Every finding on record at Go for Help Hospice, Inc

Upon patient record review, 4 of 5 (Patient #1, 2, 3, 5) 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 Patient 1: The medication list indicates hydrocortisone cream 2.5% 1 gram daily apply twice daily. This contains conflicting instructions related to frequency of dosing; the physician order verifies that twice daily is the correct instructions. Further, there are no instructions indicating a location for usage of this topical medication. (corrected onsite) Patient 2: The medication list indicates Keppra 1000mg 1 tablet daily take one tablet by mouth three times daily. This contains conflicting instructions related to frequency of dosing; the physician order verifies that three times daily is the correct instructions. (corrected onsite) Patient 3: The medication list indicates diclofenac 75mg DR 1 tablet daily take one tablet by mouth twice daily. This contains conflicting instructions related to frequency of dosing; the physician order verifies that twice daily is the correct instructions. (corrected onsite) Patient 5: The medication list indicates hydralazine 50mg 1 tablet daily take one tablet by mouth twice daily. This contains conflicting instructions related to frequency of dosing; the physician order verifies that twice daily is the correct instructions. The medication list also indicates clonidine 0.1mg 1 tablet daily take one tablet by mouth four times daily. This contains conflicting instructions related to frequency of dosing; the physician order verifies that four times daily is the correct instructions. (corrected onsite)

Upon client record review, 1 of 5 (Patient #2) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 2: SN visits are ordered for 1 x weekly; however, there was no evidence that a skilled nurse visited the patient during the week of 08.06.2023.

Condition of Participation: Patient’s Rights. L500

Upon patient record review, 10 of 14 (Patient #1,2,3,4,5,6,7,9,12,14) did not have evidence that the hospice obtained the patient's or representative's signature confirming that they received a copy of the Patient's Rights and Responsibilities. Patient#1,2,3,4,5,6,7,9,12, Patients signed their own consent and admission documents being alert and orient x2 with confusion and forgetfulness. Patient #14, No consent or admission documents signed in chart.

Upon observation, there was no evidence that the patient has the right: • To exercise his or her rights as a patient of the hospice • Have one's property and person treated with respect • To not be subjected to discrimination or reprisal for exercising his or her rights Patient #1,2 staff was not wearing their name badge, no identification. Patient #3, picture ID was from West Coast University, no picture ID from hospice agency.

Upon patient record review, 10 of 14 (Patient #1,2,3,4,5,6,7,9,12,14) did not have evidence that if a state court has not adjudged a patient incompetent, any legal representative designated by the patient in accordance with state law may exercise the patient's rights to the extent allowed by state law. Patient#1,2,3,4,5,6,7,9,12, Patients signed their own consent and admission documents being alert and orient x2 with confusion and forgetfulness. Patient #14, No consent or admission documents signed in chart.

Upon patient record review, 10 of 14 (Patient #1,2,3,4,5,6,7,9,12,14) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient#1,2,3,4,5,6,7,9,12, Patients signed their own consent and admission documents being alert and orient x2 with confusion and forgetfulness. Patient #14, No consent or admission documents signed in chart.

Upon patient record review, 10 of 14 (Patient #1,2,3,4,5,6,7,9,12,14) did not have evidence of the appropriate documentation for release of confidential information. Patient#1,2,3,4,5,6,7,9,12, Patients signed their own consent and admission documents being alert and orient x2 with confusion and forgetfulness. Patient #14, No consent or admission documents signed in chart.

Upon patient record review, 10 of 14 (Patient #1,2,3,4,5,6,7,9,12,14) did not have evidence that the patient received information about the services covered under the hospice benefit. Patient#1,2,3,4,5,6,7,9,12, Patients signed their own consent and admission documents being alert and orient x2 with confusion and forgetfulness. Patient #14, No consent or admission documents signed in chart.

Upon patient record review, 10 of 14 (Patient #1,2,3,4,5,6,7,9,12,14) did not have evidence that the patient received information about the scope of services that the hospice will provide and specific limitations on those services. Patient#1,2,3,4,5,6,7,9,12, Patients signed their own consent and admission documents being alert and orient x2 with confusion and forgetfulness. Patient #14, No consent or admission documents signed in chart.

Condition of Participation: Initial and Comprehensive Assessment of the Patient.

Upon patient record review 5 of 14 (Patient #6,10,11,12,14) 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 #6, Patient admitted on 9/8/22, SC assessment completed 9/15/22. Patient #10, Patient admitted on 11/9/22, MSW assessment completed 11/15/22, SC completed 11/20/22. Patient #11, Patient admitted on 10/11/22, SC assessment completed on 10/21/22. Patient #12, Patient admitted on 3/9/23, SC assessment completed on 3/15/23. Patient #14, Patient admitted on 1/18/23, MSW assessment completed on 1/24/23.

Upon patient record review, 1 of 14 (Patient #12) did not have evidence in the patient record that the comprehensive assessment takes into consideration the imminence of death. Patient #12, No documentation of imminence of death.

Upon patient record review, 1 of 14 (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, Medication Ergocalciferol 1.25mg daily oral, instructions state take one tab once/week.

Upon patient record review, 12 of 14 (Patient #1,2,3,4,5,7,8,9,10,11,12,13) 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 #1,2,3,4,5,7,8,9,10,11,12,13, No bereavement assessment completed after admission to hospice program.

Upon patient record review, 13 of 14 (Patient #1,2,3,4,5,6,7,8,9,10,11,12,13) 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 #1,2,3,4,5,6,7,8,9,10,11,12,13, MSW and SC did not update plan of care and did not update the comprehensive assessments. Patient #1, RN visits 3/21/23, 5/19/23. There was not evidence of an update to the comprehensive assessment by the RN between these dates. Patient #2, RN visits 4/2/23, 5/17/23, 6/27/23. There was not evidence of an update to the comprehensive assessment by the RN between these dates. Patient #3, RN visits 4/12/23, 6/10/23. There was not evidence of an update to the comprehensive assessment by the RN between these dates. Patient #4, RN visits 4/16/23, 6/14/23. There was not evidence of an update to the comprehensive assessment by the RN between these dates. Patient #5, RN visits 4/19/23 additional visits made by LVN. There was not evidence of an update to the comprehensive assessment by the RN between these dates. Patient #6, RN visits 9/8/22, 11/6/22, 1/5/23. There was not evidence of an update to the comprehensive assessment by the RN between these dates. Patient #7, RN visits 4/5/23, 6/3/23. There was not evidence of an update to the comprehensive assessment by the RN between these dates. Patient #8, RN visits 9/19/22, 12/17/22. There was not evidence of an update to the comprehensive assessment by the RN between these dates. Patient #9, RN visits 11/15/22, 1/13/23, 5/13/23. There was not evidence of an update to the comprehensive assessment by the RN between these dates. Patient #10, RN visits 11/9/22, 2/6/23. There was not evidence of an update to the comprehensive assessment by the RN between these dates. Patient #11, RN visits 10/11/22, 11/25/22. There was not evidence of an update to the comprehensive assessment by the RN between these dates. Patient #12, RN visits 3/9/23, 3/28/23. There was not evidence of an update to the comprehensive assessment by the RN between these dates. Patient #13, RN visits 3/27/23, 4/14/23, 4/21/23, 6/10/23. There was not evidence of an update to the comprehensive assessment by the RN between these dates.

Condition of Participation: Interdisciplinary Group, Care Planning, and Coordination of Services. L536

Upon patient record review, 13 of 14 (Patient #1,2,3,4,5,6,7,8,9,10,11,12,13) 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 #1, RN visits 3/21/23, 5/19/23. There was not evidence of continuous assessments of the patient by the RN. Patient #2, RN visits 4/2/23, 5/17/23, 6/27/23. There was not evidence of continuous assessments of the patient by the RN. Patient #3, RN visits 4/12/23, 6/10/23. There was not evidence of continuous assessments of the patient by the RN. Patient #4, RN visits 4/16/23, 6/14/23. There was not evidence of continuous assessments of the patient by the RN. Patient #5, RN visits 4/19/23 additional visits made by LVN. There was not evidence of continuous assessments of the patient by the RN. Patient #6, RN visits 9/8/22, 11/6/22, 1/5/23. There was not evidence of continuous assessments of the patient by the RN. Patient #7, RN visits 4/5/23, 6/3/23. There was not evidence of continuous assessments of the patient by the RN. Patient #8, RN visits 9/19/22, 12/17/22. There was not evidence of continuous assessments of the patient by the RN. Patient #9, RN visits 11/15/22, 1/13/23, 5/13/23. There was not evidence of continuous assessments of the patient by the RN. Patient #10, RN visits 11/9/22, 2/6/23. There was not evidence of continuous assessments of the patient by the RN. Patient #11, RN visits 10/11/22, 11/25/22. There was not evidence of continuous assessments of the patient by the RN. Patient #12, RN visits 3/9/23, 3/28/23. There was not evidence of continuous assessments of the patient by the RN. Patient #13, RN visits 3/27/23, 4/14/23, 4/21/23, 6/10/23. There was not evidence of continuous assessments of the patient by the RN.

Upon patient record review, 14 of 14 (Patient #1,2,3,4,5,6,7,8,9,10,11,12,13,14) 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 #1,2,3,4,5,6,7,8,9,10,11,12,13,14, No MSW or SC care plan initiated or maintained.

Upon client record review, 5 of 14 (Patient #6,7,9,12,13) 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 #6, Last IDG note was completed 3/9/23. No IDG completed since. Patient #7, Last IDG note was completed 4/5/23. No IDG completed since. Patient #9, Last IDG note was completed 3/7/23. No IDG completed since. Patient #12, No IDG note completed, patient admitted on 3/9/23 and revoked on 3/28/23. Patient #13, No IDG note completed since 3/27/23, patient revoked on 6/10/23.

Upon client record review, 1 of 14 (Patient #12) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #12, No MD orders were obtained for frequencies. RN visits on 3/9/23,3/28/23, LVN visits 3/12/23, 3/19/23, 3/26/23. MSW 3/14/23, SC 3/15/23.

Upon patient record review, 2 of 14 (Patient #1,2) did not have evidence that the IDG shares information on a on-going basis with non-hospice healthcare providers furnishing services unrelated to the terminal illness and related conditions. Patient #1,2, no care coordination between hospice agency and board and care facility.

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 nursing bag without sanitizing hands each time she went into her nursing bag. Patient 3 LVN went into bag without sanitizing hands every time she entered her bag.

Upon patient record review 2 of 14 (Patient #1, 2) 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, Aide visits on 3/22/23, 3/25/23, 3/29/23 had no documentation of tasks completed for patient. Documentation form was blank which usually occurs when care plan has not been completed prior to aide visit. Patient #1,2, no orders for Aide services. Aide visits were completed for both patients without orders for the first 2 weeks.

Upon observation, there was no evidence the hospice is primarily engaged in providing the following care and services: • Short-term inpatient care Did not have contract for short-term inpatient care, obtained prior to end of survey. (Corrected on site)

Upon patient client record review, 10 of 14 (Patient#1,2,3,4,5,6,7,9,12,14) 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 Patient#1,2,3,4,5,6,7,9,12, Patients signed their own consent being alert and orient x2 with confusion and forgetfulness. Patient #14, No consent signed in chart.

Upon patient client record review, 1 of 14 (Patient #2) 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, LVN missing credentials for visits on 4/7/23, 4/13/23, 4/17/23, 4/24/23, 4/30/23, 5/8/23.

Upon client record review, 1 of 14 (Patient #11) did not have evidence that the discharge summary includes all required information. Patient #11, d/c only summary states "wants aggressive treatment" and does not include a summary of patient's stay, treatments, symptoms, pain management, does not include the plan of care, or latest orders.

Upon client record review, 10 of 14 (Patient #1,2,3,4,5,6,7,9,12,14) did not have evidence that the written policies and procedures for managing controlled drugs was provided and discussed. Patient #1,2,3,4,5,6,7,9,12, Patients signed their own consent and admission documents being alert and orient x2 with confusion and forgetfulness. Patient #14, No consent or admission documents signed in chart.