Every finding on record at Family Hospice, Ltd.

Upon observation, 1 of 3 home visits (patient #3 ) did not evidence that the patient has the right: • To exercise his or her rights as a patient of the hospice to be able to identify personnel through agency generated photo identification. Patient #3-The Spiritual Care Provider did not have a name badge on the home visit 01/17/24.

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-The patient was admitted on 12/01/23 and the first spiritual assessment occurred on 12/07/23.

Upon patient record review, 1 of 14 (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. Patient #1: The patient has the following medications ordered as needed for pain without differentiation for administration: Morphine 15 mg tablet 1 tablet q4h prn pain and Hydrocodone 10 mg-Acetaminophen 325 mg 1 tab q6h prn pain. (corrected on site)

Upon patient record review, 1 of 14 (Patient #6) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component within 5 days 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 #6-The patient was admitted 10/18/23 and the bereavement risk assessment was performed on 10/24/23 (day 6).

Upon patient record review, 3 of 14 (Patient #1, #6, #9) did not have evidence the plan of care includes all services necessary for the palliation and management of the terminal illness and related conditions, including specific orders for all medications and treatments. Patient #1: The 01/03/24 plan of care has the following medications ordered as needed for pain without differentiation for administration: Morphine 15 mg tablet 1 tablet q4h prn pain and Hydrocodone 10 mg-Acetaminophen 325 mg 1 tab q6h prn pain. The plan of care lists nutritional requirements as : G tube as tolerated. Orders are not specific for G tube feedings/care of peg site. The patient was admitted with a urostomy and the plan of care does not address management of the urostomy. The plan of care has Oxygen ordered at 1-2 lpm prn shortness of breath. On 01/12/23 the nurse documented the patient was on 4lpm. Orders were not written to update the plan of care for 2-4 liters as needed for shortness of breath. (late entry orders/corrected on site) Patient #6-The 12/01/23 plan of care includes osteoarthritis, rheumatoid arthritis and GERD as the only diagnoses for the terminal illness. The record indicates the patient also had the following additional diagnoses upon admission: Gastrointestinal hemorrhage, Essential Hypertension, Esophagitis, Hypothyroidism and Glaucoma which were not included in the plan of care(corrected on site). Patient #9-The patient was admitted 11/29/23 with orders for the nurse to instruct on management of the urinary catheter and drainage system. Orders are not specific for catheter type/size/balloon size or management .

Upon patient record review, 1 of 14 (Patient #1 ) did not have evidence the plan of care included all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient #1-Oxygen was ordered 12/20/23. The plan of care was not updated in the equipment section for Oxygen. (corrected on site)

Upon patient record review, 2 of 14 (Patient #6, #9) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #6- On 10/08/23 the Chaplain is ordered to visit 2m3( twice monthly for 3 months). The Chaplain visited 10/19/23, 10/23/23, and 10/26/23 (three times monthly in October). Patient #9-On 12/01/23 the Chaplain is ordered to visit 2m3( twice monthly for 3 months). The Chaplain visited 12/01/23, 12/06/23, and 12/19/23 (three times monthly in December) . On 12/01/23 the Social Worker is ordered to visit 4m1(Four times monthly for one month). The Social Worker visited 12/01/23. 12/08/23, 12/14/23, 12/23/23 and 12/28/23. (Five times in December) (frequency orders updated/corrected on site)