Every finding on record at Eagle Glen Hospice Care

Upon patient record review, 14 of 14 (Patient #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14) 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 Patient #1-14: All patients were provided supplemental oxygen for PRN use at the time of admission for hospice services; however, this oxygen was not included on the medication profile. (COS for all active patients) Patient 3: The medication profile includes Voltaren 1% gel apply topically bid for pain, but fails to include the order specifications for location. (COS) Patient 4: The medication profile includes diphenhydramine 2% cream apply topically 3-4 x daily PRN for itchiness, but fails to include the order specifications for location. (COS)

Upon patient record review, 1 of 14 (Patient #2) 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: The patient was admitted for hospice services on 10.11.2024; the initial bereavement assessment was completed on 10.21.2024, which exceeds the 5 day requirement.

Upon patient record review and direct observation during the home visit, 1 of 14 (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 equipment and supply needs. Patient 1: During the patient's home visit, the patient was observed sitting in a wheelchair; however, this equipment does not appear on the patient's plan of care. (COS)

Upon patient record review, 3 of 14 (Patient #1, 2, 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: The plan of care indicates that SN visits will be made 1 x weekly; however, a nurse has seen the patient 2 x weekly every week since admission for hospice services. (COS) Patient 2: The plan of care indicates that MSW visits will be made 1 x monthly; however, there was no evidence that the MSW made a visit to the patient during the month of November 2024. Patient 3: The plan of care indicates that MSW visits will be made 1 x monthly; however, the MSW made two visits to the patient in June 2024, on 06.03.2024 and 06.06.2024.

Upon patient record review, 5 of 14 (Patient #10, 11, 12, 13, 14) 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 10, 11, 12, 13, 14: After the death of the patient, there was no evidence of an update to the bereavement plan of care indicating the type and frequency of bereavement services.

Upon patient record review, 1 of 14 (Patient #1) did not have evidence that each patient record contains: • Signed election statement in accordance with 418.24 Patient 1: The signed election of benefit statement does not indicate the effective date for the initiation of hospice services.

Upon patient record review, 2 of 14 (Patient #8, 9) 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, 9: There was no evidence of the discharge summary being forwarded to the attending physician after the revocation of hospice services.

Upon inpatient contract review, 1 of 3 (Arroyo Vista Nursing Center) did not have evidence that the hospice retains responsibility for ensuring that the training of personnel who will be providing the patient's care in the inpatient facility has been provided and that a description of the training and the names of those giving the training are documented. (COS-addendum obtained from SNF)

Upon patient record review, 5 of 5 records (Patients #1,#2,#3,#4,#5) 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: Patient 1, 2, 3, 4: The medical record contained an order stating Oxygen may be titrated from 2-5 Liters as needed for shortness of breath. The medication profile stated Oxygen 2 Liters as needed without identifying the range allowable and indication for use. Patient 5: The medical record contained an order stating Oxygen may be administered as needed for shortness of breath. The medication profile stated Oxygen as needed without identifying the indication for use.

Upon patient record review, 5 of 5 records (Patients #1,#2,#3,#4,#5) 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 Patient 1: The plan of care included social work and spiritual care frequencies PRN and nursing frequency once weekly and PRN. There was no evidence of quantity of PRN visits allowable or indication for visits. There was no evidence of scheduled frequency for spiritual care due to patient declining services. Patient 2, 3, 5: The plan of care included spiritual care frequency PRN, social work frequency once monthly and PRN, and nursing frequency once weekly and PRN. There was no evidence of quantity of PRN visits allowable or indication for visits. There was no evidence of scheduled frequency for spiritual care due to patient declining services. Patient 4: The plan of care included nursing frequency once weekly and PRN. There was no evidence of quantity of PRN visits allowable or indication for visits.

Upon patient record review, 5 of 5 records (Patients #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: The medical record contained nursing documentation upon admission identifying patient use of a hospital bed and bed rails. There was no evidence of the hospital bed and bed rails included on the plan of care. Patient 2: The medical record contained nursing documentation upon admission identifying patient use of bedside tables and bed rails. There was no evidence of the table and bed rails included on the plan of care. Patient 3: The medical record contained nursing documentation upon admission identifying patient use of full bed rails. There was no evidence of bed rails included on the plan of care. Patient 4: The medical record contained nursing documentation upon admission identifying patient use of half bed rails. There was no evidence of bed rails included on the plan of care. Patient 5: The medical record contained nursing documentation upon admission identifying patient use of full bed rails. There was no evidence of bed rails included on the plan of care.