Every finding on record at Good Fellows Hospice Services Inc

Upon patient record review, 4 of 4 (Patient #1,2,3,4) 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: All documentation is in initial comprehensive assessment, dated 08/28/2024: Patient has documentation of walker and cane for mobility. There is no evidence of mobility plan of care to include problems goals and interventions for mobility on or after 08/30/2024. Patient has documentation of high risk for falls as evidenced by fall risk score of 11. There is no evidence of fall plan of care to include problems goals and interventions for falls on or after 08/30/2024. Patient has documentation of aspiration risk, AEB documentation of aspiration precautions. While there is evidence of a nutrition plan of care, there is no evidence of interventions that include aspiration precautions on or after 08/30/2024. Patient has documentation of continuous oxygen use. While there is evidence of a respiratory plan of care, there is no evidence of interventions that include oxygen, include oxygen flow rate with route oxygen is to be delivered on or after 08/30/2024. Patient 2: All documentation is in recertification comprehensive assessment, dated 08/21/2024: Patient has documentation of continuous oxygen use. While there is evidence of a respiratory plan of care, there is no evidence of interventions that include oxygen, include oxygen flow rate with route oxygen is to be delivered on or after 08/30/2024. Patient has documentation of walker, wheelchair, and cane for mobility. There is no evidence of mobility plan of care to include problems goals and interventions for mobility on or after 08/30/2024. Patient has documentation of high risk for falls as evidenced by fall risk score of 14. There is no evidence of fall plan of care to include problems goals and interventions for falls on or after 08/30/2024. Patient has documentation of aspiration risk, aeb documentation of aspiration precautions. While there is evidence of a nutrition plan of care, there is no evidence of interventions that include aspiration precautions on or after 08/30/2024. Patient 3: All documentation is in recertification comprehensive assessment, dated 09/02/2024: Patient has documentation of high risk for falls as evidenced by fall risk score of 12. There is no evidence of fall plan of care to include problems goals and interventions for falls on or after 08/30/2024. Patient has documentation of edema. There is no evidence of edema plan of care to include problems, goals, and interventions for edema on or after 08/30/2024. Patient has been admitted to hospice liver cancer. There is no evidence of cancer, digestive, or endocrine plan of care to include problems, goals, or interventions for cancer on or after 08/30/2024. Patient has documentation of high skin breakdown risk AEB Braden score 9. There is no evidence of integumentary plan of care to include problems, goals, or interventions for skin breakdown on or after 08/30/2024. Patient 4: All documentation is in recertification comprehensive assessment, dated 07/16/2024: Patient has documentation of continuous oxygen use. While there is evidence of a respiratory plan of care, there is no evidence of interventions that include oxygen, include oxygen flow rate with route oxygen is to be delivered on or after 08/30/2024. Patient has documentation of walker for mobility. There is no evidence of mobility plan of care to include problems goals and interventions for mobility on or after 08/30/2024. Patient has documentation of high risk for falls as evidenced by fall risk score of 11. There is no evidence of fall plan of care to

Upon patient record review, 3 of 4 (Patient #1,2,4) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient 1: Visit frequency orders for the following disciplines were written 08/28/2024 and remain active: MSW, SC. Physician’s orders are once per certification period and as needed. There is no evidence of specified number of PRN visits for these disciplines. Patient 2: Visit frequency order for MSW as noted on most recent POC update, dated 09/28/2024. Physician’s order is once per certification period and as needed. There is no evidence of specified number of PRN visits for this discipline. Patient 4: Two visit frequency orders for SN as noted on most recent POC, dated 08/31/2024. First visit frequency order is once weekly and 3 PRN. The second visit frequency order is once weekly and PRN. There is no evidence of specified number of PRN visits for this discipline.

Upon patient record review, 5 of 5 (Patient #1,2,3,4,5) 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 • Drug therapy currently associated with laboratory monitoring Patient 1,2,3,4,5 medication profile did not have evidence of max dosage included for each patient: Acetaminophen 325mg 1 every 4 hours PRN and Acetaminophen 500mg 2 every 6 hours PRN. No evidence of maximum dose of 4000mg daily.

Upon patient record review, 4 of 5 (Patient #1,3,4,5) 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 1, 3,4,5 No evidence of an initial bereavement risk assessment.

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

Upon patient record review, 2 of 5 (Patient #1,2) 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 admitted with primary terminal diagnosis of Hypertensive Heart Disease with Heart Failure. No evidence of a cardiac POC. Patient 2 had spiritual care involved, no evidence of spiritual plan of care to include problems goals and interventions for spiritual care.

Upon patient record review, 4 of 5 (Patient #1,2,3,4) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient 1 order on 6/27/24 for RN initial/recertification and once per week and prn for needs. No evidence of a specific number of PRN visits within the order. Patient 2 order on 6/5/24 for RN initial/recertification and once per week and prn for needs. No evidence of a specific number of PRN visits within the order. Patient 3 order on 5/24/24 for RN initial/recertification and once per week and prn for needs. No evidence of a specific number of PRN visits within the order. Patient 4 order on 11/20/23 for RN initial/recertification and once per week and prn for needs. No evidence of a specific number of PRN visits within the order.

Upon patient record review, 5 of 5 (Patient #1,2,3,4,5) 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 order on 6/27/24 for Acetaminophen 325mg 1 every 4 hours PRN. No evidence of max dosage included. Acetaminophen 500mg 2 every 6 hours PRN. No evidence of maximum dose of 4000mg daily. Patient 2 order on 6/15/24 for Acetaminophen 325mg 1 every 4 hours PRN. No evidence of max dosage included. Acetaminophen 500mg 2 every 6 hours PRN. No evidence of maximum dose of 4000mg daily. Patient 3 order on 5/24/24 for Acetaminophen 325mg 1 every 4 hours PRN. No evidence of max dosage included. Acetaminophen 500mg 2 every 6 hours PRN. No evidence of maximum dose of 4000mg daily. Patient 4 order on 11/20/23 for Acetaminophen 325mg 1 every 4 hours PRN. No evidence of max dosage included. Acetaminophen 500mg 2 every 6 hours PRN. No evidence of maximum dose of 4000mg daily. Patient 5 order on 9/20/23 for Acetaminophen 325mg 1 every 4 hours PRN. No evidence of max dosage included. Acetaminophen 500mg 2 every 6 hours PRN. No evidence of maximum dose of 4000mg daily.

Upon client record review, 3 of 5 (Patient #1,3,4) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 1 order on 6/27/24 for RN initial/recertification and once per week and PRN for needs; visits on 6/27/24 then next one 7/4/24; missing second visit for the week of 6/27/24. Patient 3 order on 6/27/24 for RN initial/recertification and once per week and PRN for needs; visits on 5/24/24 then next one 5/31/24; missing second visit for the week of 5/24/24. Patient 4 order on 11/20/23 for RN initial/recertification and once per week and PRN for needs; visits on 11/20/23 then next one 11/29/23; missing second visit for the week of 11/20/23.

Upon patient client record review, 5 of 5 (Patient #1,2,3,4,5) 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 Consent did not contain the BFCC- QIO information and how to contact Livanta. Patient 2 Consent did not contain the BFCC- QIO information and how to contact Livanta. Patient 3 Consent did not contain the BFCC- QIO information and how to contact Livanta. Patient 4 Consent did not contain the BFCC- QIO information and how to contact Livanta. Patient 5 Consent did not contain the BFCC- QIO information and how to contact Livanta.