Every finding on record at Heavenly Hospice Care, Inc.

Upon patient record review, 4 of 14 (Patients #1,#3,#8,#9) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications. Patient 1: The medication profile contained Cefuroxime Axetil for 7 days with a start date of 4/17/23 as still an active medication. Corrected on site. Patient 3: The medication profile contained Keflex for 10 days with a start date of 4/16/23 as still an active medication. Corrected on site. Patient 8: The medication profile contained triamcinolone and clobetasol topical prescriptions with no area defined for administration. Corrected on site. Patient 9: The medication profile contained amoxicillin for 5 days with start date of 2/6/23 as still an active medication. Corrected on site.

Upon patient record review, 6 of 14 (Patients #3,#5,#6,#9,#10,#11) 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 3: The medical record contained nursing documentation upon admission identifying patient was a high risk for skin impairment and aspiration. There was no evidence of problems, goals, and interventions related to risk for skin impairment and aspiration included on the plan of care. Corrected on site. Patient 5: The medical record contained nursing documentation upon admission identifying patient was a high risk for aspiration. There was no evidence of problems, goals, and interventions related to risk for aspiration included on the plan of care. Corrected on site. Patient 6: The medical record contained nursing documentation 4/26/23 identifying patient was a high fall risk. There was no evidence of problems, goals, and interventions related to risk for falls included on the plan of care. Corrected on site. Patient 9: The medical record contained nursing documentation 4/24/23 identifying patient was a high risk for skin impairment. There was no evidence of problems, goals, and interventions related to risk for skin impairment included on the plan of care. Patient 10: The medical record contained nursing documentation 4/26/23 identifying patient issues with high risk for skin impairment and g-tube for nutritional needs. There was no evidence of problems, goals, and interventions related to risk for skin impairment and nutritional deficit included on the plan of care. Patient 11: The medical record contained nursing documentation 10/18/22 identifying patient had a sacral ulcer. There was no evidence of problems, goals, and interventions related to skin impairment included on the plan of care.

Upon patient record review, 2 of 14 (Patients #8,#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 8: The medical record contained orders for triamcinolone and clobetasol topical prescriptions with no defined area for administration. Corrected on site. Patient 11: The medical record contained nursing documentation 10/18/22 identifying wound care was started for a sacral ulcer. There was no evidence of an order for wound care.

Upon patient record review, 5 of 14 (Patients #1,#2,#6,#9,#10) 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 medical record contained nursing documentation 4/17/23 identifying patient use of an over the bed table and wheelchair. There was no evidence of the table and wheelchair included as DME on the plan of care. Corrected on site. Patient 2: The medical record contained nursing documentation upon admission identifying patient use of a wheelchair. There was no evidence of the wheelchair included as DME on the plan of care. Corrected on site. Patient 6: The medical record contained nursing documentation 4/26/23 identifying patient use of a hospital bed, over the bed table, and walker. There was no evidence of the bed, table, and walker included as DME on the plan of care. Corrected on site. Patient 9: The medical record contained nursing documentation 4/24/23 identifying patient use of a wheelchair. There was no evidence of the wheelchair included as DME on the plan of care. Patient 10: The medical record contained nursing documentation 4/26/23 identifying patient use of a hospital bed, air mattress, over the bed table, and nebulizer. There was no evidence of the bed, mattress, table, and nebulizer included as DME on the plan of care.

Upon client record review, 8 of 14 (Patients #1,#2,#3,#5,#6,#9,#10,#11) 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 medical record contained an ordered frequency for social worker initial assessment and every recertification. There was no evidence of any social work visits completed. The record also contained an order stating patient declined spiritual care visits. There was evidence of an initial visit completed by the chaplain. Patient 2: The medical record contained an ordered frequency for social worker initial assessment and every recertification. There was no evidence of an initial social work visit completed. The record also contained an order stating patient declined spiritual care visits. There was evidence of an initial visit completed by the chaplain. Patient 3: The medical record contained an ordered frequency for RN visits every 14 days. There was evidence of RN visits completed weekly on 4/10/23, 4/18/23, and 4/24/23. Patient 5: The medical record contained an ordered visit by social worker within 5 days of admission. There was no evidence of the visit completed. Patient 6: The medical record contained ordered frequencies for social work and spiritual initial visits and every recertification. There was no evidence of a social work recertification visit or any spiritual care visits completed. The record also contained an order for skilled nursing twice weekly and RN every 15 days. There was no evidence of second visits completed the weeks of 3/5/23, 3/12/23, and 4/9/23 and no visits completed the weeks of 4/16/23 and 4/23/23. Patient 9: The medical record contained an ordered frequency for RN visits every 14 days. There was completed LVN documentation 2/20/23 and 3/6/23, and RN documentation 2/14/23, 2/28/23, 3/14/23, 3/24/23, 3/28/23, 4/5/23, 4/10/23, 4/18/23, 4/24/23. The social worker completed an initial assessment with no evidence of an order for services. Patient 10: The social worker completed an initial assessment and recertification visit 3/6/23 with no evidence of an order for services. The medical record contained an order for the spiritual care provider to complete an initial assessment within 5 days of admission. There was no evidence of a spiritual visit completed. Patient 11: The medical record contained nursing documentation 10/26/22 stating RN completed a dressing change for wound care. There was no evidence of an order for wound care.

Upon observation, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. During the home visit with the Spiritual Coordinator, guitar bag and supply bag where placed on a chair and floor without a barrier to protect.

Upon patient record review, 1 of 14 (Patient #4) did not have evidence that the medical director or physician designee provides written certification that it is anticipated that the patient's life expectancy is 6 months or less if the illness runs its normal course. The physician must consider the following when making this determination: • The primary terminal condition • Related diagnosis • Current subjective and objective medical findings • Current medication and treatment orders • Information about the medical management of any of the patient's conditions unrelated to the terminal illness Patient 4: The CTI upon admission contains MD narrative with data entry error for wrong patient stating patient is a 68 year old male.

Upon patient record review, 2 of 14 (Patients #10,#11) did not have evidence that before the recertification period for each patient, the medical director or physician designee must review the patient's clinical information and provide written documentation that it is anticipated that the patient's life expectancy is 6 months or less. Patient 10: The face to face completed 2/5/23 was not timely for benefit period starting 3/10/23. Patient 11: The CTI for benefit period 8 was signed 8/3/22 prior to face to face completion 8/7/22. Start of care occurred in the eighth benefit period 8/5/22.

Upon patient client record review, 1 of 14 (Patient #7) 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 7: The election statement was signed 4/26/23 with effective date of 4/26/23. The agency did not admit and start services until 4/27/23.

Upon patient client record review, 3 of 14 (Patients #4,#7,#8) 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 4: The visit frequencies listed on the plan of care stated LVN twice weekly and social work declined. The orders for nursing were skilled nursing once weekly and RN once every 14 days, and social work every recertification. Plan of care and orders conflicted. Corrected on site. Patient 7: The visit frequencies listed on the plan of care stated LVN twice weekly and aide three times weekly. The orders for nursing were skilled nursing once weekly and RN once every 14 days, and aide twice weekly. Patient 8: The visit frequencies listed on the plan of care did not include the spiritual care frequency ordered for an initial visit and recertification.