Every finding on record at Hope & Peace Hospice Care Inc

Upon patient record review 9 of 14 (Patient #1,#2,#4,#5,#6,#7.#8,#9,#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 #1,#2,#4,#5,#6,#7.#8,#9,#10: No evidence of initial spiritual assessment completed by any team member within 5 days. The spiritual coordinator made a phone call within 5 days of admission for each patient. The record indicates that on each call he documented that family requested a visit in a month.

Upon patient record review, 2 of 14 (Patient #1,#3) 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 record indicated for Dulcolax, Robitussin, and Claritin to be administered daily there was no indication for PRN. Per discussion with DPCS these are PRN medications. Corrected on site. Patient#3: The record indicated for Coloplast hydrophilic wound dressing and iodosorb 0.9% topical gel. Per family during home visit these are no longer being used. Family states tetracyte is now being used for wound and was present in home. The record indicates diclofenac Sodium 1% order date 8/12 has no indication for specific area of application. Corrected on site.

Upon patient record review, 1 of 14 (Patient #4) 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. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient#4: The record indicates an initial bereavement assessment was made on 7/26/24. There is no evidence of a primary bereaved name or contact information documented in the visit. Corrected on site.

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

Upon patient record review, 1 of 14 (Patient #3) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient #3: There was no evidence the RN was monitoring and assessing patient wound that was being managed by Wound Pro co. There is no record of documentation from hospice nurses regarding a wound care order, measurements or assessment for stage 3 wound to left hip.

Upon patient record review, 2 of 14 (Patient #5,#6) 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#5,#6: There is no evidence that the plan of care reflected spiritual or psycho social problems goals or interventions for patient/family however, both disciplines were seeing the patients. Corrected on site.

Upon patient record review, 1 of 14 (Patient #2) 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 the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient#2:The record indicated the order on 7/3/24 for nursing visits frequency as LVN "visit per week" and RN 1 visit every 14 days. There is no number on the LVN frequency to indicate how many times per week the LVN is to visit. Corrected onsite.

Upon patient record review, 1 of 14 (Patient #3) 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 #3: The record indicates patient had a stage 1 wound to coccyx. There is no evidence of wound care order containing frequency of care. The record indicates the patient had a stage 3 wound to left lateral hip 8/8/24. There is no evidence of a wound care order for dressing changes or frequency on the plan of care. Corrected on site.

Upon patient record review, 8 of 14 (Patient #1,#2,#3,#5,#6,#7,#8,#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 equipment and supply needs. Patient#1: The record indicates patient having a bed, shower chair, over the bed table, walker, wheelchair, and cane. There is no evidence of order for equipment. Corrected on site. Patient#2: The record indicates patient having a walker. There is no evidence of order for equipment. Corrected on site. Patient#3: The record indicates patient having a bed, wheelchair, and shower chair. There is no evidence of order for equipment. Corrected on site. Patient#5: The record indicates patient having a wheelchair. There is no evidence of order for equipment. Corrected on site. Patient#6: The record indicates patient having a oxygen concentrator. There is no evidence of order for equipment. Corrected on site. Patient#7: The record indicates patient having a oxygen concentrator, suction, walker, and cane. There is no evidence of order for equipment. Corrected on site. Patient#8:The record indicates patient having a bed, full rails, Hoyer lift, wheelchair. There is no evidence of order for equipment. Corrected on site. Patient#9: The record indicates patient having a cane, walker, shower chair, and wheelchair. There is no evidence of order for equipment. Corrected on site.

Upon client record review, 4 of 14 (Patient #3,#5,#7,#9) 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 visit frequency for spiritual care frequency was 1 time per month and 1 PRN on admission. The record indicates visit on 3/2 the family declined further spiritual care. The order for visits 1 time per month is still active however, visits are no longer being made. Corrected on site. Patient#5: The skilled nursing frequency was RN 1 visit every 14 days on admission. The record indicates the RN visiting 1 time every 14 days and an LVN visiting 1 time a week. There is no evidence of order to include the LVN visits. Corrected on site. Patient#7: On admission order for spiritual care only indicates an initial visit within 5 days. The record indicates further spiritual care services were declined at initial visit. The record also indicates a spiritual visit was made on 8/3/24. Documentation indicates on 8/3 visit that a follow-up visit was scheduled for next month. There is no evidence of an order to resume visits for spiritual care. Corrected on site. Patient #9: The visit frequency for spiritual care frequency was 1 time per month and 1 PRN on admission. The record indicates visits were only made on 2/5/24, 5/3/24, and 8/1/24. Corrected on site.

Upon patient record review 1 of 14 (Patient #4) did not have evidence that the IDG ensures that the care and services provided are based on all assessments of the patient and family needs. Patient#4: On admission order for spiritual care only indicates an initial visit within 5 days. There is no evidence of order for ongoing visits. Family did indicate accepting of spiritual services. Corrected on site.

Upon patient record review, 1 of 14 (Patient #3) did not have evidence that the IDG documents the sharing of information between all disciplines providing care and services in all settings, whether the care and services are provided directly or under arrangement. Patient #3: There was no evidence in the record the IDG documents sharing of information between Wound Pro co. care of wound as there was no documentation in the record from Wound Pro. There is documentation that from 08/08/24 - 08/20/24 wound pros made visits to assess and completed wound care. Documentation of wound pro visits and assessment have been uploaded to chart prior to end of survey.

Upon observation, there was no evidence the hospice is in compliance with accepted professional standards and principles for all core services which includes nursing services, medical social services and counseling services. Upon client record review, 1 of 14 (Patient#3) did not have evidence that wound care as a core nursing service was being completed, managed or assessed by nurses employed by the hospice agency. There is no record of documentation from hospice nurses regarding a wound care order, measurements or assessment for stage 3 wound to left hip and no documentation this wound is not related.

Upon patient record review 1 of 14 (Patient #1) 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 record indicates the Aide visit frequency was ordered 3 times per week. During the week of 8/11/24 only 2 visits were documented. Visits were on 8/11/24 and 8/13/24. Corrected on site.

Upon contract review, 1 of 10 (Wound Pro) did not have evidence the agreement to furnish any services under arrangement included that the hospice must retain administrative and financial management, and oversight of staff and services for all arranged services, to ensure the provision of quality care. Arranged care/services are supported by written contract/agreement that requires all care/services are: • Authorized by the hospice • Furnished in a safe and effective manner by qualified personnel • Delivered in accordance with the patient's plan of care Upon contract review, there is no evidence of a contract with wound pros that indicated an agreed upon arrangement for administrative/financial, staff/services, or delivery of quality of care in accordance with patient plan of care.

Upon patient client record review, 1 of 14 (Patient #2) did not have evidence that each patient record contains Advance Directives. Patient#2: Upon review of client record, the scanned document on admission indicates patient signed document to be a full code on 07/03/24. The nurse documents in narrative on initial assessment 07/03/24 that patient is DNR. The plan of care order states code status is DNR. The advanced directives of the patient is not clear. Corrected on site. A visit was made to patient in person and patient signed a DNR per her wishes.