Every finding on record at Dignity Care Hospice Inc

Upon patient record review, 10 of 14 (Patient #1, 2, 3, 4, 5, 6, 7, 8, 9, 10) did not have evidence that the hospice informed and provided written information to the patient concerning its policies on advance directives, including a description of applicable state law. #1, 2, 3, 4, 5, 6, 7, 8, 9, 10-No evidence of the hospice providing information on advance directive policies to patients and families.

Upon patient record review, 10 of 14 (Patient #1, 2, 3, 4, 5, 6, 7, 8, 9, 10) did not have evidence that the hospice obtained the patient's or representative's signature confirming that they received a copy of the Patient's Rights and Responsibilities.

Upon patient record review, 5 of 14 (Patient #4, 5, 6, 8, 9) 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. #4-Order dated 4/15 to take prednisone for 9 days remains active on medication list. #5-Topical medications lidotral and diclofenac ordered without indication of area for application. Both COS. Duplicate orders for Abilify, one dated 8/9/23 and one dated 8/19/24. #6-Diclofenac ordered without indication of area for application. COS. #8-Hospice order for Atropine not on ALF MAR. ALF order for hyoscyamine not on hospice medication list. Hospice order for ondansetron has frequency Q8hrs prn and ALF MAR order for ondansetron has frequency Q4hrs prn.-both COS. #9-Lidocaine patch ordered with no area for application.

Condition of Participation: Interdisciplinary Group, Care Planning, and Coordination of Services. L536

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. #5-Nursing assessments document dysphagia and fall risk, there are no problems, interventions or goals open to address dysphagia, fall risk, psychosocial or spiritual issues for patient.

Upon patient record review, 10 of 14 (Patient #1, 2, 3, 4, 6, 7, 8, 9, 10)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. #1, #2, #3, #4, #5, #6, #7, #8, #9, #10-MSW PRN frequency does not have the number of PRN visits specified. #1, #2, #3, #4, #5, #6, #8, #9-SC PRN frequency does not have the number of PRN visits specified. #1, #2, #3, #4, #5, #6, #7, #8, #9-SN PRN frequency does not have the number of PRN visits specified.

Upon patient record review, 3 of 14 (Patient #5, #6, and #9) 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. #5-Topical medications lidotral and diclofenac ordered without indication of area for application. COS. #6-Diclofenac ordered without indication of area for application. COS. #9-Lidocaine patch ordered with no area for application.

Upon patient record review, 3 of 14 (Patient #1, #5, and #8) 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. #1-Documentation on initial RN visit indicates patient is in hospital bed with bed rails. Plan of care orders do not include these two items. #5-Documentation in medical record indicates patient is in hospital bed. Plan of care orders do not include a hospital bed. #8-Upon observation at visit, patient resting in hospital bed with rails. Plan of care orders do not include these items. COS.

Upon patient record review, 2 of 14 (Patient #5, 12) 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. #5 Patient has diagnosis of cancer of larynx and Thick-it was ordered 8/1/2024, with no updates to the plan of care. #12 There was no evidence of updates to plan of care regarding discharge plans for patient.

Upon client record review, 10 of 14 (Patient #1, 2, 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. #1-SW made visit on 8/20 without an order. #2, #5, #6, #7, #8, #9, #10-SW and SC made monthly visits without an order. #3-SC made visits on 7/10 and 7/28 without an order. SN made 2 visits on week of 7/7, but SN frequency was one time per week. #4-SN made 2 visits on the weeks of 7/7, 7/21, and 8/4, but SN frequency was ordered one time per week. #6-SN frequency ordered one time per week. No SN visits weeks of 7/7 and 7/21. Two SN visits weeks of 7/28 and 8/11. #7-SN frequency ordered one time per week. No SN visit week of 7/28. #8-SN frequency ordered one time per week. Two SN visits weeks of 7/7, 7/21 and 8/4. #9-SN frequency ordered one time per week. Two SN visits weeks of 7/14 and 8/11.

Upon patient record review, 1 of 14 (Patient #13) 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. • 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 #13-Post death bereavement risk assessment stated that family declined bereavement correspondence, but record reflects that letters were sent at one and three months after patient's death.

Upon observation, there was no evidence the hospice ensures that non-core services are provided to hospice patients and their families according to applicable laws and regulations. Non-core services include Physical Therapy, Occupational Therapy and Speech-Language Pathology. Upon observation of therapy contracts, it was noted that prior to survey there was no evidence of a contract for SLP.-Corrected on-site with new contract including SLP dated 8/27/2024.

Upon patient record review, 1 of 14 (Patient #2) 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 #2 Aide Care Plan tasked aide with taking vital signs but did not give parameters.

Upon patient record review 1 of 14 (Patient #2) 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 #2- The aide did not not take vital signs as assigned in aide care plan.

Upon contract review, 2 of 5 (Priority Physical Therapy, PT and Priority Physical Therapy, OT) did not have evidence the agreement to furnish any services under arrangement included that the hospice must retain administrative and financial management, and oversight of staff and services for all arranged services, to ensure the provision of quality care. Arranged care/services are supported by written contract/agreement that requires all care/services are: • Authorized by the hospice

Upon patient client record review, 2 of 14 (Patient #1, 5) did not have evidence that all entries are dated in accordance with the organizations policies and procedures and currently accepted standards of practice. #1-CTI documented face to face was completed on 7/22 when face to face was completed on 7/14. #5-The 6th benefit period the CTI stated face to face was completed on 7/23 when face to face was completed on 7/22.

Condition of Participation: Personnel Qualifications.

Upon personnel record review, 1 of 11 (Personnel #11) did not have evidence that all Speech Therapy Services are provided by a qualified licensed Speech-Language Pathologist (SLP) or Audiologist in accordance with the state's Speech-Language Pathology Practice Act and the hospice's policies and procedures and/or job descriptions. Personnel 11: The agency was unable to obtain information for a Speech Language Pathologist from their contracted agency.

Upon personnel record review, 1 of 11 (Personnel #11) did not have evidence the hospice obtained a criminal background check on all contracted individuals who have direct patient care and access to patient records. Personnel 11: The agency was unable to obtain information for a Speech Language Pathologist from their contracted agency.