Every finding on record at Divine Hospice and Palliative Care Inc

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

Upon patient record review, 4 of 5 (Patient #2,3,4,5) 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 2: Patient with physician's order for skin and aspiration precautions. There is no evidence of these problems in the patient's care plan. Patient 3,5: Patient with physician's order for falls, skin and aspiration precautions. There is no evidence of these problems in the patient's care plan. Patient 4: Patient with physician's order for falls and aspiration precautions. There is no evidence of these problems in the patient's care plan. Patient with physician's order for Pradaxa 150mg capsule twice daily for anticoagulation. There is no evidence of bleeding precautions in the plan of care.

Upon patient record review, 2 of 5 (Patient #2,5) 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: Plan of care: Physician's order for Fluocinonide cream 0.1 percent. Apply thin layer topical one to two times a day for dry skin. There is no evidence of application site in the order. Patient 5: Plan of care: Physician's order for Lidocaine 5 percent transdermal patch every 12 hours as needed to affected area for moderate pain. There is no evidence of the following: Application site, on/off instructions. ALL OF THE ABOVE CORRECTED ON SITE.

Upon patient record review, 5 of 5 (Patient #1,2,3,4,5) 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: No evidence of physician's order for hoyer lift on patient's plan of care. Patient 2: No evidence of physician's order for hospital bed, walker, wheelchair on patient's plan of care. Patient 3: No evidence of physician's order for hospital bed, walker on patient's plan of care. Patient 4: No evidence of physician's order for hospital bed, walker, cane on patient's plan of care. Patient 5: No evidence of physician's order for hospital bed, walker on patient's plan of care. ALL OF THE ABOVE WAS CORRECTED ON SITE.

Upon client record review, 1 of 5 (Patient #3) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 3: Initial spiritual care assessment states chaplain will follow up monthly. Chaplain has been visiting monthly. There is no evidence of a physician's order for these monthly visits.

Upon patient record review, 2 of 14 (Patient #4, 6) 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. Patient #4, No evidence of new consents for admission on 4/17/24, consents were signed on 11/2/2 from previous admission. Patient #6, Patient signed his own consents with primary diagnosis of Alzheimer disease.

Upon patient record review, 2 of 6 (Patient #4,6) 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. Patient #4, No evidence of new consents for admission on 4/17/24, consents were signed on 11/2/2 from previous admission. Patient #6, Patient signed his own consents with primary diagnosis of Alzheimer disease.

Upon patient record review, 2 of 14 (Patient #4,6) did not have evidence that if a state court has not adjudged a patient incompetent, any legal representative designated by the patient in accordance with state law may exercise the patient's rights to the extent allowed by state law. Patient #4, No evidence of new consents for admission on 4/17/24, consents were signed on 11/2/2 from previous admission. Patient #6, Patient signed his own consents with primary diagnosis of Alzheimer disease.

Upon patient record review, 2 of 14 (Patient #4,6) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient #4, No evidence of new consents for admission on 4/17/24, consents were signed on 11/2/2 from previous admission. Patient #6, Patient signed his own consents with primary diagnosis of Alzheimer disease.

Upon patient record review, 2 of 14 (Patient #4,6) did not have evidence of the appropriate documentation for release of confidential information. Patient #4, No evidence of new consents for admission on 4/17/24, consents were signed on 11/2/2 from previous admission. Patient #6, Patient signed his own consents with primary diagnosis of Alzheimer disease.

Upon patient record review, 2 of 14 (Patient #4,6) did not have evidence that the patient received information about the services covered under the hospice benefit. Patient #4, No evidence of new consents for admission on 4/17/24, consents were signed on 11/2/2 from previous admission. Patient #6, Patient signed his own consents with primary diagnosis of Alzheimer disease.

Upon patient record review, 2 of 14 (Patient #4,6) did not have evidence that the patient received information about the scope of services that the hospice will provide and specific limitations on those services. Patient #4, No evidence of new consents for admission on 4/17/24, consents were signed on 11/2/2 from previous admission. Patient #6, Patient signed his own consents with primary diagnosis of Alzheimer disease.

Upon patient record review 1 of 14 (Patient #8) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient #8, MSW initial completed on 4/12/24, No evidence MSW initial was completed in 5 days, assessment completed in 8 days.

Upon patient record review 4 of 14 (Patient #2,6,9,10) 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 #2,6, MSW and SC was declined. No evidence of spiritual and psych social assessment completed on RN initial assessment. Patient #9, 10 MSW was declined. No evidence of spiritual and psych social assessment completed on RN initial assessment.

Upon patient record review, 8 of 14 (Patient #1,2,3,4,5,7,9,12) 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 #1,2,3,4,5,7,9,12, No evidence of oxygen documented under medication list. Oxygen was documented under treatment list.

Upon patient record review, 2 of 14 (Patient #2,6) 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 #2,6, No evidence of initial bereavement assessment.

Upon patient record review, 1 of 14 (Patient #4) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual's attending physician, if any) • Changes that have taken place since the initial assessment • Information on the patient's progress toward desired outcomes • Reassessment of the patient's response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days Patient #4, No evidence of RN visits every 15 days. RN visit on 5/1/24, 5/15/24, then 6/2/24 which is 18 days.

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

Upon patient record review, 10 of 14 (Patient #3,4,5,6,7,8,9,11,12,13) 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 #3,4,5,8,11,12,13, No evidence of initial care plan for spiritual and psychosocial. Patient #6,7, No initial care plans for nursing, spiritual and psychosocial. Patient #9, No initial care plan for spiritual.

Upon patient record review, 1 of 14 (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 medications and treatments. Patient #3, Oxygen 3lPM via nasal cannula as needed. No evidence of indicator for as needed.

Upon patient record review, 3 of 14 (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, Plan of care documents O2 concentrator, half rails, upon home visit, patient has shower chair, hospital bed and overbed table. No evidence of all DME was documented on plan of care. Patient #2, Plan of care documents O2 concentrator, full rails, upon home visit, patient has hospital bed and w/c. No evidence all DME was documented on plan of care. Patient #3, Plan of care documents O2 concentrator, full rails, w/c, upon home visit, patient has hospital bed. No evidence all DME was documented on plan of care.

Upon client record review, 1 of 14 (Patient #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 #10, IDG notes dated 5/31/24 then 6/17/24. No evidence IDG was completed within 15 days.

Upon client record review, 6 of 14 (Patient #3,8,9,11,12,13) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1, Order states to notify if bp >160 systolic and <90 diastolic. LVN note on 5/6/24 documents b/p 165/120. No evidence documented of MD notified. LVN documented CM notified, no evidence of CM documented they were notified. Patient #3,MSW visit on 4/12/24 was completed as telephone visit. No evidence of order for telephone visit. Patient #4, Order states to notify if bp >160 systolic and <90 diastolic. LVN not 5/3/24 documents b/p 169/80. No evidence of documentation MD or CM was notified. Patient #8, MSW visit on 4/12/24 and SC visit on 4/5/24, No evidence of orders for MSW and SC visits. Patient #9 RN frequency every 14 days. Visits completed on 4/3, 4/6. No evidence visits were every 14 days. Patient #11, RN frequency every 14 days. Visits completed 11/10, 11/19. No evidence visits were every 14 days. Patient #12, MSW visit on 9/9/23 completed as telephone visit. No evidence of order for telephone visit. Patient #13, RN frequency every 28th and 14th day. Visits completed 2/7, 2/9, 2/22, No evidence visits were every 28th and 14th day. MSW visit on 3/14/24 telephone visit. No evidence of order for telephone visit. SC frequency states per month, patient seen 2/8, 4/12. No evidence of amount per month.

Upon observation, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient #1,3, LVN removed clean items such as b/p, temp, pulse ox from dirty side of bag where the dirty items are keep.

Upon patient record review, 1 of 14 (Patient #9) 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 #9, Aide assignment documented under bath: documented shower chair. No evidence of identifying what type of bath to be given.

Upon patient record review 3 of 14 (Patient #4,9,14) 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 #4,14 Care plan directs aide to document fall risk, no evidence this was completed. Patient #9, Care plan directs aide to document shower chair, no evidence this was completed.

Upon patient client record review, 2 of 14 (Patient #2,4) 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 #4, No evidence of new consents for admission on 4/17/24, consents were signed on 11/2/2 from previous admission. Patient #6, Patient signed his own consents with primary diagnosis of Alzheimer disease.

Upon patient client record review, 5 of 14 (Patient #2,3,5,7,9) 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 #2, IDG note on 6/7/24 and 6/1024, no evidence of SC signature. No evidence of information regarding advanced directive was completed on informed consent and treatment authorization form as this area was blank. Patient #3, MSW note on 4/12/24 was incomplete, no evidence of narrative note. Patient #5, No evidence of information regarding advanced directive was completed on informed consent and treatment authorization form as this area was blank. Patient #7, IDG note on 4/8/24, 5/6/24, 6/17/24, no evidence of MSW signature. Informed consent missing staff signature. Patient #9, IDG note on 4/3/24, 6/3/24, no evidence of SC signature.

Upon observation, there was no evidence the hospice discussed the policies and procedures for managing the safe use and disposal of controlled drugs with the patient or representative and the family in a language and manner that they understand to ensure that these parties are educated regarding the safe use and disposal of controlled drugs. Patient #4, No evidence of new consents for admission on 4/17/24, consents were signed on 11/2/2 from previous admission. Patient #6, Patient signed his own consents with primary diagnosis of Alzheimer disease.

Upon client record review, 2 of 14 (Patient #4,6) did not have evidence that the written policies and procedures for managing controlled drugs was provided and discussed. Patient #4, No evidence of new consents for admission on 4/17/24, consents were signed on 11/2/2 from previous admission. Patient #6, Patient signed his own consents with primary diagnosis of Alzheimer disease.