Every finding on record at Gilbert's Hospice Care, LLC

Upon patient record review 1 of 19 (Patient #5) 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 5: The medical record contained an initial spiritual assessment completed by the RN 3/1/24 with a start date of 2/23/24.

Upon patient record review, 5 of 19 (Patients #5,#6,#10,#11,#13) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications. Patient 5: The medication profile contained miralax oral powder with no instructions for a diluent. Corrected on site. Patient 6: The medication profile contained oxygen with no delivery method. Corrected on site. Patient 10: The medication profile contained oxygen with no delivery method. Corrected on site. Patient 11: The medication profile contained duplicative lorazepam listings. Corrected on site. Patient 13: The medication profile contained differing daily doses of zoloft with no instructions to take together. Corrected on site.

Upon patient record review, 1 of 19 (Patient #5) 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 5: There was no evidence of a bereavement assessment. Corrected on site.

Upon patient record review, 1 of 19 (Patient #3) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual's attending physician, if any) • Changes that have taken place since the initial assessment • Information on the patient's progress toward desired outcomes • Reassessment of the patient's response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days Patient 3: There was no evidence the comprehensive assessment was completed by an RN between 2/26/24 and 3/15/24.

Upon patient record review, 3 of 19 (Patients #11,#13,#14) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient 11: There was no evidence of wound assessments since 3/18/24 and no measurements this benefit period starting 3/9/24. Wound policy states assessments and measurements are required no less than once weekly. Patient 13: There was no evidence of wound assessments from 3/7/24 to 3/26/24 when wound inactivated, and no measurements since 2/22/24. Wound policy states assessments and measurements are required no less than once weekly. Patient 14: There was no evidence of wound assessments since 3/19/24, and no measurements since 3/4/24.Wound policy states assessments and measurements are required no less than once weekly.

Upon patient record review, 4 of 19 (Patients #5,#6,#10,#13) 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 5: The medical record contained an order for miralax oral powder with no instructions for a diluent. Corrected on site. Patient 6: The medical record contained an order for oxygen with no delivery method. Corrected on site. Patient 10: The medical record contained an order for oxygen with no delivery method. Corrected on site. Patient 13: The medical record contained differing orders for daily doses of zoloft with no instructions to take together. Corrected on site.

Upon patient record review, 4 of 19 (Patients #1,#7,#8,#14) 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 medical record contained nursing documentation upon admission identifying patient use of a cane and walker. There was no evidence of orders for the equipment included in the plan of care. Corrected on site. Patient 7: The medical record contained nursing documentation upon admission identifying patient use of a bedside table and bedrails. There was no evidence of orders for the equipment included in the plan of care. Corrected on site. Patient 8: The medical record contained nursing documentation upon admission identifying patient use of bedrails. There was no evidence of orders for the equipment included in the plan of care. Corrected on site. Patient 14: The medical record contained nursing documentation upon admission identifying patient use of a nebulizer. There was no evidence of orders for the equipment included in the plan of care. Corrected on site.

Upon patient record review, 1 of 19 (Patient #15) did not have evidence the hospice offers bereavement counseling that includes: • Making bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. Bereavement counseling also extends to residents of a SNF/NF or ICF/IID when appropriate and identified in the bereavement plan of care • Ensuring that bereavement services reflect the needs of the bereaved • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery Patient 15: Three was no evidence the bereavement care plan tasks assigned were completed.

Upon personnel record review, 1 of 15 (Personnel #6) 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.) ·Reading and recording temperature, pulse, and respiration Personnel 6: There was no evidence the aide performed the reading and recording temperature, pulse, and respiration as part of the initial competencies.

Upon patient record review 2 of 19 (Patients #3,#11) 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 Patient 3: The medical record contained an ordered aide frequency of twice weekly. There was no evidence of a second visit completed the week of 4/7/24. Corrected on site with late entry of missed visit documentation. Patient 11: The medical record contained an ordered aide frequency of five times weekly on 4/10/24. There was only evidence of two visits completed the week of 4/7/24.

Upon patient client record review, 1 of 19 (Patient #12) did not have evidence that each patient record contains: • Signed election statement in accordance with 418.24 Patient 12: The medical record contained an election form identifying patient/representative wish to receive the Notification of Non-Covered Items. There was no evidence the notification was received.

Upon patient client record review, 3 of 19 (Patients #4,#10,#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 4: The CTI for the benefit period starting 3/17/24 was electronically signed by the RN 3/3/24 and stated verbal order was received 3/13/24. Patient 10: The CTI for the benefit period starting 3/12/24 was electronically signed by the RN 2/26/24 and stated verbal order was received 3/5/24. Patient 11: The CTI for the benefit period starting 1/9/24 was electronically signed by the RN 1/1/24 and stated verbal order was received 1/2/24. The CTI for the benefit period starting 3/9/24 was electronically signed by the RN 2/23/24 and stated verbal order was received 2/27/24.

Upon client record review, 1 of 19 (Patient #11) 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 11: The medical record contained an order 4/10/24 for twice weekly visits by the chaplain. There was no evidence of a second chaplain visit the week of 4/7/24. Corrected on site with late documentation of missed visit.