Every finding on record at Healthfield Hospice Services, LLC

Upon patient record review 2 of 19 (Patient #7, #10) 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, #10-A spiritual assessment is not on record. The patient declined Chaplain services and an assessment was not performed by the RN, Social Worker or Chaplain. (corrected on site)

Upon patient record review, 2 of 19 (Patient #1, #10) 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-The patient was admitted 07/28/23 on Oxygen. Oxygen is not included in the medication profile. (corrected on site) Patient #10-The medication profile includes Nitro .3mg SL 1 tab as needed for chest pain. The frequency the medication can be administered and maximal number of doses is not specified on the profile. (corrected on site)

Upon patient record review, 3 of 19 (Patient #6, #9, #13) 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 #6- A bereavement risk assessment is not on record. (corrected on site) Patient #9-A bereavement risk assessment is not on record. (corrected on site) Patient #13-The patient was admitted 03/31/22 and a bereavement risk assessment was not performed until 08/25/23.

Upon patient record review, 1 of 19 (Patient #14) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient based on the psychosocial problems identified in the initial, comprehensive, and updated comprehensive assessments. Patient #14-The social worker visited the patient on 08/14/23 and identified the caregiver reported the need to make funeral arrangements for end of life planning. The IDG/plan of care updates on record for 08/17/23, 08/24/23, and 09/07/23 do not address the identified problem. Each of the social worker notes document no problems were identified and the social worker will provide companionship. (late entry correction on site)

Upon patient record review, 2 of 19 (Patient #1, #10) did not have evidence the plan of care includes all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #1-The patient was admitted on 07/28/23 on Oxygen. The Oxygen liter flow and management are not included in the plan of care. On 08/10/23 the patient became a DNR and the orders/plan of care were not updated with the DNR status. (corrected on site) Patient #10-The 07/16/23 plan of care includes Nitro .3mg SL 1 tab as needed for chest pain. The frequency the medication can be administered and maximal number of doses is not specified in the plan. (corrected on site)

Upon patient record review, 2 of 14 (Patient #10, #11) 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 #10-The 08/03/23 Social worker documentation in the IDG/Plan of care only documents Social Worker did initial evaluation and patient declined services. The update IDG note does not include the initial psychosocial assessment findings. (late entry correction on site) Patient #11-The 08/03/23 Social worker documentation in the IDG/Plan of care only documents the 08/01/23 initial evaluation did not have findings. However, community resources were identified and shared with patient. The IDG note documentation does not include the initial assessment findings, plans for monthly visits, and what specific resource needs were identified and shared with the patient. (late entry correction on site)

Upon patient record review, 3 of 19 (Patient #1, #8, #9) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1-The Chaplain is ordered to visit twice monthly effective 08/01/23. The record documents a missed visit on 08/29/23. The second visit that was ordered in August is not on record and there is no documentation regarding the missed visit. (corrected on site) Patient #8-On 07/12/23 the Chaplain was ordered to visit monthly for one month and then twice monthly. There are no Chaplain visits on record for August and no documentation regarding the missed visits. On 07/14/23 the social worker was ordered to visit twice monthly. In July one visit was performed on 07/14/23 and in August one visit was performed on 08/10/23. There is no documentation regarding the missed visits. (corrected on site) Patient #9-On 08/01/23 the Chaplain was ordered to perform visits four times monthly. Three visits were made on 08/14, 08/17, and 08/25/23. The visit scheduled for 08/31/23 was not made as ordered. (corrected on site)

Upon personnel record review, 1 of 13 (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.) ·(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 Personnel #5-The Aide was hired 01/25/22. The competency assessments in the file performed initially and annually did not evidence the Aide has been directly observed performing the required tasks.

Upon patient record review, 1 of 19 (Patient # 1) did not have evidence in the patient record that hospice aide assignments and duties are: • Complete written patient care instructions for a hospice aide prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 Patient #1- The Aide care plan does not include oxygen precautions, fall precautions or bleeding precautions which are applicable to the patients care. On 08/10/23 the patient became a DNR and the aide care plan was not updated with the DNR status. (corrected on site)

Upon patient record review, 2 of 19 (Patient #1, #6) did not have evidence that the medical director or physician designee provides accurate written certification in the narrative section of the CTI. Patient #1- On the 07/19/23 Certification of Terminal Illness the physician writes the patient has a wound to the left calf that needs to be dressed and also has a left leg amputation due to PVD. The documentation is inaccurate as the patient declined a left leg amputation and this procedure was never performed.(corrected on site) Patient #6-The recertification of terminal illness 07/06/23 documents the patient is 94 years old. The patient was 95 years old at the time of the recertification. (corrected on site)

Upon patient record review, 3 of 19 (Patient #2, #3, #14) did not have evidence that all entries are clear, complete, and appropriately authenticated in accordance with the organizations policies and procedures and currently accepted standards of practice. Patient #2-On 07/24/23 an Aide paper visit note is on record. The signature does not include credentials. (corrected on site) Patient #3-On 07/06/23 the nurse documented a prn visit was made due to complaints the patient was in and out of consciousness and lethargic. The documentation indicates the patient had started back on a medication that could cause these symptoms. The documentation does not specify the medication of reference. (late entry correction on site) Patient #14-On 08/24/23 the nurse documented the daughter was educated on the medication change per MD and RN was assessing for effectiveness. On 09/01/23 the nurse documents asking the patient/family if the medication change has been effective. The documentation does not include the name of the medication being discussed and evaluated. (late entry correction on site)

Upon patient record review, 1 of 19 (Patient #18) did not have evidence that the discharge summary includes all required information. Patient #18-The patient revoked the hospice election on 03/12/23. The discharge summary only states the patient revoked to receive more aggressive treatment. It does not include a summary of the patient's stay, including treatments, symptoms and pain management