Every finding on record at G.M.H. Hospice and Palliative Care, Inc.

Upon patient record review 5 of 14 (Patient #1,2,3,4,8) 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 RN initial assessment documented need for MSW initial assessment. There was no initial psychosocial assessment completed. Patient #2: The RN initial assessment documented need for MSW initial assessment. There was no initial psychosocial assessment completed. Patient #3: The RN initial assessment documented need for MSW initial assessment. There was no initial psychosocial assessment completed. Patient #4: The RN initial assessment documented the need for MSW initial assessment. There was no initial psychosocial assessment completed. Patient #8: The MSW documented that she made a call to family for initial psychosocial assessment and they declined social work services. There is no evidence of any initial psychosocial assessment in the record, as that visit note with the phone call is blank.

Upon patient record review, 5 of 14 (Patients #2, 3, 6, 7, 9) 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: There is no evidence of interventions or goals for use of suction or nebulizer. The patient sees SC monthly there are no interventions or goals for spiritual care. Patient #3: The patient see SC monthly there are no interventions or goals for spiritual care. Patient #6: The patient sees SC monthly there are no interventions or goals for spiritual care. Patient #7: The patient see SC monthly there are no interventions or goals for spiritual care. Patient #9: There is no evidence of interventions or goals for the use of suction or nebulizer. The patient see SC monthly there are no interventions or goals for spiritual care.

Upon patient record review, 1 of 14 (Patient #9) 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 #9: The aide POC orders state that the patient transfers with a mechanical lift. There is no mechanical lift on the POC.

Upon patient record review, 1 of 14 (Patient #2) did not have evidence that the IDG in collaboration with the attending physician reviewed, revised and documents the individualized plan as frequently as the patient's condition requires but no less frequently then every 15 calendar days. Patient #2: The Physician had not signed IDG notes from date of admission 03/06/25 until the time of survey.

Upon patient record review, 2 of 14 (Patient #4, 9) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #4: The record includes an order for LVN weekly. The LVN only saw patient every other week. Patient #9: The MSW order is for monthly visits. There was no MSW visit in May.

Upon patient record review, 2 of 14 (Patients #4, 9) 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 #4: The aide POC did not include bleeding precautions as the patient is on Eliquis. Patient #9: The aide POC does not include bleeding precautions as the patient is on Eliquis.

Upon patient record review 2 of 14 (Patients #1, 3) 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: There was no evidence of aide visits included in the record at time of chart review. The patient, during home visit, stated that aide had not given her a shower in two weeks. Patient #3: The aide was ordered for visits twice weekly. There were no aide visits entered in the patient record.

Upon patient record review 1 of 14 (Patient #1) did not have evidence in the patient record that the hospice aides report: • Changes in the patient's medical, nursing, rehabilitative, and social needs to a registered nurse, as the changes relate to the plan of care and quality assessment and improvement activities • Hospice aides must also complete appropriate records in compliance with the hospice's policies and procedures Patient #1: The patient stated during RN visit that the aide had not performed a shower on her in over two weeks. There was no documentation of missed tasks or contacting the RN to report any changes needed to plan of care.

Upon patient record review, 1of 14 (Patient #3) 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 #3: The aide was ordered for visits twice weekly. There were no aide visits entered in the patient record. Aide was being supervised without visits in the record.

Upon patient record review, 3 of 14 (Patient #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: There is no evidence of interventions and goals for SNF facility coordination. There is no evidence of interventions or goals for use of suction, nebulizer, or for the primary diagnosis of kidney cancer. The patient sees SC monthly there are no interventions or goals for spiritual care. Patient #4: There is no evidence of interventions or goals for SNF facility coordination. The patient sees SC monthly there are no interventions or goals for spiritual care. Patient #5: The MSW did an initial phone call with daughter. The order was for follow up each certification period. There is no documentation of the MSW seeing the patient at the SNF or coordinating with the facility social worker. Although there are many interventions to "plan/teach facility/caregiver", there is no evidence of interventions or goals for SNF facility coordination. In addition, the patient sees SC monthly there are no interventions or goals for spiritual care. The patient is on a pureed diet which is not on the plan of care.

Upon patient record review, 1 of 14 (Patient #4) did not have evidence that the hospice plan of care identifies the care and services that are needed and specifically identify which provider (nursing facility or hospice) is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care. Patient #4: There are 5 wounds documented on this patient. The orders are not complete. They are all as follows: "(location), cleanse with NS, pat dry, apply betadine, cover with bandage (BD) change q shift." It does not specify number of changes by hospice RN versus facility staff.

Upon patient record review, 8 of 11 (Patient #2,3,5,6,8,9,10,11) did not have evidence that the patient chooses a health care provider, including an attending physician. Patients 2,3,5,6,8,9,10,11 was missing documentation of patient electing own MD or declining to choose own MD on admission paperwork.

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 #2 RN went in and out of bag multiple times without washing hands with either sanitizer or washing hands with soap and water.

Upon patient client record review, 8 of 11 (Patients #2,3,5,6,8,9,10,11) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patients 2,3,5,6,8,9,10,11 was missing documentation of patient electing own MD or declining to choose own MD on admission paperwork.

Upon patient client record review, 2 of 11 (Patient #2 and 5) 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 #2, IDG note from 4/10/22 and 4/22/22 missing MD signature, IDG note from 5/20/22 missing MD and SC signature. Patient #5, IDG note from 4/28/22, 5/6/22, 5/20/22, 6/3/22, 6/17/22 missing MD signature.