of feelings about pain” No interventions or follow up on pain during the visit to ensure continuous assessment by RN. Patient 5: SN documented on 5/20/25 “Moderate pain in lower back. Encourage verbalization of feelings about pain. Provided comfort measures like change in positioning, encouraged techniques such as deep breathing exercise, and adequate rest periods to prevent fatigue” there is no follow up to the interventions documented on pain to ensure continuous assessment by RN. Patient 6: On 5/2525 the SN, documented “With mild lower back pain Encouraged verbalization of feelings about pain. Provided comfort measures like change in positioning, encouraged techniques such as deep breathing exercise and adequate rest periods to prevent fatigue. No interventions were followed up on for pain relief or if interventions were effective to ensure continuous assessment by RN. Patient 7: On 4/14/25 "NP told pt. to go to the emergency room for signs and symptoms of stroke, patient went to the ER". There is no evidence in the record of a follow up to the patient going to the ER. The next nursing visit was on 4/28/24, there was no evidence of follow up on patient going to the ER or follow up for signs and symptoms of stroke in the SN assessment. Patient 11: On 11/5/24 there is a coordination note, "BB has expired at SFHR 1215 Sunday, called friend and coordinated regarding with funeral arrangements since patient is Mormon.” Pt. passed on 11/3/24 there was not a visit made by the nurse to assess family needs and coordinate potentially needed activities between other IDG members.

Upon patient record review, 3 of 15 (Patient #9,10,12) 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 9: On the POC asper creme lidocaine cream 4% thin layer to affected area arms and joint pains every 6 hours for pain. Does not state specific joints to apply the medication. Patient 10: Salonpas adhesive patch 4% apply to affected area as needed for back pain. Does not say where to apply the patch. Voltaren Arthritis pain gel 1% topical 1 application four times a day. Does not say where to apply pain medication. Patient 12: MiraLAX there is no diluent, Medi honey gel topical apply a thin layer to the wound. The order does not state where the wound is. Triamcinolone acetonide 0.1% cream 1 application three times per day as needed does not state where to apply.

Upon client record review, 2 of 15(Patient #8,10) did not have evidence that the IDG in collaboration with the attending physician reviewed, revised and documents the individualized plan as frequently as the patient's condition requires but no less frequently then every 15 calendar days. Patient 8: On 3/20/24 the IDG note does not contain a signature from spiritual care or social work to show collaboration and review/revision of POC if needed. Patient 10: On 10/30/24 the IDG note does not contain signatures rom the skilled nursing, spiritual care or social work to show collaboration and review/revision of POC if needed.

Upon patient record review, 3 of 15 (Patient #3,8,10) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient 3: On 3/21/25 on the RN comprehensive assessment, "patient will be provided with psychosocial needs emotional support within 2 weeks" there is no evidence of updates during the IDG about the psychosocial needs, documentation has remained the same for each IDG including the most recent IDG on 6/18/25 there is no evidence that a psychosocial visit was made to patient or goals and interventions updated in the POC. Patient 8: On 3/20/24 the IDG note does not contain updates to goals/interventions from spiritual care or social work. Patient 10: On 10/30/24 the IDG note does not contain updates to goals/interventions from the skilled nursing, spiritual care or social work.

Upon client record review, 9 of 15 (Patient #1,3,4,5,6,7,8,9,10) 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 the current POC SN is ordered once a week. There was a missed SN visit the week of 1/12/25 without documentation of the missed visit. Patient 3: On the current POC there is an order for MSW eval for psychosocial and once a month visit, there is no evidence in the patient record that an eval has been completed or monthly visits have been made. Patient 4: On the current POC there is an order for "SN one time per week". There were two SN visits made 5/26/25. Patient 5: On the current POC SN visits ordered one time per week, on 4/22/25 there are 2 SN visits documented. On 5/13/25 there are 2 SN visits documented. Patient 6: On the current POC SN visits are ordered one time per week, on 5/5/25 there were two SN visits completed. Patient 7: On the current POC there is an order for SN visits once a week, on 3/25/25 a SN visit was completed and an RN supervisory visit was completed. The POC has an order for SN once per week. On 4/14/25 two SN visits were made, there is no evidence that the SN order was updated. The week of 4/20/25, there is a missed SN visit without documentation of missed visit. Patient 8: On the POC 3/10/24 SN visits ordered one time per week, there were no SN visits until 4/7/24 and 4/14/24 after the RN comprehensive assessment was completed. On 4/18/24 a SN visit is documented, on 5/5/24 there is an NP assessment after the patient was discharged on 4/13/24. Patient 9: On the POC 11/19/24 does not contain an order for SN visits, there are SN visits documented on 11/26/24, 12/3/24, 12/10/24, 12/17/24, 12/24/24, during the benefit period. Patient 10: On the POC 1/9/25 does not contain new orders for SN visits, or any orders and visits were being made.

Upon patient record review, 1 of 15 (Patient #11) did not have evidence the hospice offers bereavement counseling that includes: • Making bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. Bereavement counseling also extends to residents of a SNF/NF or ICF/IID when appropriate and identified in the bereavement plan of care • Ensuring that bereavement services reflect the needs of the bereaved • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery Patient 11: There is no evidence of bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient.

Upon patient record review, 1 of 15 (Patient #15) 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 15: On the Aide POC 9/19/24 there is an order for assist with bath-chair, shampoo hair, Comb hair, mouth care, hand and foot care, meals, housekeeping, without a frequency. .

Upon patient record review 1 of 15 (Patient #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 Patient 14: On the current POC there is documentation that the aide is visiting 2 times per week throughout the 7th benefit period, the POC does not contain an order for aide visits two times per week.

Upon patient record review, 2 of 15 (Patient #9,12) did not have evidence that before the recertification period for each patient, the medical director or physician designee must review the patient's clinical information and provide written documentation that it is anticipated that the patient's life expectancy is 6 months or less. Patient 9 On 9/26/24 the CTI does not contain a narrative statement specific to the patient. Patient 12: on 1//9/25 the CTI does not contain a narrative statement specific to the patient.

Condition of Participation: Clinical Records.

Upon patient client record review, 6 of 15 (Patient #1,2,3,4,5,6) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient 1,2,3,4,5,6: In the Patient notification of hospice non covered items, services and drugs- there are two boxes and none of them are checked. The patient did not choose.

Upon patient client record review, 7 of 15 (Patient #1,3,4,5,6,7,8) 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: On the F2F for 4/27/25 the NP documented the same narrative as the CTI for 1/27/25, and 10/29/25. Patient 3: In the patient record there is a document for Revocation, it is signed by the patient, without a date or time recorded, or signature from a hospice representative. Patient 4: On 6/2/25 the SN documented a narrative for the visit, this documentation was the same as the previous SN narrative documentation. Patient 5: There is evidence of a revocation paperwork signed by the patient without a date or time recorded, or a signature from a hospice representative. Patient 6: On 4/3/25 and 4/29/25 there is a face to face documented. The same face to face narrative is documented for each date and by different NP providers. It is not individualized to the face to face visit. Patient 7: On the RN comprehensive assessment the RN documented "female and male reproductive parts are within normal limits". Patient 8: CTI signed for recertification after the patient was discharged on 4/13/24.

Upon client record review, 4 of 15 (Patient #8,9,10,13) did not have evidence that if a patient revokes the election of hospice care or is discharged from hospice in accordance with §418.26, the hospice must forward to the patient's attending physician: • A copy of the hospice discharge summary • The patient's clinical record, if requested Patient 8:The record indicates that the patient revoked on 4/13/24 for curative treatment. There is no evidence of coordination of care, recent order, summary of patient care and current condition, or plan of care being sent or communicated to attending physician. Patient 9: The record indicates that the patient revoked on 1/13/25 for curative treatment. There is no evidence of coordination of care, recent order, summary of patient care and current condition, or plan of care being sent or communicated to attending physician. Patient 10: The record indicates that the patient revoked on 4/4/25 for curative treatment. There is no evidence of coordination of care, recent order, summary of patient care and current condition, or plan of care being sent or communicated to attending physician. Patient 13: In the patient record there is no evidence of a hospice discharge summary forwarded to the patient's attending physician after the patient revoked hospice for curative treatment.

Upon client record review, 4 of 15 (Patient #8,9,10,13) did not have evidence that the discharge summary includes all required information. Patient 8,9,10,13: There is no evidence the discharge summary after the patient was discharged from hospice included any other documentation that will assist in post-discharge continuity of care or that is requested by the attending physician

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- Order dated 4/23/22 indicated wound care to be performed daily. The SN frequency was 1 x week. The order did not include who would be responsible for wound care when the SN was not present.