Every finding on record at Grace Hospice, LLC

Upon patient record review 1 of 14 (Patient #12) 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 #12 - SOC date 03/19/24 - SC visit made initial 03/26/24 (day 7) to complete spiritual assessment and MSW made initial visit 03/25/24 (day 6) to complete psychosocial assessment.

Upon patient record review, 1 of 14 (Patient #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 #5 - Medication profile at facility contained Ipratropium-Albuterol solution 1 vial every 6 hours PRN for SOB - started on 01/11/24 but not on hospice list of medications. Effective 03/14/24 hospice medication profile contained Bisacodyl 10mg rectal suppository 1 daily PRN for constipation, Eliquis 5 mg 1 tab 2 x day, Lorazepam 2mg/ml oral concentrate 0.25mg every 2 hours PRN anxiety or Morphine concentrate 100mg/5ml 0.25 ml every 2 hours PRN moderate to severe pain or air hunger but not on facility medication profile. (Corrected on site)

Upon patient record review, 3 of 14 (Patient #7, 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 #7 - SOC 04/12/24 unable to locate initial bereavement assessment. Patient #12 - SOC 03/19/03/24 - initial bereavement assessment 04/02/24. Patient #13 - SOC 03/07/24 - unable to locate initial bereavement assessment.

Upon patient record review, 1 of 14 (Patient #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. Medications missing Patient #5 - POC dated 03/08/24 did not contain Ipratropium-Albuterol solution 1 vial every 6 hours PRN for SOB - started on 01/11/24.

Upon client record review, 5 of 14 (Patient #6, 7, 8, 9, 12,) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #6 - POC 03/28/24 SN visit frequency 1 wk1, 2wk12 - week 2 and 3 only made 1 SN visit documented a phone visit wk 2 and 3 but phone visits not on POC. Patient #7 - POC dated 03/08/24 - SC visit frequency 1wk1, 1 every 4wks 4 - SC visit made week 1 and then week 3. Patient #8 - POC dated 03/22/24 - SN visit frequency 2 wk 4 effective 03/24/24. SN visit made on 03/22/24 - no order for this visit. Patient #9 - POC dated 03/03/24 - SC visit frequency 1wk1, 1 every 5wk - visit made week 1 and week 3. Patient #12 - POC dated 03/19/24 - SN visit frequency 3wk1, 2wk 12 - 2 visits made week 1 - no documentation of missed visit. POC dated 03/19/24 did not contain wound care orders for L thigh wound but RN documented wound care on 03/27, 03/29, 04/03, 04/05, 04/10, 04/12 and 04/15/24 to L thigh.

Upon patient record review 1 of 14 (Patient #14) 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 #14 - Aide frequency 2 x wk. Aide care plan task ordered: shower 1 x week and shampoo 1 x week. Week of 3/10/24 aide completed shower and shampoo 2 x week. Visit dates 02/13, 02/20, 02/22, 03/19 and 03/28 aide completed sponge bath.

Upon client record review, 2 of 14 (Patient #5, 13) 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 #5 - POC dated 03/08/24 - SN documented that facility provided wound care on 03/08/24 but no wound care orders on POC. SN documented on visit 03/31/24 "wound care supplies to coordinator NB per wound care nurse dressing to be changed qod" no wound care orders documented. Patient #13 - POC dated 03/07/24 - SC visit frequency 1wk1, 1 every 6 wks - visit made wk 1 and wk 4.