Every finding on record at Fairy Hospice Care, Inc.

Upon patient record review, 3 of 14 (Patient #1, 2, 4) 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 01: The patient was admitted on 5/30/24 with a primary diagnosis of COPD, there is evidence in the patient record that the patient utilizes oxygen for shortness of breath, the medication profile does not include oxygen. (Updated during survey.) Patient 02: The medication profile includes Lidocaine 4% topical patch, apply for 12 hours daily for pain, it does not include an application site. (Updated during survey.) Patient 04: The medication profile includes Diclofenac Sodium, 1% topical gel, apply to affected area 3 times a day, it does not include an application site. (Updated during survey.)

Upon patient record review, 1 of 14 (Patient #8) 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 08: The patient record does not include a comprehensive assessment of the patient every 15 days, the patient was admitted on 4/26/24 and was routinely visited by the LVN who entered a visit note at each weekly visit through 6/19/24, there is no evidence of a comprehensive assessment performed by the RN until 6/21/24.

Upon patient record review, 1 of 14 (Patient #8) 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 08: The patient was admitted on 4/26/24 and was actively being treated for a urinary tract infection with antibiotics, the plan of care does not include a genitourinary problem statement with interventions and goals. The patient has identified edema upon admission, there are no interventions and goals included in the plan of care for the management of the edema.

Upon patient record review, 2 of 14 (Patient #5, 7) 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 • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient 05: The visit frequency orders for spiritual care are ordered "as needed and at recertification." The order does not include a quantity for PRN visits. Patient 07: The patient was admitted on 6/18/24, the record does not include visit frequency orders for SN, SW, SC or Aide services.

Upon patient record review, 3 of 14 (Patient #1, 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 01: The patient was admitted on 5/30/24 with a primary diagnosis of COPD, there is evidence in the patient record that the patient utilizes oxygen for shortness of breath, there are no orders in the plan of care for the use of oxygen. (Ordered entered during survey.) Patient 02: Medication orders on 7/12/23 include Lidocaine 4% topical patch, apply for 12 hours daily for pain, it does not include an application site. (Order correction entered during survey.) Patient 04: The medication orders for Diclofenac Sodium, 1% topical gel, apply to affected area 3 times a day, it does not include an application site. (Order correction entered during survey.)

Upon patient record review, 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 01: The patient has a primary diagnosis of COPD and utilizes oxygen the plan of care record does not include oxygen in the patient equipment needs. (Updated and corrected during survey.)

Upon client record review, 2 of 14 (Patient #5, 8) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 05: Spiritual care orders are entered as "PRN and at each recertification," the spiritual care counselor has made monthly visits since being admitted which are documented as routine visits. Patient 08: There is no evidence in the patient record of an RN assessment of the patient since 6/7/24.

Upon patient record review, 1 of 14 (Patient #2) 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 02: The hospice aide task assignment includes "change linens," it does not include a frequency for performing the task. (Updated and corrected on site.)

Upon patient record review 2 of 14 (Patient #1, 3) 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 01: During the home visit, it was witnessed that the hospice aide performed a vital signs assessment of the patient, taking her blood pressure and pulse, this is not included in the hospice aide task assignment. Patient 03: The hospice aide order for visits is indicated for 2 times per week, the aide visits were performed one time per week for the period from 6/2/24 - 6/22/24. (Visits made on 6/5/24, 6/12/24, and 6/19/24.)

Upon patient record review 1 of 14 (Patient #1) 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 01: The hospice aide services were started on 6/4/24, there is no evidence in the patient record of an RN supervisory visit to date.

Upon patient client record review, 1 of 14 (Patient #8) did not have evidence that each patient record contains responses to medications, symptom management, treatments, and services. Patient 08: The patient was treated for a urinary tract infection at the time of admission on 4/26/24, the record does not include information regarding the response of the antibiotic or symptom management for the treatment.

Upon patient client record review, 2 of 14 (Patient #1, 10) 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 01: The patient was admitted on 5/30/24, the initial admission visit performed by the RN has not been signed and authenticated. Patient 10: The patient received a visit on 6/6/24 performed by the RN, the documentation was not completed and electronically signed until 6/25/24.

Upon patient record review, 3 of 11 (Patients #3, #7, and #11) did not have evidence in the patient record that the comprehensive assessment included a bereavement component which included 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. Patients #3, #7 and #11: During the RN Start of Care, a Bereavement Screening was conducted by the RN, however, the screening failed to incorporate all components of the Agency's standard Bereavement Assessment, including: "Risk/Stressors for Bereaved, Suicide Ideation, Possible alcohol/substance abuse, History of Mental health concerns, Extreme dependency, Extreme anger/guilt/fear, Conflicted relationships, History of family violence, Sense of Hopelessness, Estranged or Isolated from support system, Inadequate coping skills, Multiple losses, Difficulty coping with past losses, Inadequate financial concerns, Pre-existing health concerns, Neglect of appearance, Exhaustion, Signs of spiritual distress, Unprepared for death, Legal concerns and Anticipatory grief. There was no evidence any other member of the IDG completed this bereavement assessment.

Upon client record review, 4 of 11 (Patient #2, #5, #6 and #10) did not have evidence that the IDG ensured that the care and services were provided in accordance with the plan of care. Patient #2: The Initial Plan of Care dated 1/22/2022, included Physician orders that included, LVN nursing visits of 1 x week. There was no documentation to indicate the LVN made a visit during the week of 2/6/2022. Patient #5: The Initial Plan of Care dated 11/12/2021, included Physician orders that included, LVN nursing visits of 1 x week. There was no documentation to indicate the LVN made a visit during the weeks of 11/10/2021, and 11/21/2021. Patient #6: The Initial Plan of Care dated 7/7/2021, included Physician orders that included, LVN nursing visits of 1 x week. There was no documentation to indicate the LVN made a visit during the week of 12/26/2021. Patient #10: The Initial Plan of Care dated 7/7/2021, included Physician orders that included, LVN nursing visits of 1 x week. There was no documentation to indicate the LVN made a visit during the week of 8/8/2021.

Upon patient record review, 2 of 2 applicable (Patients #9 and #10) did not have evidence the hospice follows the bereavement plan of care. Patient #9, #10: The Bereavement Plan of Care stated included in interventions that a sympathy card would be sent and the bereaved would receive mailings. There was missing evidence these interventions were provided.

Upon patient record review 2 of 10 applicable (Patients #8 and #9) did not have documentation in the patient record that a hospice aide provided services that were ordered by the IDG and included in the plan of care. Patient #8: An Aide care plan dated 6/4/2021, directed the Aide to check the patient vital signs on every visit. There was no documentation to indicate the vital signs were checked on the visits conducted on 6/8/2021, 6/10/2021, 6/14/2021 and 6/17/2021. Patient #9: An Aide care plan dated 7/3/2021, directed the Aide to check the patient vital signs on every visit. There was no documentation to indicate the vital signs were checked on the visit conducted on 7/20/2021

Upon observation, there was no evidence the hospice documents and demonstrates viable and ongoing efforts to recruit and retain volunteers.

Upon client record review, 1 of 1 (Patient #8) did not have evidence that the hospice forwarded a summary and a copy of the patient record, if requested, to a facility when transferring the patient to that facility. Patient #8: A faxed document from the receiving Hospice, requested the current hospice send a copy of the Certification of Terminal Illness, Insurance Information, and the patient demographics. There was no documentation to indicate the Hospice sent the requested information.