Every finding on record at Eden Hospice Care Inc

Upon patient record review 1 of 14 (Patient #12) did not have evidence in the patient record that the comprehensive assessment identifies the 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 12: Did not have a spiritual assessment completed.

Upon patient record review, 1 of 14 (Patient #3) 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 3: During home visit medication reconciliation, patient confirmed they are taking Nortriptyline 25mg by mouth twice daily and oxybutynin 5mg by mouth twice daily. There is no evidence of these medications on the medication profile.

Upon patient record review, 1 of 14 (Patient #13) 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 13: No evidence of an initial bereavement assessment.

Upon patient record review, 4 of 14 (Patient #2,5,6,9) 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: Identified needs: pain, mobility, anxiety, dyspnea, nausea/vomiting, weakness, high risk for falls. No evidence of problems, goals, or interventions on the plan of care: nausea/vomiting. Patient 5: Identified needs: dyspnea, high risk for skin breakdown, pain, constipation, high risk for falls. No evidence of problems, goals, or interventions on the plan of care: dyspnea, pain, high risk for falls. Patient 6: Identified needs: high risk for skin breakdown, constipation, high risk for falls, anxiety, decreased appetite, seizure precautions. No evidence of problems, goals, or interventions on the plan of care: high risk for skin breakdown. Patient 9: Identified needs: high risk for skin breakdown, high risk for falls, anxiety, decreased appetite, decreased mobility. No evidence of problems, goals, or interventions on the plan of care: high risk for skin breakdown.

Upon patient record review, 2 of 14 (Patient #7,9) 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. Patient 7: Plan of care orders: ibuprofen 800mg by mouth every 8 hours as needed for pain 0-3. Oxycodone 10mg by mouth every 4 hours as needed for pain 7-10. There is no evidence of intervention for pain 3-7 on the plan of care. Patient 9: Plan of care orders: baclofen 20mg by mouth daily for mild pain 0-3. Hydrocodone/Tylenol 10mg/325mg by mouth every 4 hours as needed for severe pain 7-10. There is no evidence of intervention for pain 3-7 on the plan of care.

Upon patient record review, 8 of 14 (Patient #1,2,3,5,6,7,8,9) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 1,2,3: Social worker visit frequency order is monthly and 3 prn. There is no evidence of social worker visit made in December 2024. Patient 2,3: Volunteer coordinator assessed volunteer need for weekly visits. Volunteer has been visiting patient weekly. There is no evidence of physician’s order for these visits. Patient 5: There are documented volunteer visits on 1/6/2024, 1/23, and 1/30. There is no evidence of a physician’s order for these visits. Patient 6: There are multiple, conflicting orders for social worker. There are two orders for initial social worker visits to be made. There is evidence of an initial visit made. Additionally, there are visit frequency orders written on 1/25/24 for monthly visits. There is no evidence of a scheduled social worker visit made 1/25/24-3/1/24. Patient 7: The nursing visit frequency order is weekly and 3 as needed. There is no evidence of a scheduled nursing visit made during the week of February 18-24, 2024. Patient 8: There is a physician order for weekly volunteer visits. There is no evidence of a scheduled visit made during the weeks of 3/11/24 to 4/22/24. Patient 9: There is a physician order for weekly volunteer visits. There is no evidence of a scheduled visit made during the weeks of 2/12/24 to 3/4/24 and 3/18/24 to 4/15/24.

Upon patient record review, 4 of 14 (Patient #4,5,6,7) 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 4,7: Aide tasks without evidence of frequency on the care plan: dressing in street clothes. No evidence of precautions on aide care plan: fall. Patient 5: Aide tasks without evidence of frequency on the care plan: dressing in street clothes, record bowel movement. No evidence of precautions on aide care plan: fall. Patient 6: Aide tasks without evidence of frequency on the care plan: record bowel movement, dressing in street clothes. No evidence of precautions on aide care plan: fall, seizure.

Upon patient record review 1 of 14 (Patient #4) 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: During 7/1/24 aide visit, task brush teeth was not performed by the aide.

Upon patient record review 1 of 14 (Patient #7) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs. Patient 7: There is no evidence of any documented supervisory visit in the patient's medical record. Aide visit frequency order is weekly and documented aide visits were weekly 1/25/2024 to 4/25/2024.

Upon patient record review, 1 of 12 (Patient #8) 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 8: Patient was admitted to hospice on 1/29/24. They revoked their hospice benefit on 4/28/24. Benefit period 1: 1/29/24-4/27/24. There is no evidence of CTI for benefit period 2 in the medical record.

Upon patient record review, 2 of 14 (Patient #10,14) did not have evidence that each patient record contains Physician certification and recertification of terminal illness. Patient 10,14: Attending physician CTI for benefit period 1 does not have a terminal diagnosis listed in the space on the CTI.

Upon patient record review, 2 of 14 (Patient #5,6) 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 5: Spiritual care visits made on 4/3/24 by spiritual care provider KA and on 4/5/24 by YV. There is evidence that the narrative notes from these visits are identical. Patient 6: Patient was discharged on 5/27/24. Discharge summary states patient was discharged from Affinity hospice.

Upon personnel record review, 1 of 12 (Personnel #11) did not have evidence that personnel credentialing activities are conducted to verify qualifications of all credentialed/licensed personnel in the positions they hold at the time of hire, at renewal or in accordance with specific state practice act requirements. Personnel 11: There was no evidence of current licensure in personnel file. COS