Every finding on record at Green Life Hospice Inc

Upon patient record review, 1 of 14 (Patient #2) did not have evidence in the patient record that the comprehensive assessment takes into consideration complications and risk factors that affect care planning. Patient 2: In the patient record there is evidence that the patient has schizophrenia and taking medications for schizophrenia. There is no evidence that the comprehensive assessment takes into consideration complications and risk factors that affect care planning. There is no secondary diagnosis for schizophrenia listed or mentioned in the comprehensive assessment.

Upon patient record review, 4 of 14 (Patient #1,2,3,4) did not have evidence in the patient record that the comprehensive assessment takes into consideration the imminence of death. Patient 1: On the RN comprehensive assessment 4/25/25 there is no evidence that the comprehensive assessment takes into consideration the imminence of death. Patient 2: On the RN comprehensive assessment 01/02/25 there is no evidence that the comprehensive assessment takes into consideration the imminence of death. Patient 3: On the RN comprehensive assessment 02/11/25 there is no evidence that the comprehensive assessment takes into consideration the imminence of death. Patient 4: On the RN comprehensive assessment 3/5/25 there is no evidence that the comprehensive assessment takes into consideration the imminence of death.

Upon patient record review, 1 of 14 (Patient #2) 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 2: During a patient home visit the patient states he is taking Trazadone 50mg at night for sleeping aide. Trazadone was not included on the medication profile. Corrected on site.

Upon patient record review, 1 of 14 (Patient #8) 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 8: On the comprehensive assessment there is a diagnosis of HIV, there is no evidence that the POC contains a risk for infections related to HIV.

Upon patient record review, 1 of 14 (Patient #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 4: The SN visit orders states, "1x/week and PRN", the order does not include the frequency for the PRN visits. Corrected on site.

Upon patient record review, 1 of 14 (Patient # 2) 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 2:During the patient home visit patient stated taking Trazadone 50mg at night for sleeping aide. Trazadone 50mg was not on the plan of care.

Upon client record review, 7 of 14 (Patient #2,3,4,5,8,9,10) 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 ordered one time per week and two prn, there was a SN visit made on 1/16/25 and 1/17/25. Visit was not documented as a supervisory visit or prn, documented as scheduled visits. Patient 3: SN visits ordered one time per week and two PRN, the RN saw pt on 5/6/25 and the LVN saw pt. on 5/6/25, both visits were documented as scheduled visits. Patient 4: SN visits ordered one time per week and two PRN, the RN saw pt on 5/6/25 and the LVN saw pt. on 5/6/25, both visits were documented as scheduled visits. Patient 5: SN visits ordered one time per week and two prn per week, there was a SN visit made on 3/16/25 and 3/21/25. Visit was not documented as a supervisory visit or prn, documented as scheduled visits. Patient 8: SN visits ordered one time per week and two prn per week, there was a SN visit made on 1/21/25 and 1/24/25 both visits were documented as scheduled visits. Patient 9: SN visits ordered one time per week and two prn per week, there was a SN visit made on 3/10/25 and 3/13/25, both visits were documented as scheduled visits. Pt. was seen by SN on 3/27/25 and 3/31/25, both visits were documented as scheduled visits. Patient 10: SN visits ordered one time per week and two prn per week, there was a SN visit made on 3/20/25 for a scheduled and supervisory visit and another SN visit on 3/24/25, visit was documented as a scheduled visit.

Upon personnel record review, 1 of 14 (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.) ·Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff. ·Reading and recording temperature, pulse, and respiration ·Safe transfer techniques and ambulation. ·Normal range of motion and positioning ·Appropriate and safe techniques in personal hygiene and grooming that include-- ·(A) Bed bath ·(B) Sponge, tub, and shower bath ·(C) Shampoo, sink, tub, and bed ·(D) Nail and skin care ·(E) Oral hygiene ·(F) Toileting and elimination The other subject areas in this section may be evaluated through written examination, oral examination or after observation of a Hospice Aide with a patient. Personnel 6: The Aide did not have evidence of have a competency on Sponge bath, shampoo in sink, tub and bed.

Upon patient client record review, 3 of 14 (Patient #3,4,6) 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 3: On the MSW initial assessment The MSW documented, “He has fair appetite and his sleep pattern is bad”. The patient's is female. Patient 4: MSW initial assessment documented ”he takes naps from time to time when he lacks energy” the patient's gender is female. Patient 6: On 4/21/25 the RN documented on supervisory SN visit, "aide services meet patients needs, good communication with patient and family, demonstrates competence with assigned tasks and complies with infection control policies and procedures", the patient does not have an aide ordered.