Every finding on record at High Plains Hospice LLC

Upon patient record review 1 of 14 (Patient #9) 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 #9: The patient admitted 01/09/2023 however, the spiritual assessment was completed 01/23/2023.

Upon patient record review 3 of 14 (Patient #6, #7, #8) 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 #6: There was no evidence of spiritual comprehensive assessment. Patient #7: There was no evidence of psychosocial or spiritual comprehensive assessment. Patient #8: There was no evidence of spiritual comprehensive assessment.

Upon patient record review, 4 of 14 (Patient #1, #8, #11, #13) 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 listed Aquaphor topical to affected area without evidence of specific location(s), Miralax without evidence of mixing directions, and acetaminophen 500mg 2 tablets every 4 hour PRN fever/aches without evidence of maximum allowable dose. corrected on site Patient #8: The medication profile listed Bactroban topical to affected area without evidence of specific location(s) and Miralax without evidence of mixing directions. Patient #11: The medication profile listed Miralax without evidence of mixing directions. Patient #13: The nurse documented patient was on oxygen however, this was not listed on the medication profile.

Upon patient record review, 1 of 14 (Patient #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 #3: The nurse noted on admit the patient has a defibrillator however, there was no evidence of problems/interventions/goals associated with this need. corrected on site

Upon patient record review, 4 of 14 (Patient #1, #8, #11, #13) 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 orders for Aquaphor topical to affected area did not contain evidence of specific location(s), Miralax did not contain mixing directions, and acetaminophen 500mg 2 tablets every 4 hour PRN fever/aches did not contain maximum allowable dose. corrected on site Patient #8: The orders for Bactroban topical to affected area did not contain evidence of specific location(s) and Miralax did not contain evidence of mixing directions. Patient #11: The order for Miralax did not contain of mixing directions. Patient #13: The nurse documented patient was on oxygen however, there was no evidence of an order for oxygen. In addition, the patient had an order for foley to be inserted and change PRN without indication for PRN and was missing details of catheter size and balloon size.

Upon patient record review, 4 of 14 (Patient #1, #3, #5, #6) 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 oxygen, nebulizer, wheelchair and hospital bed were not listed on the plan of care. corrected on site Patient #3: The walker was not listed on the plan of care. corrected on site Patient #5: The nebulizer was not listed on the plan of care. corrected on site Patient #6: The oxygen and nebulizer were not listed on the plan of care.

Upon client record review, 8 of 14 (Patient #1, #2, #,3, #5, #6, #8, #12, #13) 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 spiritual care visit on 09/21 was a telephone visit however, there was no evidence of an order for telephone visits. corrected on site Patient #2: The social work and spiritual care visits were documented as telephone visits however, there was no evidence of orders for telephone visits. In addition, the social work visit frequency 08/02 was 2/month 2 PRN however, there was no evidence of any visits in September. corrected on site Patient #3: The nurse visit frequency 08/20 was 2/week and 3 PRN however, the week of 08/27 there was only evidence of one missed visit note on 08/29. In addition, the social work visits were documented as telephone visits however, there was no evidence of orders for telephone visits. corrected on site Patient #5: The social work and spiritual care visits were documented as telephone visits however, there was no evidence of orders for telephone visits. corrected on site Patient #6: The social work visits were documented as telephone visits however, there was no evidence of orders for telephone visits. Patient #8: The social work visit frequency 07/12 was 2/week 2 PRN however, there was no evidence of any visits in July or August. Patient #12: The nurse visit frequency 06/06 was 3/week and 2 PRN, 06/08 daily and 4 PRN, 06/15 3/week and 4 PRN, and 06/24 daily visits however, routine visits were performed 06/06, 06/07, 06/08, 06/09, 06/10, 06/11, 06/12, 06/13, 06/14, 06/19, 06/22, 06/23, 06/24 and one PRN on 06/21. Patient #13: The spiritual care visit on 03/12 was a telephone visit however, there was no evidence of an order for telephone visits.

Upon patient record review, 1 of 14 (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: The duties assigned to aide were assigned weekly however, the aide was visiting twice a week. corrected on site

Upon patient record review 2 of 14 (Patient #1, #12) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #1: The aide visit frequency 09/19 was 2/week and 09/25 3/week however, after 09/17 there was only evidence of visits on 09/21, 09/25 and 09/29. corrected on site Patient #12: The aide visit frequency 06/12 was 2/week however, the week of 06/11 there was only evidence of one visit on 06/13.

Upon client record review, 2 of 14 (Patient #6, #7) did not have evidence that if a patient revokes the election of hospice care or is discharged from hospice in accordance with §418.26, the hospice must forward to the patient's attending physician: • A copy of the hospice discharge summary • The patient's clinical record, if requested Patient #6 and #7: The agency did not have evidence a discharge summary was sent to attending.

Upon observation, there was no evidence a copy is provided of the hospice written policies and procedures on the management and disposal of controlled drugs to the patient or patient representative and family. The agency was only providing page 1 of their 3 page policy #4-054.1-3. corrected on site

Upon inpatient contract review, 1 of 6 (Beaver Nursing Home contract) did not have evidence that the hospice patient's inpatient clinical record includes a record of all inpatient services furnished and events regarding care that occurred at the facility; that a copy of the discharge summary be provided to the hospice at the time of discharge; and that a copy of the inpatient clinical record is available to the hospice at the time of discharge. corrected on site

Upon personnel record review, 2 of 14 (Personnel #11, #13) did not have evidence the hospice obtained a criminal background check on all contracted individuals who have direct patient care and access to patient records. Personnel #11 and #13: The files do not contain evidence of criminal background check.