Every finding on record at H & H Hospice Inc.

Upon patient record review, 1 of 14 (Patient #4) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications. Patient 4: The medication profile contained Narcan for narcotic overdose to be administered daily without instructions for medication to be PRN. Corrected on site.

Upon patient record review, 2 of 14 (Patients #1,#3) 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: The record contained a POLST with full code preference. The plan of care incorrectly identified the patient as DNR in error. Corrected on site. Patient 3: The record contained a POLST with DNR preference. The plan of care incorrectly identified the patient as full code in error. Corrected on site.

Upon patient record review, 1 of 14 (Patient #4) 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 4: The medical record contained an order for Narcan for narcotic overdose to be administered daily without instructions for medication to be PRN. 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 equipment and supply needs. Patient 2: The medical record contained nursing documentation 4/16/25 identifying patient use of a wheelchair. There was no evidence of an order for the wheelchair included in the plan of care. Corrected on site.

Upon personnel record review, 1 of 12 (Personnel #5) 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 5: There was no evidence of competency assessment completed for showers and tub baths.

Upon patient client record review, 1 of 14 (Patient #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 6: The medical record contained nursing documentation upon recertification assessments 1/27/25 and 3/24/25 with inaccurate documentation stating consents were signed and social work and chaplain will call to introduce themselves. Patient admitted 11/4/24 and had been receiving monthly visits from the social worker and the chaplain.

Upon patient record review 1 of 5 (Patient #5) 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 #5, SC assessment completed on 4/22/22, Patient was admitted on 4/15/22.