Every finding on record at Full Care Hospice and Palliative Care Inc

Upon patient record review 3 of 14 records reviewed (Patient #1, #2, #7) 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: The record indicated the start of care for hospice is 05/14/25, there was no psychosocial and or spiritual comprehensive assessment completed at the time of the survey on 5/21 record review. Patient #2: The record indicated the start of care for hospice is 05/03/25, there was no spiritual comprehensive assessment completed at the time of the survey. Patient #7: The record indicated the start of care for hospice is 04/04/25, there was no spiritual comprehensive assessment completed 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 medication profile had acetaminophen 325mg po 2 tabs po Q4hours prn pain/fever and acetaminophen suppositories 650mg PR Q6hours prn pain/fever. There was no max daily dose of 4gm on the profile. COS.

Upon patient record review, 2 of 14 records reviewed (Patient #1, #6) 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 indicated the patient was admitted to hospice on 05/14/25, there was no initial bereavement assessment completed at the time of the survey. Patient #6: The record indicated the patient was admitted to hospice on 04/12/25, the initial bereavement assessment was not completed until 05/10/25.

Upon patient record review, 3 of 14 records reviewed (Patient #1, #9, #10) 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 on the medication profile the patient was taking Metoprolol 25mg 1/2 tab po QHS and to hold if systolic blood pressure was less than 108 and or heart rate was less than 60. The individualized plan of care did not include these parameters and or who would take the blood pressure and or if the patient had a blood pressure cuff and or if the hospice needed to provide a BP cuff. COS. Patient #9: The social worker assessment on 02/28/25 indicated that the patient did not have funeral arrangements and the code status was undecided, there was no individualized written plan of care to reflect the patient/family goals and interventions regarding these problems. Both COS. Patient #10: The record indicated the patient was on Xarelto 15mg po daily for atrial fibrillation, there was no individualized written plan of care for bleeding precautions reflecting the patient/family goals and interventions based on this problem. COS.

Upon patient record review, 1 of 14 records reviewed (Patient #1) 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 #1: The order was written for acetaminophen 325mg po 2 tabs po Q4hours prn pain/fever and acetaminophen suppositories 650mg PR Q6hours prn pain/fever. There was no max daily dose of 4gm in the order. COS.

Upon patient record review, 1 of 14 records reviewed (Patient #1) 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 the patient was to check her blood pressure prior to taking Metoprolol 25mg 1/2 tab po QHS with instructions to hold if SBP is less than 108 and or HR is less than 60. There was no BP Cuff listed in the plan of care. COS.

Upon patient record review 3 of 14 charts reviewed (Patient #2,3,9) 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 #2: The record indicated the patient did not have funeral arrangements at the start of care, no follow up visits had been made as of the time of the survey. The needs of the patient and family were not met at the time of the survey. COS. Patient #3: The record indicated by the spiritual comprehensive assessment that the patient was lonely, had social isolation and distress from a poor prognosis and the psychosocial comprehensive assessment indicated the patient/family needed to work on making a decision for a mortuary. There was no follow up visits had been made as of the time of the survey. The needs of the patient and family were not met at the time of the survey. COS. Patient #9: The Social Worker assessment on 02/25/25 determined there were no funeral arrangements in order, no follow up visits had been made as of the time of the survey. The needs of the patient and family were not met at the time of the survey.

Upon patient record review, 2 of 14 records reviewed (Patient #1, #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: The record indicated the Hospice Aide frequency was ordered for 2 X week. There was no Hospice Aide Care Plan completed at the time of the survey. COS. Patient #10: The record indicated the Hospice Aide did not have bleeding precautions on the care plan, the patient was taking Xarelto 15mg po daily. COS.

Upon patient record review 1 of 14 records reviewed (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 on 05/14/25 that the Hospice Aide was ordered 2 x W. There was no aide visits on the chart as being completed at the time of the survey.

Upon patient record review 1 of 14 records reviewed (Patient #3) 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 #3: The record indicated the Hospice Aide was ordered to visit 2 X W, the first visit was made on 05/01/25. The RN visits made on 5/6/25, 5/9/25, 5/12/25, and 5/16/25 did not have an aide supervisory visit completed at the time of the survey.

Upon personnel record review, 1 of 16 records reviewed (Personnel #7) did not have evidence in the hospice aide personnel file that a registered nurse made an annual on-site visit to the location where a patient is receiving care in order to observe and assess each aide while he or she is performing care. The supervising nurse must assess an aide's ability to demonstrate initial and continued satisfactory performance in meeting outcome criteria that include all required content. Personnel Records #7: The HR file did not have a completed annual on-site visit to observe and assess the hospice aide while she was performing care, it was due by November 15, 2024. COS.

Upon personnel record review, 1 of 15 personnel records (Personnel #10) did not have evidence the hospice obtained a criminal background check on all contracted individuals who have direct patient care and access to patient records. Personnel #10: The personnel file for the Speech Therapist did not have a criminal background check at the time of the survey. COS.

It is required that a hospice aide provides services included in the plan of care. This standard was not met as evidenced by observation, interview, and clinical record review. 1 of 2 (50%) applicable clinical records of patients receiving Hospice Aide services revealed the hospice did not ensure the Hospice Aide was compliant with services included in the hospice aide plan of care. Record #91627 was reviewed and home visit to the patient was made 6/16/22 with the Hospice Aide in a residential care facility. The Hospice Aide plan of care assigned to "shave" patient "every visit". During home visit observation, the Hospice Aide did not shave the patient. During interview 6/16/22, the Hospice Aide stated, "I did not shave the patient because the patient did not need to be shaved". Review of the Hospice Aide visit note 6/16/22 included, "shave not done" and "does not need a shave at this time, will do next visit". There was no verbal or documented communication with the Hospice RN as to why the assigned service to shave patient was not completed. Additionally, the Hospice Aide was observed taking the patient's blood pressure, which was not assigned on the Hospice Aide plan of care. During interview 6/16/22, the Hospice Aide stated, "I don't see that the blood pressure was assigned on the care plan but I take the blood pressure because it makes me feel good". There was no verbal or documented communication with the Hospice RN to perform the blood pressure.