Every finding on record at Family Hospice, Ltd.

Upon patient record review 2 of 15 (Patients #1,#9) 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 1: The medical record contained an initial comprehensive spiritual assessment completed 12/14/23 with a start of care 12/8/23. Patient 9: The medical record contained an initial comprehensive spiritual assessment completed 4/24/23 with a start of care 4/18/23.

Upon patient record review 1 of 15 (Patient #4) 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 4: There was no evidence of a comprehensive spiritual assessment.

Upon patient record review, 2 of 15 (Patients #1,#10) 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 medication profile contained duplicative Colace listings. Corrected on site. Patient 10: The initial care plan order contained an order for oxygen equipment. There was no evidence of oxygen included in the medication profile. Corrected on site.

Upon patient record review, 1 of 15 (Patient #1) 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: The medical record contained an initial bereavement assessment completed 12/14/23 with a start of care 12/8/23

Upon patient record review, 4 of 15 (Patients #2,#3,#5,#6) 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 2: The medical record contained nursing documentation upon admission identifying patient is a high risk for falls. There was no evidence of problems, goals, and interventions related to safety included in the plan of care. Corrected on site. Patient 3: The medical record contained nursing documentation upon recert visit 12/7/23 identifying patient is a high risk for falls. There was no evidence of problems, goals, and interventions related to safety included in the plan of care. Corrected on site. Patient 5: The medical record identified patient was on hospice services for dysphagia following a CVA. There was no evidence of problems, goals, and interventions related to the risk for aspiration included in the plan of care. Corrected on site. Patient 6: The medical record contained nursing documentation upon admission identifying patient is a high risk for skin impairment. There was no evidence of problems, goals, and interventions related to skin included in the plan of care. Corrected on site.

Upon patient record review, 1 of 15 (Patient #10) 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 10: The initial care plan order contained an order for oxygen equipment. There was no evidence of an order for the oxygen dose, frequency, and delivery method. Corrected on site.

Upon patient record review, 3 of 15 (Patients #3,#5,#6) 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 3: The medical record contained nursing documentation upon admission identifying patient use of walker for ambulation. There was no evidence of the walker included as DME in the plan of care. Corrected on site. Patient 5: The medical record contained nursing documentation 12/15/23 identifying patient use of a walker for ambulation. There was no evidence of the walker included as DME in the plan of care. Corrected on site. Patient 6: The medical record contained IDT documentation 12/27/23 identifying patient use of a hospital bed. There was no evidence of the bed included as DME in the plan of care. Corrected on site.

Upon observation, there was no evidence the hospice investigates all adverse events, incidents, accidents, variances or unusual occurrences that involve patient care and develops a plan of correction to prevent the same or similar event from occurring again. Patient 7: The medical record contained nursing documentation 12/7/23 identifying patient had a fall 12/1/23. There was no evidence of an incident report and investigation of the fall. Corrected on site.

Upon patient record review, 6 of 15 (Patients #1,#2,#5,#6,#9,#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 1,2,5,9: The aide care plans did not contain instructions for transfer assist needed. Corrected on site. Patient 6,10: The aide care plans contained task for shower with no task for transfers and instructions for transfer assist needed. Corrected on site.

Upon patient client record review, 1 of 15 (Patient #1) did not have evidence that each patient record contains Advance Directives. Patient 1: The medical record contained social work documentation identifying a DNR form was completed. There was no evidence of a copy of the form in the medical record.

Upon patient client record review, 1 of 15 (Patient #14) did not evidence that each patient record contains physician orders. Patient 14: There was no evidence of an order to discharge upon patient transfer.

Upon patient client record review, 1 of 15 (Patients #11) 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 11: The on-call log contained documentation of a PRN nursing visit completed but there was no documentation of the visit completed in the medical record.

Upon client record review, 1 of 15 (Patient #14) did not have evidence that the hospice forwarded a summary and a copy of the patient record, if requested, to a facility when transferring the patient to that facility. Patient 14: There was no evidence of coordination of care with the receiving hospice agency for a transfer.