Every finding on record at Freudenthal Home Health, LLC

Upon patient record review, 7 of 19 (Patients #1,2,3,4,8,9,14) 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: Hospice medication profile indicated a daily Multi-Vitamin. Per wife, patient unable to swallow this tablet and is no longer giving him. Agency obtained DC order during survey. Corrected on Site. Patient #2: Hospice medication profile indicated Polyethylene Glycol 17 gm powder with no diluent. Medication reconciliation with facility did not have Albuterol MDI or Duo Neb on their med profile. Patient had been refusing respiratory medications per hospice nurse. Agency obtained clarification order for Polyethylene Glycol and DC orders for albuterol and Duo Neb. Corrected on Site. Patient #3: Hospice medication profile indicated Vitamin D 125mcg, Tums 500mg, Seroquel 25mg, Saccharomyces Boulardii 250mg, Ondansetron 4mg, Nexium 20mg and MVI 0.4mg. These medications were not profiled at the facility. Agency obtained DC orders. Corrected on Site. Patient #4: Hospice medication profile indicated Polyethylene Glycol 17 gm powder with no diluent. Corrected on Site. Patient #8: Hospice medication profile indicated Polyethylene Glycol 17 gm powder with no diluent. Also, record indicated patient had an O2 Concentrator. Oxygen was not on medication profile. Corrected on Site. Patients #9 and #14: The record(s) indicated patient(s) had an O2 Concentrator. Oxygen was not on medication profile. Corrected on Site.

Upon patient record review, 2 of 19 (Patients #7, 18) 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 #7: The initial bereavement risk assessment was not timely. This assessment was performed on 4/6/24; this patient was admitted on 2/9/24. Patient #18: The initial bereavement risk assessment was not timely. This assessment was performed on 12/8/23; this patient was admitted on 2/2/23.

Upon patient record review, 3 of 19 (Patients #2,4,8) did not have evidence the plan of care (POC) must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #2: The Initial POC indicated Polyethylene Glycol 17 gm powder with no diluent. Patient #4: The Initial POC indicated Polyethylene Glycol 17 gm powder with no diluent. Patient #8: The Initial POC indicated Polyethylene Glycol 17 gm powder with no diluent.

Upon patient record review, 2 of 19 (Patients #6, #9) did not have evidence the plan of care (POC) must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patients #6, #9: The record(s) indicated these patients had Duo Neb solution/inhalation medication. There was no DME-Nebulizer Machine listed on POC. Corrected on Site.

Upon personnel record review, 1 of 12 (Personnel #8 ) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) Personnel #8: The Range of Motion competency for the Aide was not evaluated with a patient or pseudo patient. The competency form was left blank.

Upon patient record review 3 of 19 (Patients #2, #6, #8) 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 (POC) Patient #2: The POC listed Aide visit frequency of, 2 X's per week (11/12/23 start). The Aide visited this patient 1X before start date took effect on 11/9/23. Patient #6: The POC listed Aide visit frequency of, 2 X's per week (1/11/24). For first Benefit Week, there was only 1 visit on 1/11/24. Patient #8: The POC listed Aide visit frequency of, 2 X's per week (4/13/24). For first Benefit Week, there were no visits performed by the Aide.

Upon patient client record review, 19 of 19 (Patients #1 through #19) did not have evidence that each patient record contains: • Signed election statement in accordance with 418.24 Patients #1 through #19: Did not have Notice of Non-Covered Items or BFCC-QIO information on Election form.

Upon client record review, 1 of 19 (Patient #16) did not have evidence that the discharge summary includes all required information. Patient #16: The patient's current plan of care was not included with other discharge summary documents.

Upon observation, there was no evidence a copy is provided of the hospice written policies and procedures on the management and disposal of controlled drugs to the patient or patient representative and family.

Upon patient record review, 1 of 13 (Patient #11) 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 #11 Did not have an initial bereavement risk assessment on record.

Upon patient record review, 2 of 13 (Patients #1 and #2) 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 This patient had a hospital bed and fall pad. This was not included on the Plan of Care. corrected on site. Patient #2 This patient had a hospital bed, LAL mattress and lift chair. This was not included on the Plan of Care. corrected on site.

Upon patient record review, 6 of 13 (Patient #1, #4, #5, #8, #12, #13) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1 The POC dated 12/30/21 listed Nursing visit frequency of 2 x per week. There was only 1 visit documented week of 11/21/21. Patient #4 The POC dated 9/20/21 listed Nursing visit frequency of 2 x per week. There was only 1 visit documented week of 11/14/21. Patient #5 The POC dated 10/20/21 listed Spiritual Counselor visit frequency of 2 x per 4 weeks (not calendar month). There was evidence of visits made on 10/20/21 and 11/23/21 which were greater than 4 weeks apart. Patient #8 The POC dated 10/30/19 listed Nursing visit frequency of 2 x per week. Weeks of 12/8/20 and 12/22/20 there was evidence of 3 visits each week. Patient #12 The POC dated 6/17/21 listed Nursing visit frequency of 2 x per week. Week of 6/13/21 there was evidence of 3 visits. Patient #13 The POC dated 6/6/21 listed Nursing visit frequency of 7 x per week. Week of 6/6/21 there was evidence of only 4 visits.

Upon patient record review 3 of 12 applicable (Patient #5, #6 and #7) did not have evidence documentation in the patient record that a hospice aide provides services that are ordered by the interdisciplinary group and included in the plan of care Patient #5 The POC dated 10/24/21 listed Aide visit frequency of 2 x per week. There was only 1 Aide visit documented week of 11/14/21. Patient #6 The POC dated 12/7/21 listed Aide visit frequency of 2 x per week. There was only 1 Aide visit documented week of 12/6/21. Patient #7 The POC dated 11/30/21 listed Aide visit frequency of 2 x per week. There was only 1 Aide visit documented week of 11/28/21.

Upon personnel record review, 1 of 1 applicable (Personnel #2 ) did not have evidence the alternate administrator's personnel record included a signed job description for this role. The job description was signed during survey and corrected on site.