Every finding on record at Greenfield Hospice and Palliative Care Inc

Upon patient record review 1 of 6 (Patient #3) 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 #3 Patient's SOC was 7/22/22. MSW performed psychosocial assessment 7/28/22.

Upon patient record review, 1 of 6 (Patient #3) 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 #3 Patient's SOC was 7/22/22. MSW performed bereavement assessment 7/28/22.

Upon patient record review, 3 of 6 (Patients #2, 3, 5) 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 #2: 5/26/22 Initial POC MSW 1 one-time then prn. Patient #3: 7/22/22 Initial POC frequencies for MSW one-time and then prn. SC 1 one time and then prn was ordered frequency. Patient #5: Initial POC 2/19/22 MSW 1x and then PRN.

Upon patient record review, 1 of 6 (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: Foley catheter upon admission (last changed 5/22/22 per initial assessment). POC includes Change Foley catheter monthly and prn. Size is not specified. No updates to orders noted thru 8/30/22 IDG.

Upon patient record review, 1 of 6 (Patient #2) 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 #2: 8/24/22 Communication note documented that CG informed the office that they went to hospital for some symptoms and that patient tested positive for COVID. Note states that Dr., Med Dir and rest of team were notified. There is no documentation/update to 8/30/22 POC/IDG Review.

Upon client record review, 4 of 6 (Patients #1, 2, 4, 5) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1: 2/1/22 POC SC evaluation then recertification plus 1x/month PRN for spiritual needs. SC Visits were made monthly. 1/28, 2/19, 3/13, 4/13, 5/23, 6/23/22, 7/15/22. Patient #2: SC frequency for initial POC was declined. SC visits made 5/29, 6/24, 7/15/22 without orders. Foley catheter upon admission (last changed 5/22/22 per initial assessment). POC includes Change Foley catheter monthly and prn. Documented catheter change by nurse 6/23/22. No evidence of change in July or August. Patient #4: SC 1x/mo and/or as needed. Patient was seen monthly. POC 2/1-3/29/22 states 1x/mo prn for spiritual needs. Initial POC 2/1/22 MSW 1 evaluation then recertification plus 1x/month PRN for psychosocial needs. 1/24/22 MSW assessment concludes with "... recertification or as needed." No further visits were made. Patient #5: Initial POC. No subsequent updates/changes to frequency. SC 1x and then prn. Patient was seen monthly 2/21, 3/17, 4/12 without clearly ordered frequency.

Upon personnel record review, 1 of 1 applicable (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.) ·(C) Shampoo, sink, tub, and bed Personnel # 6: The competency check off form utilized by the agency does not differentiate the different types of shampoo, but merely states "shampoo". Therefore, cannot validate that competency in all types of shampoo were verified.

Upon patient record review, 1 of 1 applicable (Patient #1) 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 #1: HA was provided 2x/week until 7/22/22. 7/26/22 Communication note documenting that patient/RP had requested to discontinue HA. Note further stated that case manager and IDG informed. However, there was no notation or update to the IDG/POC regarding the discontinuance of service. Frequency remains HA 2x/wk as of 8/30/22 POC/IDG review.

Upon patient client record review, 5 of 6 (Patient #1, 2, 3, 4, 6) 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, 6: Election Statement effective date is blank.

Upon patient client record review, 1 of 6 (Patient #4) did not evidence that each patient record contains physician orders. Patient #4: There is no documented physician order by Medical Director for the discharge.