Every finding on record at Family First Hospice, Inc

Upon patient record review, 4 of 5 (Patient #1,2,4,5) 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. This review includes, but is not limited to: Patient 1: The current medication profile contains an order for Betamethasone cream with the directive to apply topically to the affected foot twice daily. It does not have a directive of an amount such as a thin layer. Corrected on site. Patient 2: The current medication profile contains Nystatin powder 1 application to affected area left breast once daily until resolved. It does not contain a directive like thin layer for the amount to apply. The medication profile contains Aspercreme with directive of 1 application twice daily as needed to affected area. It does not specify where the cream can be applied or an amount that can be applied, such as thin layer. Corrected on site. Patient 4: The current medication profile contains Acetaminophen suppository 650mg every 6 hours prn for mild pain or fever and Acetaminophen 325mg 2 tablets every 4 hours prn. There is no directive to not exceed 3000mg daily of acetaminophen. The medication profile contains Lorazepam 0.5mg 1 tab every 6 hours as needed on the medication profile twice. Corrected on site. Patient 5: The current medication profile contains Diclofenac gel topical four times daily as needed. It does not contain a site to apply or an amount to apply like 1 inch strip or thin layer. The medication profile contains Nystatin Powder 1 application to the below left breast daily until resolved. No directive of amount to apply. Corrected on site.

Condition of participation: Initial and Comprehensive assessment of the patient

Upon patient record review 8 of 14 records (Patient #1, #2, #3, #4, #6, #7, #8, #9) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient #1: There was no evidence the psychosocial and or spiritual comprehensive assessment was completed within 5 days of the hospice admission at the time of the survey. Patient #2: There was no evidence the psychosocial and or spiritual comprehensive assessment was completed within 5 days of the hospice admission at the time of the survey. Patient #3: There was no evidence the psychosocial and or spiritual comprehensive assessment was completed within 5 days of the hospice admission at the time of the survey. Patient #4: There was no evidence the psychosocial and or spiritual comprehensive assessment was completed within 5 days of the hospice admission at the time of the survey. Patient #6: There was no evidence the psychosocial and or spiritual comprehensive assessment was completed within 5 days of the hospice admission at the time of the survey. Patient #7: There was no evidence the psychosocial and or spiritual comprehensive assessment was completed within 5 days of the hospice admission at the time of the survey. Patient #8: There was no evidence the psychosocial and or spiritual comprehensive assessment was completed within 5 days of the hospice admission at the time of the survey. Patient #9: There was no evidence the psychosocial and or spiritual comprehensive assessment was completed within 5 days of the hospice admission at the time of the survey.

Upon patient record review, 1 of 14 records reviewed (Patient #1) 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: The patient was receiving oxygen 2 lpm via NC, this was not listed on the medication profile. Upon home visit, the medication profile had Gabapentin 800 mg po TID and Gabapentin 300mg po Q6 hours, the patient was taking Gabapentin 800mg po TID. COS.

Upon patient record review, 9 of 14 charts reviewed (Patient #1, #2, #3, #4, #6, #7, #8, #9, #10) 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: There was no bereavement risk assessment completed within 5 calendar days from the start of hospice care at the time of the survey. Patient #2: There was no bereavement risk assessment completed within 5 calendar days from the start of hospice care at the time of the survey. Patient #3: There was no bereavement risk assessment completed within 5 calendar days from the start of hospice care at the time of the survey. Patient #4: There was no bereavement risk assessment completed within 5 calendar days from the start of hospice care at the time of the survey. Patient #6: There was no bereavement risk assessment completed within 5 calendar days from the start of hospice care at the time of the survey. Patient #7: There was no bereavement risk assessment completed within 5 calendar days from the start of hospice care at the time of the survey. Patient #8: There was no bereavement risk assessment completed within 5 calendar days from the start of hospice care at the time of the survey. Patient #9: There was no bereavement risk assessment completed within 5 calendar days from the start of hospice care at the time of the survey. Patient #10: There was no bereavement risk assessment completed within 5 calendar days from the start of hospice care at the time of the survey.

Upon patient record review, 3 of 14 records reviewed (Patient #1, #3, #10) 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 #1: The record indicated an RN visit on 2/20/25. An RN did not visit again until 03/17/25, the comprehensive assessment was not updated in 15 days. Patient #3: The record indicated an RN visit on 03/26/25. An RN did not visit again until 04/28/25, the comprehensive assessment was not updated in 15 days. Patient #10: The record indicated an RN visit on 08/15/24. An RN did not visit again until 09/27/24, the comprehensive assessment was not updated in 15 days.

Upon patient record review, 3 of 14 records reviewed (Patient #1, #2, #3) 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 #1: The pain assessment on 02/20/25 was a "3", the self identified threshold was a "2" for generalized pain, there was no follow up on the pain assessment during the next nursing visit on 02/22/25, therefore there was no continuous RN assessment. Patient #2: The pain assessment on 04/03/25 was a "3", the self identified threshold was a "2" for generalized pain, there was no follow up on the pain assessment during the next nursing visit on 04/05/25, there was no continuous RN assessment. Patient #3: The pain assessment on 03/26/25 was a "4", the self identified threshold was a "3" for generalized pain, there was no follow up on the pain assessment during the next nursing visit on 03/28/25, there was no continuous RN assessment.

Upon patient record review, 4 of 14 records reviewed (Patient #1, #3, #7, #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 #1: The record indicated the patient was taking Humalog 100U/ml 5 Units SQ daily with meals TID and Lantus 100U/ml 20U SQ BID, there was no individualized interventions to include blood sugar checks (by whom) and what levels to report and who this should be reported to. COS. Patient #3: The record indicated the patient had a 16 French foley the plan of care did not reflect the patient/family goals. COS. Patient #7: The record indicated the patient was a full code and did not have mortuary plans, there was no individualized interventions to include patient/family goals. Patient #8: The record indicated the patient was a full code and did not have mortuary plans, there was no individualized interventions to include patient/family goals.

Upon patient record review, 1 of 14 (Patient #3) 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 #3: The record indicated the patient had a 16 French foley there was no orders to include how much (saline and or sterile water) to put in the balloon and or when to change the foley catheter. COS.

Upon patient record review 2 of 14 records (Patient #4, #10) did not have evidence that the IDG ensures that the care and services provided are based on all assessments of the patient and family needs. Patient #4: The pain assessment on 11/21/24 was a "4", the self identified threshold was a "3" for generalized pain, the follow up was on 11/23/24 with a pain level of "8-9", the patient needs were not being met. Patient #10: The pain assessment on 08/15/24 was a "3", the self identified threshold was a "2" for generalized pain, the pain was reassessed during the next nursing visit on 08/19/24 the nurse marked yes to pain but no details, the patients needs were not being met.

Upon patient record review, 1 or 14 records reviewed (Patient #1) did not have evidence that the IDG shares information on a on-going basis with non-hospice healthcare providers furnishing services unrelated to the terminal illness and related conditions. Patient #1: The record indicated the patient was taking Humalog 100U/ml 5 Units SQ daily with meals TID and Lantus 100U/ml 20U SQ BID, there was no individualized interventions to include blood sugar checks (by whom) and what levels to report and who this should be reported to, the facilities responsibilities were not included in who would check the blood sugar and how often and who to report what readings to.  COS.

Upon patient record review 1 of 14 charts reviewed (Patient #5) 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 #5: The record indicated the hospice aide made the first visit on 02/03/24, there was no RN supervisory completed on 02/17/24 or anytime after 02/03/24 and or before 02/17/24.

Upon client record review, 1 of 14 records reviewed (Patient #3) did not have evidence that all drugs and biologicals are labeled in accordance with currently accepted professional practice and include appropriate usage and cautionary instructions, as well as an expiration date, if applicable. Patient #3: Upon a home visit the liquid morphine was found in the refrigerator, it states on the box this should be stored at room temperature (68 degrees F to 77 degrees F), the medication was not stored at the proper temperature. COS.