Every finding on record at Faith Hospice Care LLC

Upon patient record review 1 of 10 (Patient #1) did not have evidence that the hospice Registered Nurse must complete an initial assessment within 48 hours after the election of hospice care in accordance with §418.24 Patient #1: There is evidence that the election statement indicated the start of care date was 9/18/24. The initial RN assessment was completed on 9/22/24. Not within 48 hours.

Upon patient record review, 6 of 10 (Patient #1,2,3,5,6,7) 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: There was evidence during the home visit the facility medication record contained medications not on the agency medication record. Missing from the agency record were Seroquel 25 mg 2 times a day; sucralfate 1 gram 3 times a day; Flomax 0.4mg daily and Lorazepam 1 mg 2 times a day. (corrected on site) Patient #2: There was evidence on the medical record of an order for DME oxygen 3L/min via NC continuous. Oxygen is not on the medication record. (corrected on site) Patient #3: There was evidence on the medical record of an order for DME oxygen concentrator 2L/min via NC. Oxygen is not on the medication record. (corrected on site) Patient #5: There was evidence during the home visit the facility medication record contained medications not on the agency medication record. Missing from the agency record were ascorbic acid 500 mg 2 times a day; Haldol 2mg/ml, give 0.5 ml q 6hr PRN for agitation. In addition, the facility medication record listed Lorazepam 1mg every 6hr PRN agitation and the agency record stated Lorazepam 0.5 mg every 6hr PRN agitation. (corrected on site) Patient #6: There was evidence on the medical record of an order for DME oxygen 3L/min via NC. Oxygen is not on the medication record. (corrected on site) Patient #7: There was evidence in the medical record nurses note 9/6/24 "patient is on oxygen 3 L/min continuously. Oxygen is not on the medication record. (corrected on site)

Upon patient record review, 5 of 10 (Patient #1,2,3,4,5) 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 #1-5: There was evidence in the chart that each patient had a visit frequency of MSW 1XMonth and 1 PRN for psychosocial issues and each patient had a visit frequency of chaplain 1XMonth and 1PRN for spiritual issues. None of the patients had a psychosocial plan of care nor a spiritual plan of care. (All plans of care were corrected on site)

Upon patient record review, 6 of 10 (Patient #1,2,3,5,6,7) 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: There was evidence during the home visit the facility medication record contained medications not on the agency medication record an no evidence of orders. Missing from the agency record were Seroquel 25 mg 2 times a day; sucralfate 1 gram 3 times a day; Flomax 0.4mg daily and Lorazepam 1 mg 2 times a day. (corrected on site) Patient #2: There was evidence on the medical record of an order for DME oxygen 3L/min via NC continuous. Oxygen is not on the plan of care. (corrected on site) Patient #3: There was evidence on the medical record of an order for DME oxygen concentrator 2L/min via NC. Oxygen is not on the plan of care. (corrected on site) Patient #5: There was evidence during the home visit the facility medication record contained medications not on the agency medication record. Missing from the agency record were orders forvascorbic acid 500 mg 2 times a day; Haldol 2mg/ml, give 0.5 ml q 6hr PRN for agitation. In addition, the facility medication record listed Lorazepam 1mg q 6hr PRN agitation and the agency record order stated Lorazepam 0.5 mg every 6hr PRN agitation. (corrected on site) Patient #6: There was evidence on the medical record of an order for oxygen 3L/min via NC. Oxygen is not on the plan of care. (corrected on site) In addition, there is an order for foley catheter, change every 30 days and as needed per facility. The size of the catheter is not indicated. (corrected on site) Patient #7: There was evidence in the medical record nurses note 9/6/24 "patient is on oxygen 3 L/min continuously. Oxygen is not on the plan of care. (corrected on site)

Upon patient record review, 1 of 10 (Patient #7) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient #7: There is evidence in the medical record of nurses note 9/6/24 "patient no longer taking food or fluids, on scheduled morphine and Ativan for terminal restlessness". The plan of care was not updated to include imminent death and terminal restlessness.

Upon client record review, 1 of 10 (Patient #7) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #7: There was evidence in the medical record the social worker visit frequency was 1xmonth and 1 PRN. In September, 2024, the social worker visited on 9/3, 9/5, 9/6 and 9/7/24.

Upon patient record review, 1 of 10 (Patient #1) 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: There is evidence in the record that the patient is on seizure precautions. Seizure precautions were not listed on the aide plan of care. (corrected on site)

Upon patient record review, 1 of 10 (Patient #1) did not have evidence that the medical director or physician designee provides written certification that it is anticipated that the patient's life expectancy is 6 months or less if the illness runs its normal course. The physician must consider the following when making this determination: • The primary terminal condition • Related diagnosis • Current subjective and objective medical findings • Current medication and treatment orders • Information about the medical management of any of the patient's conditions unrelated to the terminal illness Patient #1: There is evidence that the election statement indicated the start of care date was 9/18/24. The verbal certification of terminal illness was completed until 9/22/24.

Upon patient client record review, 1 of 10 (Patient #1) 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: The IDG notes on 9/24/24, the nurse indicated the patient was FAST 7D and the physician indicated the patient was FAST 7C.