Every finding on record at Holy Redeemer Home Health and Hospice Services

Upon patient record review, 2 of 19 (Patient #6, 17) 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 #6 - POC dated 06/16/2023 NP note on 05/17/2023 states "Patient is using thicken with protein powder to liquids and requires a pureed diet" POC 06/16/2023 was not updated to include new diet. Patient #17 - POC dated 05/17/2023 skin tear not 06/11/2023 - Facility applied bandage to R forearm - no evidence the POC was revised.

Upon client record review, 5 of 19 (Patient #7,8,11, 12, 14) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #7 - POC 06/26/2023 - MSW missed visit 07/01/2023 stated would visit the following week. No make up visit as of 07/13/2023. Patient #8 - POC dated 05/28/2023 PT visit frequency 1 wk 9 - No visit week of 06/04/2023. SC visit frequency 1M1, 1-2M2 - No visit made in May. Patient #11 - POC dated 06/16/2023 MSW visit frequency 2M2, 1M1 - Only 1 visit made in June. Patient #12 - POC dated 05/27/2023 OT visit frequency 1 wk 3 - 2 visits made week of 06/04/2023. Patient #14 - POC dated 04/25/2023 MSW visit frequency effective 05/01/2023 1-2 M1, 1M2 - 2 visits made month of June.

Upon patient record review 4 of 19 (Patient #9,16,17,18) 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 Patient #9 - Cert period 05/06/2023 HHA visit frequency 5 wk12 - only 4 visits made week of 05/28/2023 no documentation of missed visit. Task shampoo to be completed 1x wk - week 05/15/2023 completed 5 x week and week 06/12/2023 completed 4 x week. Patient #16 - POC dated 06/12/2023 Aide frequency 4 wk1, 5 wk12 - only 4 visits made week of 07/02/2023. Patient #17 - POC dated 05/17/2023 Aide frequency 3 wk1, 5 wk8 - only 4 visits made week of 07/02/2023. Task shampoo, shaving and nail care 1 x wk week of 06/26/2023 nail care completed 3 x week, shampoo 5 x wk and shaving completed 3 x wk. Patient #18 - POC dated 05/29/2023 Aide frequency 2 wk1, 5 wk12 - only 4 visits made week of 07/02/2023. Task shampoo and nail care 1 x wk, week of 07/03/2023 nail care completed 4 x week and shampoo 3 x wk.

Upon patient record review 2 of 19 (Patient #17,18) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs. Patient #17 - Aide supervisory visit made 06/06/2023 and then again 06/22/2023 - greater than every14 days Patient #18 - Aide supervisory visit made 06/13/2023 and then again 06/29/2023 - greater than every14 days

Upon client record review, 3 of 19 (Patient #9, 16, 17) 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 #9 - POC dated 05/06/2023 SC visit frequency 1-2M 3M - 3 visits made month of June. Patient #16 - POC dated 06/12/2023 SC 1M1, 1-2M2, 1M1 - 2 visits made month of June. Patient #17 - POC dated 05/17/2023 Foley catheter change every 30 days, catheter changed 06/01/2023 and 06/26/2023 - less than every 30 days.