Every finding on record at Elegant 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 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 #1,2,3,4,5,6,7,8,9,10,11,12,13,14 -SC initial assessment was blank with only time documented on form.

Upon patient record review, 13 of 14 (Patient #1,2,3,4,6,7,8,9,10,11,12,13,14) 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 #1,2,3,7,11,14, No evidence of initial SC care plan. Patient #4,6, No evidence of initial MSW care plan. Patient #8,9,10,12,13, No evidence of initial MSW or SC care plan.

Upon patient record review, 2 of 14 (Patient #2,4) 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, Wound care order states new skin tear on left hand treated as follows cleanse with ns pat dry, apply triple antibiotic ointment and cover with large bandage daily. No evidence documented item to pat dry and no evidence of who would complete the dressing change. Patient #4, Wound care order states left buttock pressure ulcer stage 3, cleanse with NS pat dry, apply hydrogel to the wound bed cover with border dressing change every 2 days and as needed for dislodgement or soiled. No evidence of item to pat dry and no evidence of who would complete the dressing change.

Upon patient record review, 2 of 14 (Patient #1,6) 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 #1,6, Aide care plan documented shower chair for bath, no evidence of shower, bed, tub, identified as type of bath.

Upon patient client record review, 14 of 14 (Patient #1,2,3,4,5,6,7,8,9,10,11,12,13,14) 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 #1,2,3,4,5,6,7,8,9,10,11,12,13,14, SC initial assessment dated with time, no evidence of documentation noted on form. Patient #1, IDG note on 4/12/24, no evidence MSW updated, documented as NA. No evidence of RN, MSW signature on IDG on 6/7/24. Patient #2, IDG note on 3/15/24 and 3/29/24, no evidence MSW or SC updated, documented NA.

Observed in Individual Tracer. It was noted that after sanitizing the blood pressure cuff, pulse oximetry machine and a thermometer the staff placed these items on a dirty towel, before placing these instruments in the clean side of the bag. Also the staff did not cleanse their hands before reaching into the clean side of the bag .

Observed in Competency Session. It was noted that the MSW, the Chaplain, and the Volunteer Coordinator were oriented to tasks that were inappropriate to their function. All had documented orientation to preparing food for the patients as well as patient's body function and safe transferring positions for the patients.