Every finding on record at Family Hospice, Ltd.

Upon observation, there was no evidence the annual report documents the use of volunteers providing day to day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract personnel. There was no evidence that volunteer hours equaled 5% of total patient care hours.

Upon patient record review 1 of 13 records (Patient #2) 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 #2: The record indicated with comprehensive spiritual assessment was not performed until 02/18 however, patient admitted on 01/31.

Upon patient record review 1 of 13 records(Patient #3) 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 #3: The record did not contain evidence of comprehensive spiritual assessment.

Upon patient record review, 8 of 13 records (Patients #2, #3, #4, #7, #8, #9, #11, #12) 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 #2: The medication profile included acetaminophen 325mg tablet take 2 PO every 4 hours as needed for pain ordered 2/2 and hydrocodone 5mg-325mg acetaminophen take one tablet twice a day for pain ordered 7/15 without evidence of maximum allowable dose. [COS] The medication profile included oxygen 1-5lpm as needed for dyspnea, sob, or chest pain without delivery route. [COS] Patient #3: The medication profile included clotrimazole AF 1% topical cream, apply 1 gram as needed to affected area for rash without listed affected area. [COS] Patient #4: The medication profile included acetaminophen 650mg 1 tablet by mouth every 4 hours as needed and acetaminophen rectal suppository to insert 1 sup rectally every 4 hours as needed without evidence of maximum allowable dose. [COS] Patient #7: The medication profile included acetaminophen 325mg take 2 every 6 hours prn pain on 5/11, and hydrocodone 5/325 take one tablet every 4 hours PRN for pain 5/11 without evidence of maximum allowable dose. [COS] Patient #8: The medication profile included oxygen order on 6/13/22 use 1-5 LPM for dyspnea and sob without delivery route. [COS] Patient #9: The record indicated 9/7 nurse educated on Zofran after patient had 2 episodes of nausea and vomiting that morning however, the medication profile did not contain Zofran. [COS] Patient #11: The medication profile included Voltaren 1% apply 2g topically 4xper day PRN-no area or reason 10/19/21. Patient #12: The medication profile included acetaminophen 650 mg rectally every 4 hours PRN pain/temp and on 2/25/22 acetaminophen rectally every 4 hours pain/temp-duplicate orders, 10/7/20 polyethylene glycol 3350 `7 gram/dose oral powder as directed for constipation, 2 duplicate Zofran orders--10/7/21 Zofran 4mg tablet 1 tablet every 8 hours as directed and 2/24/22 Zofran take 1 tablet every 4 hours as needed.

Upon patient record review, 1 of 13 records (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 record contained evidence that bereavement assessment was not performed until 07/26 however, patient admitted 07/10/22.

Upon patient record review, 3 of 13 (Patient #1, 9, 12) 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 did not contain evidence of plan of care including dysphagia and facility coordination however, record contained IDG note on 8/3 indicated episode over weekend of 7/30/22 in which she became unconscious for a period of time and caregiver indicated patient choked on water and passed out along with note on 09/01 that patient was placed in LTCF permanently. [COS] Patient #9: The record indicated 9/7 nurse visit revealed patient went to emergency room for nausea and dizziness and nurse educated on Zofran after patient had 2 episodes of nausea and vomiting that morning however, the plan of care was not updated with problems/interventions/goals for nausea and vomiting. [COS] The record indicated the patient was a DNR however, there was no evidence of OOH-DNR form. After administrator reviewed record, it was discovered patient was full code. [COS] Patient #12: The record indicated patient was admitted with multiple sclerosis without any neurological problems/interventions/goals.

Upon patient record review, 8 of 13 records (Patient #2, #3, #4, #7, #8, #9, #11, #12) 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 #2: Acetaminophen 325mg tablet take 2 PO every 4 hours as needed for pain ordered 2/2 and hydrocodone 5mg-325mg acetaminophen take one tablet twice a day for pain ordered 7/15 without evidence of maximum allowable dose. [COS] Order for oxygen 1-5lpm as needed for dyspnea, sob, or chest pain without delivery route. [COS] Patient #3: The order included clotrimazole AF 1% topical cream, apply 1 gram as needed to affected area for rash without listed affected area. [COS] Patient #4: The order included acetaminophen 650mg 1 tablet by mouth every 4 hours as needed and acetaminophen rectal suppository to insert 1 sup rectally every 4 hours as needed without evidence of maximum allowable dose. [COS] Patient #7: The order included acetaminophen 325mg take 2 every 6 hours prn pain on 5/11, and hydrocodone 5/325 take one tablet every 4 hours PRN for pain 5/11 without evidence of maximum allowable dose. [COS] Patient #8: The oxygen order on 6/13/22 use 1-5 LPM for dyspnea and sob without delivery route. [COS] Patient #9: The record indicated 9/7 nurse visit educated on Zofran after patient had 2 episodes of nausea and vomiting that morning however, no evidence of an order for Zofran. [COS] Patient #11: The order included Voltaren 1% apply 2g topically 4xper day PRN-no area or reason 10/19/21. Patient #12: The orders included acetaminophen 650 mg rectally every 4 hours PRN pain/temp and on 2/25/22 acetaminophen rectally every 4 hours pain/temp-duplicate orders, 10/7/20 polyethylene glycol 3350 `7 gram/dose oral powder as directed for constipation, 2 duplicate Zofran orders--10/7/21 Zofran 4mg tablet 1 tablet every 8 hours as directed and 2/24/22 Zofran take 1 tablet every 4 hours as needed.

Upon patient record review, 4 of 13 records (Patient #1, #2, #5, #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 equipment and supply needs. Patient #1: The record indicated patient has an electric scooter which was not listed on plan of care. [COS] Patient #2: The record indicated patient has a bedside commode which was not listed on plan of care. [COS] Patient #5: The record indicated patient has a gel/foam overlay, oxygen, and nebulizer not listed on plan of care. [COS] Patient #7: The record indicated patient has bedside commode, wheelchair, and over the bed table not listed on plan of care. [COS]

Upon client record review, 3 of 7 applicable records (Patient #2, #8, #12) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #2: The record indicated patient was to receive weekly chaplain visit however, there was no visit the week of 08/21. [COS] Patient #8: The record indicated patient had volunteer visit on 08/18 however, there was no evidence of visit frequency on plan of care or order. [COS] Patient #12: The record indicated orders for nursing 7 times per week however, the week of 3/13 there was only evidence of 5 visits on 3/13, 3/14, 3/16, 3/17, 3/18.

Upon observation, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient #1 observed nurse go to sink to wash hands however, did not observe nurse use soap when washing before and after patient per agency Hand Hygiene policy #6-006.

Upon patient record review 1 of 10 applicable (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 record indicated HHA only had 2 visits the week of 9/4 by HHA (9/7 and 9/9) and visit frequency was ordered 3 times per week. [COS]

Upon client record review, 3 of 6 applicable (Patients #1, #4, #5) did not have evidence that a written hospice plan of care is established and maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided is in accordance with this hospice plan of care. Patient #1: The record indicated patient received 2 nurse visits the week of 8/28 on 8/29 and 8/30 (PRN on 8/28, 9/1 and 9/3), visit frequency for 3 times per week. In addition, there were no chaplain visits in the month of July which was ordered one time per month. [COS] Patient #4: The record indicated order for social worker monthly however, there was no evidence of visit in July. [COS] Patient #5: The record indicated order for spiritual care twice a month however, the chaplain performed 3 visits in August-8/2, 8/12 and 8/26.