Every finding on record at Fairmont Hospice LLC

Upon patient record review, 7 of 19 (Patient #1,2,3,5,6,7,10) 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: Patient has 2 orders for acetaminophen on the medication profile, Tylenol 500mg PO q4h PRN and Tylenol suppository 650mg PR q6h PRN. There is no evidence of maximum dose warning. Patient 2: Patient has order for nystatin topical in plan of care. There is no evidence of application site. Patient has order for Keflex tablet X 7 days. Order written 9/17/23, but remains active on the medication profile. Patient 3: Patient has order for nystatin topical powder X10 days. Order written 2/15/23, remains active on the medication profile. Application instructions state “topical to skin infection.” Patient 5: Patient has order written 6/8/24 for Augmentin X5 days. Order remains active on the medication profile. Patient 6: Patient has order written 9/28/23 for bacitracin 2 percent for application to affected area for ten days. Patient has order written 5/24/24 for nystatin 100,000units/gram topical powder. Instructions read to apply to skin infection for ten days. Orders remain active on the medication profile and do not contain specific area of application. Patient has order written 9/28/23 for ophthalmic irrigation; extraocular solution. Apply one drop twice daily to affected eye twice daily without identifying which eye or eye(s). Patient 7: Patient with following subcutaneous medications ordered: enoxaparin 40mg and lispro insulin. There is no evidence of instructions to rotate injection sites on the medication profile. Patient with physician’s order for lispro insulin every six hours per sliding scale. There is no evidence of sliding scale on the medication profile. Patient with order for Bisacodyl enteric coated tablets. Administration instructions in plan of care state to administer via peg tube. Patient with physician’s order for Miralax 17 grams daily. There is no evidence of reconstitution instructions on the medication profile. Patient 10: Patient has physician’s order for Bactrim DS written 1/2/24: Bactrim 800/160mg, take one tablet twice a day for 7 days. This order is remains active on the medication profile.

Upon patient record review, 1 of 19 (Patient #5) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient #5: Patient with documentation of wound care being provided. There is no documentation of wound assessment, measurements in the patient’s medical record.

Upon patient record review, 12 of 19 (Patient #1,2,3,4,5,6,7,9,11,12,13,14) 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: There is no evidence of the following care plans: pain, edema, falls, mobility. There is no evidence of the following precautions in the plan of care: falls. Patient 2: There is no evidence of the following care plans: oxygen, aspiration. There is no evidence of the following precautions in the plan of care: falls, aspiration. Patient 3: There is no evidence of the following care plans: fall, gastro/feeding tube, oxygen, pain, mobility. There is no evidence of the following precautions in the plan of care: falls, oxygen. Patient 4: There is no evidence of the following care plans: fall, gastro/feeding tube, bleeding, aspiration. There is no evidence of the following precautions in the plan of care: falls, oxygen, bleeding, aspiration. Patient 5: There is no evidence of the following care plans: oxygen, bleeding, aspiration, wound, neuro, foley. There is no evidence of the following precautions in the plan of care: wound, aspiration, bleeding, oxygen. Patient 6: There is no evidence of the following care plans: oxygen, fall, constipation. There is no evidence of the following precautions in the plan of care: wound, fall, oxygen. Patient 7: There is no evidence of the following care plans: neuro, constipation. There is no evidence of the following precautions in the plan of care: seizure, bleeding. Patient 9: There is no evidence of the following care plans: oxygen, bleeding. Patient 11: There is no evidence of the following care plans: oxygen, fall, constipation, aspiration, agitation, suicidal ideation, current pathological fracture related to osteoporosis. Patient 12: There is no evidence of the following care plans: oxygen, neuro, constipation. There is no evidence of the following precautions in the plan of care: oxygen. Patient 13: There is no evidence of the following care plans: mobility, constipation. Patient 14: There is no evidence of the following care plans: neuro, oxygen, falls, mobility.

Upon patient record review, 7 of 19 (Patient #1,2,3,5,6,7,10) 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 1: Patient has 2 orders for acetaminophen in the plan of care. Tylenol 500mg PO q4h PRN and Tylenol suppository 650mg PR q6h PRN. There is no evidence of maximum dose warning in the physician’s orders. Patient with documentation of foley catheter and bilateral peritoneal drains in place. There is no evidence of physician’s orders for any of these drains in the plan of care. Patient 2: Patient has physician’s order for nystatin topical 100,000 units/gram, apply small amount to affected area. There is no evidence of application site in the physician’s order. Patient has physician’s order written 9/17/23 for Keflex tablet X 7 days, 1 tablet my mouth daily for 7 days active on POC. Patient 3: Patient with documentation of feeding tube. There is no evidence of physician’s orders for feeding tube in the plan of care. Patient has physician’s order written 2/15/24 for nystatin topical powder 100,000units/gram powder topical to skin infection 3times daily for 10 days active on POC. Patient 5: Patient with documentation of wound care being provided. There is no evidence of physician’s orders for a wound in the plan of care. Patient has physician’s order written 6/8/24 for augmentin 250-62.5mg/5ml-take 5ml twice daily for 5 days active on POC. Patient 6: Patient has order written 9/28/23 for ophthalmic irrigation; extraocular solution. Apply one drop twice daily to affected eye twice daily. This order without evidence of application site. Patient has order written 9/28/23 for bacitracin 2 percent for application to affected area for ten days. Patient has order written 5/24/24 for nystatin 100,000units/gram topical powder. Instructions read to apply to skin infection for ten days. Both order remain active on POC. Patient 7: Patient with following subcutaneous medications ordered: enoxaparin 40mg and lispro insulin. There is no evidence of instructions to rotate injection sites in the physician’s order. Patient with physician’s order for lispro insulin every six hours per sliding scale. There is no evidence of sliding scale in the physician’s order. Patient with order for Bisacodyl enteric coated tablets. Administration instructions in physician’s order state to administer via peg tube. Patient with physician’s order for Miralax 17 grams daily. There is no evidence of reconstitution instructions in the physician’s order. Patient 10: Patient has physician’s order for Bactrim DS written 1/2/24: Bactrim 800/160mg, take one tablet twice a day for 7 days. This order is still active.

Upon client record review, 2 of 19 (Patient #1,5) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 1: Patient with documentation of foley catheter and bilateral peritoneal drains in place. There was evidence nurse documented draining from drain per MD orders however, there is no evidence of physician’s orders for any of these drains in the plan of care. Patient 5: Patient with documentation of wound care being provided by hospice nurse however, there is no evidence of physician’s orders for a wound in the plan of care.

Upon patient record review, 11 of 19 (Patient #1,2,3,5,6,8,9,11,12,13,14) 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: Aide care plan without evidence of the following precautions: fall. Patient with documentation of foley catheter in place. No evidence of foley catheter care on aide care plan. Patient 2: Aide care plan without evidence of the following precautions: fall, oxygen, aspiration. Patient 3: Aide care plan without evidence of the following precautions: oxygen, fall. Patient 5: Aide care plan without evidence of the following precautions: oxygen, aspiration, wound. Patient with documentation of foley catheter in place. No evidence of foley catheter care on aide care plan. The following tasks are on the aide care plan: assist with feeding, transfer/ambulation. There is no evidence of ordered frequency for these tasks. Vital signs ordered every visit. There is no evidence of vital sign parameters in aide care plan. Patient 6: Aide care plan without evidence of the following precautions: oxygen, fall. The following tasks are on the aide care plan: transfer/ambulation. There is no evidence of ordered frequency for this task. Patient 8: The following tasks are on the aide care plan: transfer/ambulation. There is no evidence of ordered frequency for this task. Patient 9: Aide care plan without evidence of the following precautions: oxygen, bleeding. Patient 11: Aide care plan incomplete. Contains only the following information: bed bath every visit. Report abnormal findings to nurse. Patient 12: The following tasks are on the aide care plan: transfer/ambulation. There is no evidence of ordered frequency for this task. Patient 13: The following tasks are on the aide care plan: transfer/ambulation. There is no evidence of ordered frequency for this task. Patient 14: Aide care plan without evidence of the following precautions: oxygen, fall.

Upon patient record review 4 of 19 (Patient #3,9,13,14) 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 3: Aide visits ordered five times weekly beginning 6/9. There is evidence of visits made outside of frequency during weeks: 6/25,7/1, and 7/9. Visits made these weeks: 6/25,6/26,6/27,6/28,7/1,7/2,7/3,7/4,7/9,7/10,7/12. Patient 9: There is no evidence of aide visit made after 7/17, visit frequency ordered three times weekly, per physician’s order. Patient 13: There is no evidence of aide visit after 7/19, despite ordered visit frequency of three times weekly. Patient 14: Physician’s order for aide visits is three times weekly. There is no evidence of aide visit made after 7/3.

Upon patient record review 1 of 19 (Patient #12) 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 12: There is no evidence of aide supervisory visit made after 7/3/24.

Upon observation, there was no evidence the annual report documents the use of volunteers providing day to day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract personnel however, there was only evidence of 2.25% for 2023.

Upon contract review, 1 of 7 (Alternate Medical director contract) did not have evidence of a contract to fulfill the role of medical director or alternate medical director, if applicable. Contract for alternate medical director does not state that they will assume medical director’s responsibilities in absence of medical director.

Upon patient client record review, 5 of 19 (Patient #8,10,12,13,14) 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 8: Patient with physician’s order for medications without evidence of indications on agency document: ABH cream, Miralax, 3/14/24 quetiapine order. Patient 10: Patient with physician’s order for medications without evidence of indications on agency document: Bactrim DS, mirtazapine amlodipine, trazadone (order number 2). Patient 12: Patient with physician’s order for medications without evidence of indications on agency document: acetaminophen. Patient 13: Patient with physician’s order for medications without evidence of indications on agency document: rosuvastatin, citalopram, levothyroxine, melatonin. Patient 14: Patient with physician’s order for medications without evidence of indications on agency document: quetiapine, memantine, levothyroxine.

Upon SNF/NF contract review, 3 of 7 (contracts Brighstone, Capston, Cambridge) did not have a delineation of the responsibilities of the hospice and the SNF/NF to provide bereavement services to SNF/NF personnel.

Upon patient record review 2 of 13 (Patient #2, 13) 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 #2: The patient was admitted 4/11/21 there was not evidence of a psychosocial assessment by MSW in the record until 6/3/21. Patient #13: The patient was admitted 5/25/21 there was not evidence of a psychosocial assessment by MSW in the record until 6/4/21.

Upon patient record review, 2 of 13 (Patient #2, 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 #2: The patient was admitted 4/11/21 there was not evidence of a bereavement assessment in the record until 6/3/21. Patient #13: The patient was admitted 5/25/21 there was no evidence of a bereavement assessment in the record.

Upon patient record review, 1 of 13 (Patient #10) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #10: SN Visit note dated 9/8/21 referenced cleansing a hand wound and SN visit note dated 9/22/21 referenced dressing change to sacral wound per order. There was no evidence an order for wound treatment.

Upon personnel record review, 1 of 1 applicable (Personnel #5 ) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: ·Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff. ·Reading and recording temperature, pulse, and respiration ·Safe transfer techniques and ambulation. ·Normal range of motion and positioning ·Appropriate and safe techniques in personal hygiene and grooming that include-- ·(A) Bed bath ·(B) Sponge, tub, and shower bath ·(C) Shampoo, sink, tub, and bed ·(D) Nail and skin care ·(E) Oral hygiene ·(F) Toileting and elimination Patient #5: The competency checklist on file did not include the identified competencies as required.

Upon patient record review, 2 of 10 applicable (Patient #3, 8) did not have evidence in the patient record that hospice aide assignments and duties are 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 #3, 8: The aide care plan had both Complete Bed Bath and Shower assigned as tasks for HA, with frequency identified as "Patient Choice." There was no reference to patient's cognitive status and ability to make decisions.

Upon patient record review 3 of 10 applicable (Patient #3, 7, 8) did not have evidence documentation in the patient record that a hospice aide provides services that are ordered by the interdisciplinary group and included in the plan of care Patient #3: Aide care plan included Complete Bed Bath and Shower with frequency identified as "Patient Choice." Aide documentation indicated that both tasks were performed on all visits. Patient #7: The Aide Care Plan included shampoo with a frequency of "Wednesday". Aide visit notes included completion of shampoo for visits dated 8/20 (Friday), 8/23 (Monday), 8/27 (Friday), 9/3/21 (Friday). Patient #8: Aide care plan included Complete Bed Bath and Shower with frequency identified as "Patient Choice." Aide documentation indicated that neither task was completed on aide visits (7/30, 8/02, 85/4, 8/6, 8/9, 8/11, 8/13, 8/16, 8/18/21).

Upon personnel record review, 9 of 13 (Personnel #5, 6, 7, 8, 9, 10, 11, 12, 13) did not have evidence the hospice employees and contract employees have received orientation on the hospice philosophy.

Upon personnel record review, 9 of 13 (Personnel #5, 6, 7, 8, 9, 10, 11, 12, 13) did not have evidence that a skills competency assessment, specific to each discipline had been conducted for all personnel including volunteers initially during orientation.

Upon patient record review, 2 of 13 (Patient #4, #11) 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: The effective date of the Hospice Medicare Benefit election was left blank. Patient #11: The record did not contain evidence of a signed notice of patient rights in accordance with 418.24.

Upon patient record review, 1 of 13 (Patient #7) did not have evidence that each patient record contains Advance Directives. Patient #7: Patient was admitted 8/13/21. During initial nursing assessment visit it was documented that the daughter indicated patient has an advance directive and she will provide copy. There was no copy as part of the EMR at the time of survey. During surveyor's home visit for observation, the MSW again asked for copy, but daughter was unable to produce on this date.

Upon patient client record review, 1 of 13 (Patient #2) 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: There was a Missed Visit Report generated by the SC provider for initial spiritual assessment dated 4/11/21. The reason for the missed visit was that patient had expired. This patient was active at the time of survey.