Every finding on record at Great Lakes Caring Hospice C in LLC

Upon patient record review, 1 of 5 (Patient #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 4:The medical record include documentation that the patient had a port-a-cath in place in the left chest and that the patient required Plavix and aspirin for use as anticoagulation therapy. There is no evidence that the plan of care includes problems, goals and interventions for management of the port-a-cath or the risk of bleeding.

Upon patient record review 4 of 19 (Patient #1, 3, 12, 13) 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 1 admitted 7/14/24, initial spiritual assessment completed on 8/4/24. Patient 3 admitted 5/13/24, initial spiritual assessment completed on 5/20/24. Patient 12 admitted 8/15/24, initial spiritual assessment completed on 8/21/24. Patient 13 admitted 8/29/24, initial spiritual assessment completed on 9/4/24.

Upon patient record review 2 of 19 (Patient #10, 14) 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 10, 14 no evidence of an initial spiritual assessment.

Upon patient record review, 7 of 19 (Patient #1, 2, 5, 7, 8, 10, 14) 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 Nursing visits 9/19/24 and 9/26/24 oxygen in the home. No evidence of oxygen on the medication profile. Miralax on the medication profile, no evidence of a diluent or mixing instructions. Patient 2 Nursing visit on 9/9/24 documented the use of Morphine, no evidence of Morphine on the medication profile. Nursing visit on 9/16/24 documented the use of Zofran and Lorazepam, no evidence of Zofran or Lorazepam on the medication profile. Patient 5 Oxygen DME and oxygen precautions included on initial plan of care, no evidence of oxygen on the medication profile. Patient 7 Miralax on the medication profile, no evidence of a diluent or mixing instructions. Initial plan of care includes oxygen DME and oxygen precautions, no evidence of oxygen on the medication profile. Patient 8 Initial plan of care includes oxygen DME and oxygen precautions, no evidence of oxygen on the medication profile. Tylenol 325mg 2 tab Q6h prn and Tylenol 650mg sup Q6h on the medication profile, no evidence of a 4000 mg max daily dosage. Patient 10 Miralax on the medication profile, no evidence of a diluent or mixing instructions. Nursing visits 8/23/24, 8/27/24, 9/3/24, 9/13/24, 9/17/24 and 9/24/24 document the oxygen is safely stored, no evidence of oxygen on the medication profile. Patient 14 Tylenol 325mg 2 tab Q6h prn, Hydrocodone/Tylenol 5mg/325mg 1 Q4h prn, and Hydrocodone/Tylenol 5mg/325mg 2 at bedtime, no evidence of a 4000 mg max daily dosage. Oxygen is on the medication profile at 2LPM, nursing visit on 9/6 documents 4LPM, 9/11 documents 5LPM, 9/18 documents 3 and 4LPM, and 9/25 and 9/26 document 4LPM.

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 admitted on 1/11/24, initial bereavement risk assessment completed on 2/27/24.

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

Upon patient record review, 4 of 19 (Patient #3, 10, 11, 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 3, 14 on Aspirin, no evidence of bleeding precautions. Patient 10 Nursing visits 8/23/24, 8/27/24, 9/3/24, 9/13/24, 9/17/24 and 9/24/24 document the oxygen is safely stored, no evidence of a care plan for oxygen usage or safety. Patient 11 oxygen is ordered, no evidence of a care plan for oxygen usage or safety.

Upon patient record review, 8 of 19 (Patient #1, 2, 3, 5, 7, 8, 10, 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 medications and treatments. Patient 1 Nursing visits 9/19/24 and 9/26/24 oxygen in the home. No evidence of an order for oxygen. Miralax ordered, no evidence of a diluent or mixing instructions. Patient 2 Nursing visit on 9/9/24 documented the use of Morphine, no evidence of an order for Morphine. Nursing visit on 9/16/24 documented the use of Zofran and Lorazepam, no evidence of an order. Patient 3 Initial care plan includes 16fr foley. Nursing visit 9/3/24 documents 14fr foley, no evidence of an order for 14fr foley. Patient 5 Oxygen DME and oxygen precautions included on initial plan of care, no evidence of an order for oxygen usage. Patient 7 Miralax ordered, no evidence of a diluent or mixing instructions. Initial plan of care includes oxygen DME and oxygen precautions, no evidence of an order for oxygen. Patient 8 Initial plan of care includes oxygen DME and oxygen precautions, no evidence of an order for oxygen. Tylenol 325mg 2 tab Q6h prn and Tylenol 650mg sup Q6h ordered, no evidence of a 4000 mg max daily dosage. Patient 10 Miralax ordered, no evidence of a diluent or mixing instructions. Nursing visits 8/23/24, 8/27/24, 9/3/24, 9/13/24, 9/17/24 and 9/24/24 document the oxygen is safely stored, no evidence of an order for oxygen. Patient 14 Tylenol 325mg 2 tab Q6h prn, Hydrocodone/Tylenol 5mg/325mg 1 Q4h prn, and Hydrocodone/Tylenol 5mg/325mg 2 at bedtime, no evidence of a 4000 mg max daily dosage. Oxygen is ordered at 2LPM, nursing visit on 9/6 documents 4LPM, 9/11 documents 5LPM, 9/18 documents 3 and 4LPM, and 9/25 and 9/26 document 4LPM.

Upon patient record review, 5 of 19 (Patient #2, 4, 9, 10, 11) 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 2 documented use of a wheelchair, no evidence of an order for wheelchair DME. Patient 4 nursing visit 5/18/24 documents rollator walker in use, no evidence of an order for rollator walker. Patient 9 nursing visit on 9/17/24 documented Broda chair ordered, no evidence of an order for Broda chair DME. Patient 10 Nursing visits 8/23/24, 8/27/24, 9/3/24, 9/13/24, 9/17/24 and 9/24/24 document the oxygen is safely stored, no evidence of an order for oxygen DME. Patient 11 nursing visit 9/4/24 documented Broda chair ordered, no evidence of an order for Broda chair DME.

Upon patient record review, 6 of 19 (Patient #1, 8, 9, 10, 11, 14) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient 1 has an active care plan for music therapy, no music therapist is seeing the patient. Current care plan includes goal that the wound will heal by 11/6/23. Nursing visits document Oxygen in the home, and use of nebulizers. No active care plan for respiratory of oxygen usage or safety. Patient 8 social work discontinued on 9/5/24 and the care plan remains active. Patient 9 social work discontinued on 9/8/24 and the care plan remains active. Patient 10 social work discontinued on 9/8/24 and the care plan remains active. Patient 11 social work discontinued on 8/25/24 and the care plan remains active. Patient 14 care plan includes spiritual care and aide for ADL care plans, SC and the aide are not seeing the patient.

Upon patient record review, 5 of 19 (Patient #2, 3, 6, 12, 14) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 2 social worker completed phone visits on 8/19/24 and 8/23/24, no evidence of an order for phone visits. Patient 3 prn nursing visit 9/13/24 documents foley removed and not replaced, no evidence of an order to remove the foley. Patient 6 social worker completed phone visit on 9/17/24, no evidence of an order for phone visits. Patient 12 nursing frequency on initial plan of care ordered as 2w1, 1w12. Nursing prn visit completed on 9/29/24, no evidence of an order for prn nursing visits. Patient 14 order on 8/15/24 effective 9/1/24 for SW frequency of 2w1, 2every2w6w, no evidence of visits the week of 9/1/24.

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 1, during surveyor visit the Chaplain placed his tablet and Hymnal on the patient's chair without a barrier and without cleaning the chair or devices during the visit.

Upon patient record review, 3 of 19 (Patient #15, 16, 17) 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 -30 day letter due 4/6/24 and sent on 5/16/24. Patient 16 sympathy card due 2/27/24 sent on 5/16/24. 30 day letter due 3/22/24, sent 5/16/24. 60 day letter due 4/21/24, sent 5/16/24. Patient 17 -90 day letter due 4/26/24 sent 5/23/24. 180 day letter due 7/25/24 sent 8/12/24.

Upon patient record review, 6 of 19 (Patient #2, 3, 5, 8, 11, 12) 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 2 aide care plan did not include bleeding precautions. Aide care plan included full sponge bath and shower every visit. Patient 3 on Aspirin, no evidence of bleeding precautions on the aide care plan. Patient 5 aide care plan did not have evidence of bleeding, aspiration, or oxygen precautions. Patient 8 aide care plan does not include aspiration or oxygen precautions. Patient 11 no evidence of aspiration precautions on the aide care plan. Patient 12 aide care plan includes shower every visit patient may not want shampoo every visit, nail care check every visit clean/file if needed, change linen per facility protocol-patient at home from 8/31/24-9/29/24, and companionship as needed; frequency not specific for each task.

Upon patient record review 5 of 19 (Patient #3, 4, 5, 9, 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 • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient 3 aide care plan included shampoo 1x week on the first visit of the week. Aide visits on 9/4/24, 9/12/24, 9/17/24, 9/18/24, 9/19/24, 9/20/24, 9/23/24, 9/24/24, 9/26/24, 9/27/24 document shampoo completed. Patient 4 aide care plan includes shampoo every visit, and bathing every visit. Aide visit on 9/3/24 documented partial bed bath given, and 9/21/24 documented shampoo not needed today's visit. Patient 5 aide visits were completed with 2 aides for each visit, no evidence of an order or care plan for 2 person assist for each visit. Patient 9 aide care plan included ear care 1x week on Friday, hair care 1xw on Friday, shampoo 1xw on Monday, linen 1xw on Tuesday. All of these tasks were completed 2xw on Monday/Wednesday from 9/9/24 to current. Patient 11 aide visits were completed with 2 aides for each visit, no evidence of an order or care plan for 2 person assist for each visit.

Upon patient record review, 4 of 19 (Patient #1, 3, 5, 6) did not have evidence that each patient record contains responses to medications, symptom management, treatments, and services. Patient 1 nursing visit on 9/19/24 documents wound care to buttock provided per orders, no evidence of how the patient tolerated the wound care. Patient 3 nursing visits on 9/3/24, 9/19/24, 9/23/24, 9/26/24 document wound care provided, no evidence of how the patient tolerated the wound care. Patient 5 nursing visit on 8/27/24 documented skin tear right hip ordered, followed, no evidence of how the patient tolerated the care provided. Patient 6 Nursing visits on 8/30/24, 9/4/24, 9/13/24, 9/16/24, 9/23/24 documented wound care provided, no evidence of how the patient tolerated the wound care.

Upon patient record review, 6 of 19 (Patient #1, 3, 5, 6, 9, 12) 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 1 nursing visit on 9/19/24 documents wound care to buttock provided per orders, no evidence of the detail of the wound care provided. Nursing visit 9/13/24 documents aide supervision completed, no evidence of an aide ordered. Patient 3 nursing visits on 9/3/24, 9/6/24, 9/19/24, 9/23/24, 9/26/24 document wound care provided per orders and do not document the detail of the wound care provided. Patient 5 nursing visit on 8/27/24 documented skin tear right hip ordered, followed, no evidence of the detail of the care provided. Patient 6 nursing visits on 8/30/24, 9/13/24, 9/16/24, 9/23/24, 9/27/24 documented wound care per orders, no evidence of the detail of wound care provided. Nursing visit on 9/16/24 documented aide supervision, no evidence of an aide ordered. Patient 9 had an active order for suction but no evidence that suction was needed, corrected with an order to discontinue suction. Patient 12 nursing visits on 8/15/24, 9/18/24, 9/25/24 document oxygen is safely stored, there is no oxygen in use.

Upon patient record review, 1 of 19 (Patient #7) 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 7 order on 7/31/24 for SW frequency effective 8/6/24 of 1w1, 1every2w8. No evidence of a visit the week of 9/1, and visits completed 9/12 and 9/16.

Upon patient record review, 4 of 13 (Patient #1, #3, #10, #13) 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. Patient #1: O2 ordered without a route. The route was listed as "oxygen." Patient #3: O2 ordered without a route. The route was listed as "oxygen." Polymyxin was ordered on 9-6-21 for 7 days. Polymyxin was not discontinued on day 7 and was updated and continued on the medication profile on 9-23-2021. Patient #10: 4-28-21 Albuterol transcribed to the med profile with Nasal Cannula as route. On 4-27-21 oxygen was transcribed to the medication profile with "oxygen" as route. Patient #13: On a routine visit dated 2-15-21, the RN documented that medication for restless leg syndrome had been increased, and that Prochlorperazine was to be ordered for nausea/vomiting. Missing evidence of either medication on the medication profile. In addition, on a routine visit dated 3-1-21, the RN documented that Methadone was ordered for pain management. There was no evidence of methadone on the medication profile. Also, the medication profile included oxygen without a route of administration.

Upon patient record review, 3 of 13 (Patient #1,3,9) 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. Patient #1, #3, #9: Patients were a full code and there were no interventions or goals related to resuscitation.

Upon patient record review, 1 of 13 (Patient #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 #13: On a routine visit dated 2-15-21, the RN documented that medication for restless leg syndrome had been increased, and that Prochlorperazine was to be ordered for nausea/vomiting. There was no evidence of orders for medications. In addition, on a routine visit dated 3-1-21, the RN documented that Methadone was ordered for pain management. There was no evidence of an order for the methadone.

Upon client record review, 2 of 13 (Patient #2, #12) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care Patient #2: MSW frequency was 1 x week. On the week of July 4 through 10 of 2021, there was no visit and no evidence of missed visit documentation. Patient #12: A chaplain visit was ordered as part of the comprehensive plan of care. There was no documentation of a chaplain visit or evidence of a missed visit note.

Upon patient record review, 1 of 10 applicable patients (Patient #12) did not have evidence in the patient record that hospice aide assignments and duties include the tasks to be completed and the frequency of those tasks. Patient #12: On the aide plan of care, the RN assigned both "Full sponge bath" and "Shower" to be completed every visit.

Upon patient client record review, 3 of 13 (Patient #4, #5, #11) did not have evidence that all entries are legible and clear in accordance with the organizations policies and procedures and currently accepted standards of practice. Patient #4: An aide supervisory visit was done on 9-29-21 by the RN but the patient did not have any aide visits - aide services not ordered. Patient #5: The RN documented an aide supervisory visit on 9-27-21 but the first aide visit was not made until 9-30-21. Patient #11: The RN completed a supervisory visit for the aide on 9-8-21 and but the aide had not yet made the first visit.

Upon patient record review, 1 of 1 applicable patient (Patient #2) did not have evidence that the hospice provided the SNF with all required documentation. Patient #2 did not have evidence of an updated plan of care in the facility chart.