Every finding on record at Healthfield Hospice Services, LLC

Upon patient record review 1 of 14 (Patient #7) 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#7: There is no evidence of an initial spiritual assessment being completed.

Upon patient record review, 5 of 14 (Patient #1,#2,#6,#7,#9) 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: The medication profile contained Clotrimazole-betamethasone 1% - 0.05% twice a day for 7 days started on 02/06/25. There is no evidence of a specified area of application. This medication is also still active on medication profile. Corrected on Site. Patient#2: The medication profile contained doxycycline 100mg twice a day for 7 days starting 2/20/25. This medication is still active on medication profile. Additionally, the medication profile contained lidocaine 4% patch one daily to affected area. There is no evidence of a specified area of application. Corrected on site. Patient#6: The medication profile contained Zithromax Z-pak 250mg starting on 3/2/25. This medication is still showing as active. Corrected on site. Patient#7: The medication profile contained Diclofenac 1% topical four times daily prn pain to affected area. There is no evidence of a specified area of application. Corrected on site. Patient#9: During observation of home visit and medication reconciliation, the medication profile contained Levetiracetam 500mg 1 twice a day. The medication bottle in the home was for Levetiracetam 750mg 1 at bedtime. This dose was confirmed with confirmed with caregiver. Corrected on site.

Upon patient record review, 8 of 14 (Patient #1,#2,#3,#4,#5,#6,#8,#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. 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 indicates has Dysphagia as documented on 2/12/25 IDG. The aide plan of care indicates bleeding precautions are to be taken. Patient is taking Plavix (ordered 2/5/25) and has increased bruising per IDG note on 03/12/25. There is no evidence of problems with goals or interventions related to dysphagia or bleeding precautions on the plan of care. Corrected on site Patient#2: The record indicates patient is taking Eliquis daily. There is no evidence of problems containing goals and interventions for bleeding precautions. Corrected on site Patient#3: The record indicates patient is taking Warfarin 4mg daily. There is no evidence of problems containing goals and interventions for bleeding precautions. Corrected on site. Patient#4: The record indicates patient has diagnosis of heart failure and issues with pitting edema since admission. The NP F2F on 7/11/24 documents a recommendation of monitoring fluid volume. Nurse documentation indicates +2 edema on 2/19/25 visit and +3 edema on following nurse visit. There is no evidence of problems with goals and interventions related to edema. Corrected on site. Patient#5: The record indicates patient is taking Keppra for seizures and has seizure precautions listed on the aide plan of care. There is no evidence of problems, goals, or interventions related to seizure precautions on the plan of care. Documentation indicates patient previously had indwelling catheter which has been discontinued. However, goals and interventions related to this are still active on plan of care. Corrected on site. Patient#6: The patient is taking Eliquis daily. There is no evidence of bleeding precautions on plan of care. Corrected on site Patient#8: The record indicates on the 2/12/25 IDG and on the aide care plan that patient requires aspiration precautions. There is no evidence of goals or interventions related to aspiration precautions on the plan of care. Corrected on site Patient#9: The record indicates in initial bereavement assessment that family is at high risk. There is no evidence the plan of care addresses this need.

Upon patient record review, 4 of 14 (Patient #1,#2,#7,#9) 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: The record indicates an order for Clotrimazole-betamethasone 1% - 0.05% twice a day for 7 days started on 02/06/25. There is no evidence of a specified area of application. Corrected on site Patient#2: The record indicates an order for lidocaine 4% patch one daily to affected area. There is no evidence of a specified area of application. Corrected on site Patient#7: The record indicates an order for Diclofenac 1% topical four times daily prn pain to affected area. There is no evidence of a specified area of application. COS Patient#9: The record indicates an order for Levetiracetam 500mg 1 twice a day. The medication bottle in the home was for Levetiracetam 750mg 1 at bedtime. This dose was confirmed with confirmed with caregiver. Corrected on site.

Upon patient record review, 1 of 14 (Patient #1) 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#1: The record indicates patient requires use of seated walker per documentation on 2/26/25 IDG, and was also noted on the aide plan of care. There is no evidence of an order for this item. Corrected on site.

Upon patient record review, 1 of 14 (Patient#7) 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#7: The record indicates on 3/12/25 the patient complained of increased nausea that she says is being caused by the Tylenol and tramadol. Additionally, the patient was ordered ondansetron which is currently managing the nausea. There is no evidence of problems, goals, or interventions related to Nausea/gastrointestinal issues. Corrected on site.

Upon client record review, 1 of 14 (Patient #3) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient#3: The record indicates nurse frequency is ordered at 2 times a week. There is evidence of 3 visits occurring the same week on 2/24/25, 2/27, and 2/28.

Upon patient record review, 4 of 14 (Patient #1,#3,#6,#9) 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: The aide care plan (2/06/24) includes task of bathing every visit "per patient request", hair care "per patient request", and dressing "as needed". There is no evidence of bleeding precautions on the aide plan of care. Corrected on site. Patient#3: The record indicates patient is taking Warfarin 4mg daily. There is no evidence of bleeding precaution on the aide plan of care. Corrected on site. Patient#6: The record indicates patient is taking Eliquis daily. There is no evidence of bleeding precautions on aide plan of care. Corrected on site. Patient#9: The record indicates the plan of care includes seizure precautions. There is no evidence of seizure precautions on the aide plan of care. Corrected on site.

Upon patient client record review, 10 of 14 (Patient#1,#2,#3,#4,#5,#6,#7,#8,#9#10) 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,#2,#3,#4,#5,#6,#7,#8,#9#10: The record indicates all social worker visits were signed electronically in medical records. However, the credentials on social worker signature indicate Licensed Practical Nurse. There is no evidence of social worker credentials on visit signatures. Patient#1: The record indicates a documentation for a missed visit for aide on 01/14/25. However, patient was not admitted to services until 02/05/25. Patient#2: The record indicates DNR signed by patient representative on 02/21/25 and by medical director on 02/26/25. However, the social worker note on IDG 03/12/25 states patient is a full code. Patient#7: The record indicates in social worker initial evaluation that the patient was admitted with end stage renal disease. However, the CTI and RN initial assessment state admitting diagnosis is osteoarthritis of the hip. Patient#10: The record indicates the last LVN visit was made on 1/09/25 with the RN completing an supervisory visit on 2/4/25. Additionally, the RN completed LVN supervisory visits on 2/13/25, 2/20, and 3/6. There is no evidence of an LVN visit after 1/9/25.

Upon client record review, 1 of 14 (Patient #11) did not have evidence that the discharge summary includes all required information. Patient#11: There is no evidence of the discharge summary containing a summary of the patient's stay, including treatments, symptoms and pain management.

Upon patient record review, 2 of 5 (Patient #3, #4) did not have evidence the plan of care included all services necessary for the palliation and management of the terminal illness and related conditions, including specific orders for all medications and treatments. Patient #3-The 04/04/22 plan of care includes orders for the nurse to instruct and monitor the use of Oxygen. The plan of care does not include the liter flow and frequency of Oxygen. Patient #4- On 03/14/22 orders were received to crush Metronidazole tablet and apply on wound once daily. The orders are not specific for the wound location as the patient has four wounds receiving dressing changes.

Upon patient record review, 2 of 5 (Patient #2, #4) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #2- Effective 3/10/22 orders are to provide nursing visits once weekly. The record does not contain a nursing visit the week of 3/13/22-3/19/22 or 03/20/22-03/26/22. There is no documentation of missed visits on record. Patient #4-The 03/22/22 plan of care includes orders for nursing to change the patients Foley catheter using a 18 Fr 10 cc balloon upon evidence of dislocation, leakage or infection. On 03/26/22 the nurse documents changing the patients Foley catheter with a 16 Fr 10 cc balloon.

Upon observation, there was no evidence the agency has conducted exercises to test the emergency plan with all required documentation. Agency activated the emergency plan in January 2022. There is missing evidence of an analysis of this activation.

Upon patient record review, 5 of 11 (Patient #1,2,3,4, 11) 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 Nurse documented patient on oxygen 2/4/22. No evidence of oxygen on medication profile. Patient #2 Nurse documented patient on Mucinex on 1/14/22. No evidence of Mucinex on medication profile. Patient #3 Nurse documented patient on Tylenol on 1/28/22 visit. Nurse documented patient on Dulcolax on 2/3/22 and 2/10/22 visit. No evidence of Tylenol or Dulcolax on medication profile. Patient #4 Nurse documents patient on Dilaudid on visits 1/12/22-2/8/22. Nurse documents patient on Colace 1/25/22 visit. Nurse documents patient on Dulcolax 1/17/22 visit. No evidence of Dilaudid, Colace or Dulcolax on Medication profile. Patient #11 Nurse documents patient on oxygen on 7/29/21 visit. No evidence of oxygen on the medication profile.

Upon patient record review, 1 of 11 (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. Patient #3: Patient admitted 3/31/21. Bereavement risk assessment done 10/26/21.

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

Upon patient record review, 1 of 11 (Patient #4) did not have evidence that each patient and family received education and training provided as appropriate to their responsibilities for the care and services identified in the plan of care Patient #4 No evidence of education/teaching performed by SN on medication Lorazepam.

Upon patient record review, 2 of 11 (Patient #2,4) 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. Patient #2 No evidence of interventions/goals for foley catheter or blindness on plan of care starting 12/28/21. Patient #4 No evidence of interventions/goals for infection control, foley catheter or safety (fall precautions) on plan of care dated 1/15/22-3/15/22.

Upon patient record review, 5 of 11 (Patient #1,5,6,7,8) 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 a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs. A stand-alone frequency is not allowed. Patient #1 SC or SW ordered 1 prn on Plan of care. Patient #5 SW ordered 1 prn on Plan of care. Patient #6,7,8 SC or SW ordered 1 prn on Plan of care.

Upon patient record review, 5 of 11 (Patients 1,2,3,4,11) 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 medications and treatments. Patient #1 Nurse documented patient on Oxygen on 2/4/22 visit. No evidence of Oxygen on plan of care. Patient #2 Nurse documented patient on mucinex on 1/14/22. No evidence of mucinex on plan of care. Patient #3 Nurse documented patient on Tylenol on 1/28/22 visit. Nurse documented patient on dulcolax on 2/3/22 and 2/10/22 visit. No evidence of Tylenol or Dulcolax on plan of care. Patient#4 Nurse documents patient on Dilaudid on visits 1/12/22-2/8/22. Nurse documents patient on Colace 1/25/22 visit. Nurse documents patient on Dulcolax 1/17/22 visit. No evidence of Dilaudid, Colace or Dulcolax on plan of care. Patient #11 Nurse documents patient on oxygen on 7/29/21 visit. No evidence of oxygen on plan of care.

Upon patient record review, 1 of 11 (Patient #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 #11 Nurse documents that patient has DME of oxygen and hospital bed on 7/29/21. No evidence of DME (oxygen and hospital bed) on plan of care.

Upon client record review, 7 of 11 (Patient #1,2,3,6,8,9,10) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1 SN visits order 1w9 on 12/30/21 plan of care. No evidence of visit week of 2/6/2022. Patient #2 SN denoted changing foley catheter on 2/18/2022. No evidence of foley catheter orders on plan of care. MSW ordered effective 12/28/21 1x mo. No evidence of MSW visit or missed visit in December 2021. Patient #3 SC ordered effective 11/28/21 1m2, 2 prn. Visits performed 12/2/21 and 1/24/22. No evidence of visit or missed visit in November. Patient #6 Order for PT evaluation on 12/14/21. No evidence of PT evaluation or missed visit. MSW ordered effective 12/13/21 1every2mo2, 4 prn. Visits performed 12/17/21, 1/12/22, 1/27/22 and 2/14/22. No evidence that any of these are PRN visits. SC ordered effective 12/13/21 1 every2mo2, 1 prn. Visits performed 12/18/22 and 1/12/22. Patient #8 MSW ordered effective 12/11/21 1xmo, 4 prn. Visits performed 12/15/21, 1/17/22 and 1/25/22. No evidence that any of these visits are prn. Patient #9 SN ordered 1xwk. No evidence of visit or missed visit for week of 12/26/21. MSW ordered effect 12/5/21 1mo2, 2 prn. No evidence of visit or missed visit for December 2021. Patient #10 SC ordered effective 12/1/20 1 every 2mo2, 1mo1. Visits made 12/3/20, 1/15/21 and 2/16/21. MSW ordered effective 12/1/20 1 every 2mo2, 1mo1. Visits made 12/3/20, 1/27/21 and 2/16/21.

Upon patient record review, 6 of 8 applicable (Patient #1, 2, 4, 6, 7, 10) did not have evidence in the patient record that hospice aide assignments and duties include the task to be performed including the use of precautions. Patient #1 The patient was identified high fall risk and precautions were needed. Aide care plan did not include fall precautions. Patient #2 The patient was identified high fall risk and blind and precautions were needed. Aide care plan did not include fall precautions or visual precautions. Patient #4 The patient was identified high fall risk and precautions were needed. Aide care plan did not include fall precautions. Patient #6 The patient was identified high fall risk, at risk for aspiration, and poor eyesight. Aide care plan did not include fall precautions, aspiration precautions, or visual precautions. Patient #7 The patient was identified high fall risk and aspiration risk and precautions were needed. Aide care plan did not include fall precautions or aspiration precautions. Patient #10 The patient was identified high fall risk and precautions were needed. Aide care plan did not include fall precautions. Aide care plan assigned nail care per patient request.

Upon patient record review 6 of 8 applicable (Patient #1,2,6,7,9,10) did not have evidence documentation in the patient record that a hospice aide provides services that are ordered by the IDG and included in the plan of care. Patient #1 Aide care plan assigned shampoo weekly. Aide documented shampoo not done on 1/18/22 and 1/20/22. Patient #2 Aide care plan assigned linen change and stand by assistance each visit. Aide documentation on 1/5/22 and 1/7/22 denoted linens not needed. Aide documented on 1/7/22 standing assistance not needed. Patient #6 Aide care plan assigned transfer and bathing q visit. Aide documented 1/31/22 transfer and bathing not needed. Patient #7 Aide care plan assigned Shampoo once per week. Aide documented shampoo performed 2/15/22, 2/14/22, 2/12/22, 2/11/22, 2/9/22, 2/8/22. Aide care plan stated hair care q visit. Aide documented 1/27/22 not needed. Patient #9 Aide care plan assigned linen change once weekly. Aide documented performed on 1/17/22, 1/19/22 and 1/21/22. Patient #10 Aide care plan assigned oral care every visit. Aide documented on 3/3/21 oral care not needed.

Upon observation, there was missing evidence of an executed contract for the SNF used for respite purposes. Agency has provided respite care at this facility. Agency was unable to provide a copy of a contract signed by the facility.

Upon client record review, 1 of 3 applicable (Patient #5) 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 Plan of care starting 9/24/21 order nurse to perform O2 saturation q visit. No evidence found that nurse performed O2 saturation on 1/18/22, 1/24/22, 2/1/22, or 2/7/22.