Every finding on record at Family First Home Health and Hospice LLC

Upon patient record review, 6 of 14 (Patient #3,6,7,8,9,10) 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 #3, orders dated 10/12/24 state Chaplain PRN x2 and MD PRN x1, no evidence of specified frequency. Patient #6, orders dated 8/12/24 state MSW PRN x2 and MD PRN x1, no evidence of specified frequency. Patient #7, orders dated 7/12/23 state MSW PRN x2 and Chaplain PRN x1 and orders dated 8/29/24 state MD PRN x1, no evidence of specified frequency. Patient #8, 9, orders dated 7/17/24 state MSW PRN x2 and Chaplain PRN x2, no evidence of specified frequency. Patient #10, orders dated 8/14/24 state MD PRN x1 and Chaplain PRN x2 and orders dated 10/13/24 state MSW PRN x2 and Chaplain PRN x2, no evidence of specified frequency.

Upon patient record review, 1 of 14 (Patient #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 #4, order dated 8/15/24 states Mupirocin ointment to be applied to affected areas, no evidence of specific areas to be applied.

Upon patient record review 1 of 14 (Patient #1) 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 #1, the aide is documenting on visits dated 10/7/24 and 10/12/24 that shampoo and shave were completed, however the frequency is ordered as weekly.

Upon patient record review, 3 of 14 (Patient #4,5,9) did not have evidence that each patient record contains Advance Directives. Patient #4, 5, 9, the documentation at admission states the patient has advance directives that were provided to the agency, however no evidence of advance directives present.

Upon patient record review, 1 of 5 (Patient #5) 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. Patient #5 - Documentation revealed on the initial Plan of Care an order for oxygen 2L/min NC continuous. The medication list said oxygen 2.5L/min NC continuously.

Upon patient record review, 1 of 5 (Patient #1) did not have evidence of an individualized written plan of care that included all problems identified in the initial and/or comprehensive assessment. Patient #1 - The record indicated the patient had a primary terminal diagnosis of Senile Degeneration of the Brain. Documentation revealed the patient was sleeping the majority of the day (16-18 hours), increased confusion, orientated x1, hallucinations, loss of mobility and decreased appetite. There is no evidence in the Plan of Care of a neurological or cognitive problem with individualized goals and interventions.

Upon patient record review, 2 of 5 (Patient #3,5) did not have evidence the plan of care included a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs. Patient #3 - The record indicated that the chaplain services were declined but there was a visit order for the chaplain PRN x2. PRN visits can not stand alone. Patient #5 - There was a visit order for the chaplain visits monthly and PRN. There is no evidence of a frequency for the PRN visits.

Upon patient record review, 2 of 5 (Patient #1,4) 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 #1 - The record indicated an order on the initial Plan of Care and recert Plan of Care that said "O2 PRN if needed" There is no evidence of the oxygen rate, route or indicator for the PRN use. Patient #4 - The record indicated an order on the initial plan of care for O2 2L/NC PRN. There is no evidence of a indicator of the PRN.