Every finding on record at Faith & Family Supportive Care & Hospice, Inc

Upon patient record review 1 of 14 (Patient #6) 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 #6: There was no evidence of an initial spiritual care assessment was completed within 5 days of start of care.

Upon patient record review, 8 of 14 (Patient #1,2,3,4,5,7,8,10) 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: The plan of care does not include any interventions or goals for spiritual care visits being made. The plan of care does not include interventions or goals for Neurological for patient's primary diagnosis of Cerebral vascular disease and symptoms of hallucinations. The plan of care does not list bleeding precautions related to dark black stools and anemia. Patient #2: The plan of care does not include any interventions or goals for spiritual care visits being made. Patient #3: The plan of care does not include any interventions or goals for spiritual care visits being made. Patient #4: The plan of care does not include any interventions or goals for spiritual care visits being made. Patient #5: The plan of care does not include any interventions or goals for spiritual care visits being made. There is no interventions or goals for use of Zofran for nausea and vomiting. No interventions or goals for neurological, as the patients primary diagnosis is senile degeneration of the brain. Patient #7: The plan of care does not include any interventions or goals for spiritual care visits being made. There are no interventions or goals for neurological or seizures. Patient #8: The plan of care does not include any interventions or goals for spiritual care visits being made. There are no interventions or goals for anticoagulant use or bleeding concerns. There are no interventions or goals for Anxiety/Agitation despite patient having diagnosis of schizophrenia and is on medications for behaviors and diagnosis. Patient #10: The plan of care does not include any interventions or goals for spiritual care visits being made. There are no interventions or goals for anticoagulant use or bleeding concerns.

Upon patient record review, 2 of 14 (Patients #2, 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 medications and treatments. Patient #2: The patient had an order for Miralax, however, the order did not contain directions for reconstitution of this medication for administration. Patient #5: The patient had an order for Miralax, however, the order did not contain directions for reconstitution of this medication for administration.

Upon personnel record review,1 of 12 (Personnel #10) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) ·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 The other subject areas in this section may be evaluated through written examination, oral examination or after observation of a Hospice Aide with a patient. Personnel #10: The employee file does not contain evidence that direct supervision for the above requirements. There is an orientation list in the record, but it is not signed by a supervisor or RN and does not specify if tasks were completed with a patient or pseudo patient.

Upon patient record review, 4 of 14 (Patient #3, 5, 7, 10) 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 #3: The plan orders "wash hair weekly as requested". The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable. Patient #5: The plan of care also states to lotion skin. In the comments section is states "specify location" however no location is documented. Patient #7: The plan of care states "wheelchair as requested by patient". The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable. Patient #10: The plan of care states "Shave face with safety razor prn". The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable.

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. The volunteer percentage was 1.45% for 2024.

Upon personnel record review, 9 of 12 (Personnel #1, 2, 4, 5, 6, 7, 8, 10, and 11) did not have evidence the hospice employees and contract employees have received orientation on the hospice philosophy.

Upon personnel record review, 2 of 12 (Personnel #9 and #11) did not have evidence that the hospice employees have received orientation on their specific job requirements. Personnel #9: Although there was evidence that the hospice employee did receive job specific orientation for their role as BC, there was no evidence that the hospice employee received job specific orientation for their role as MSW. Personnel #11: There was no evidence that the hospice employee received job specific orientation for their role as Spiritual Care.

Upon patient record review, 2 of 8 (Patients #4 and #8) did not have evidence in the patient record that the comprehensive assessment included 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. There was no documentation by any IDG member, that a bereavement risk assessment had been conducted and incorporated into the plan of care.

Upon client record review, 3 of 8 (Patient #1, 2, 4) 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 and #4: Although the patients were receiving Chaplain services, the Plan of Care did not list the visit frequency.

Upon patient record review 2 of 6 applicable (Patients #2 and #7) did not have documentation in the patient record that a hospice aide provided services that were: • 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 #2: A document titled "Aide Care Plan" and dated 2/5/2022, included instructions to ..."document the date of the last bowel movement every visit and notify the RN if greater than 3 days..." There were no dates documented to reflect the last bowel movements. Patient #7: A document titled "Aide Care Plan" and dated 1/31/2022, included instructions to ..."document the date of the last bowel movement every visit and notify the RN if greater than 3 days..." There were no dates documented to reflect the last bowel movements.

Upon patient record review 2 of 6 applicable (Patients #3 and #7) did not have evidence in the patient record that the hospice aides reported: • Changes in the patient's medical, nursing, rehabilitative, and social needs to a registered nurse, as the changes relate to the plan of care and quality assessment and improvement activities • Hospice aides must also complete appropriate records in compliance with the hospice's policies and procedures Patient #3: On 1/26/2022, the Aide documented ..."nickel size skin tear to right arm found while undressing for shower." There was no documentation to indicate the RN had been notified of the skin tear. Patient #7: On 3/15/2022, the Aide documented ..."patient mouth was swollen today and bottom has stage 1 bedsore." There was no documentation to indicate the RN had been notified of the changes in the patient condition.

Upon personnel record review, 1 of 1 applicable (Personnel #2) did not have evidence the alternate administrator's personnel record verified that: • The employee has appropriate education and experience requirements • There is a signed job description for this role • The employee has been orientated to this role Personnel #2: There was no documentation to indicate the Alternate Administrator had been oriented to the role, and there was no personnel record to review to ensure the employee had appropriate education and experience and to ensure a signed job description was present.

Upon personnel record review, 1 of 12 (Personnel #5) did not have evidence the hospice employees and contract employees have received orientation on the hospice philosophy. Personnel #5: There was no indication the employee had received orientation on the hospice philosophy.

Upon patient client record review, 2 of 8 (Patient #5 and 7) 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 #5 admitted 1/5/22 consent/election statement signed and dated 12/15/20221. Patient #7 admitted 1/31/22 consent/elections statement signed and dated 12/10/2021.

Upon patient client record review, 6 of 8 (Patients #1, #2, #3, #5, #6 and #7) 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: (a) The Initial Chaplain Assessment was conducted on 1/28/2022. Documentation of the visit was not completed until 3/17/2022. (b) Nursing visits were conducted on 2/1/2022, 2/8/2022, 2/15/2022, 2/22/2022 and 3/2/2022. Documentation of the visits was not completed until 3/15/2022. Patient #2: (a) Nursing Visits were conducted on 2/7/2022, 2/10/2022. Documentation of the visits was not completed until 3/22/2022. (b) Nursing Visits were conducted on 2/17/2022, 2/22/2022, 2/25/2022, 3/1/2022 and 3/4/2022. Documentation of the visits was not completed until 3/23/2022. Patient #3: Nursing Visits were conducted on 1/20/2022, 1/24/2022. Documentation of the visits was not completed until 3/22/2022. Patient #5: Nursing Visits were conducted on 1/13/2022, 1/21/2022, 2/2/2022, 2/16/2022 and 2/24/2022. Documentation of the visits was not completed until 3/7/2022. Patient #6: Nursing Visits were conducted on 1/20/2022, 1/31/2022, 2/3/2022 and 2/14/2022. Documentation of the visits was not completed until 3/7/2022. Patient #7: A Chaplain Visit was conducted on 2/4/2022. Documentation of the visit was not completed until 3/15/2022. In the employee handbook a document titled "Timely Documentation" included ..."routine visits completed same day as visit"...

Upon personnel record review, 1 of 8 applicable (Personnel #2) did not have evidence that a criminal background check had been obtained in accordance with state requirements. In the absence of state requirements, criminal background checks are obtained within three months of the date of employment for all states that the individual has lived or worked in the past 3 years.

Upon patient record review, 8 of 10 applicable (Patient #1, #3, #4, #5, #6, #7, #8 and #9) 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 #1, 3, 4, 5, 6, 7, 8, 9 There was no evidence of an initial bereavement assessment having been completed.

Upon patient record review, 3 of 11 (Patient #1, #3, #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 equipment and supply needs. Patient #1 This patient had a wheel chair, shower chair, motorized scooter and lift chair. These were not included on the Plan of Care. Patient #3 This patient had a trapeze bar and bed side rails x 2. These were not included on the Plan of Care. Patient #4 Had an order for Oxygen prn, via nasal cannula. Oxygen supplies were not included on the Plan of Care

Upon patient record review, 3 of 11 (Patient #1, #10, #11) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1 SN visit frequency effective 10/13/21 was 2x week. There was evidence of only one visit by SN for the weeks of 10/13, 10/17, 10/24, 10/31 and 11/7/21 . Patient #10 The bereavement plan of care included a phone call in month 2. There was no evidence of contact with bereaved in month 2. Patient #11 SC visit frequency was 1x week. There was no evidence of a SC visit the week of 8/1/21. The bereavement plan of care included a call week 2 and week 4. There was no evidence of contact with bereaved in week 2 or 4.

Upon patient record review 3 of 9 applicable (Patient #3, #9 and #10) 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 The aide frequency was 3 x week. There was no evidence of a visit by the aide for the week of 11/10/21. Patient #9 The aide frequency was 3 x week. There was evidence of only 1 visit by the aide for the week of 10/24/21. Patient #10 The aide frequency was 3 x week. There was evidence of only 1 visit by the aide for the week of 7/4/21.

Upon personnel record review, 1 of 8 applicable (Personnel #11 ) did not have evidence that the hospice employees have received orientation on their specific job requirements. Personnel #11 Volunteer file did not have evidence of orientation in their personnel file.

Upon personnel record review, 1 of 8 applicable (Personnel #11 ) did not have evidence that a skills competency assessment, specific to each discipline had been conducted for all personnel including volunteers initially during orientation. Personnel # 11 did not have competency evaluation in their employee file. The volunteer provides administrative duties only.