Every finding on record at Hospice Family Care, Inc.

Upon observation, there was no evidence the agency has conducted exercises to test the emergency plan every two years. There was no evidence the agency engaged in community-based exercise or recorded an actual event within the last two years.

Upon patient record review 3 of 19 (Patients #8,#9,#14) 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 8: The medical record contained an initial comprehensive spiritual assessment completed 11/20/23 with a start of care 11/9/23. Patient 9: The medical record contained an initial comprehensive spiritual assessment completed 4/30/24 with a start of care 4/24/24. Patient 14: The medical record contained an initial comprehensive spiritual assessment completed 12/27/23 with a start of care 12/21/23.

Upon patient record review, 6 of 19 (Patients #1,#3,#8,#11,#12,#14) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications. Patient 1: The medical record contained nursing documentation identifying oxygen in the home starting 4/23/24. There was no evidence of oxygen included on the medication profile. Patient 3: The hospice medication profile did not match facility's medication list to included PRN orders for Tylenol, Pepto-Bismol, and Immodium. Patient 8: The medication profile contained ciclopirox and silicone topical creams with no area defined for administration, and fleet enema and Tussin DM with no time allowance determined between PRN doses. The topical creams and fleet enema were corrected on site. Patient 11: The medication profile contained azithromycin for 5 days ordered 4/18/24 and polytrim eye drops for 10 days ordered 4/25/24 still active on the profile. Corrected on site. Patient 12: The medical record contained nursing documentation identifying patient use of Tylenol and Salonpas patches for pain 4/24/24 and 6/10/24, and Miralax 6/10/24. There was no evidence of the Tylenol, Salonpas, and Miralax included on the medication profile. The profile also contained nystatin oral suspension for thrush 3/25/24 that was still active on the medication list. Corrected on site. Patient 14: The medical record contained nursing documentation upon admission and 5/6/24 identifying patient use of oxygen. There was no evidence of the oxygen listed on the medication profile.

Upon patient record review, 4 of 19 (Patients #2,#4,#8,#9) 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 2: The medical record contained nursing documentation since admission identifying patient as a high risk for falls and a diagnosis of senile degeneration of the brain. There was no evidence of problems, goals, and interventions related to fall safety and neurological dysfunction included in the plan of care. Patient 4: The medical record contained nursing documentation since admission identifying patient as a high risk for falls, risk of skin impairment, and dyspnea with oxygen use. There was no evidence of problems, goals, and interventions related to fall safety, risk for skin impairment, and respiratory dysfunction included in the plan of care. Patient 8: The medical record contained nursing documentation since admission identifying patient as a high risk for falls. There was no evidence of problems, goals, and interventions related to fall safety included in the plan of care. Patient 9: The medical record contained nursing documentation since admission identifying patient as a high risk for falls and issues with dysphagia. There was no evidence of problems, goals, and interventions related to fall safety and dysphagia included in the plan of care.

Upon patient record review, 5 of 19 (Patients #1,#7,#8,#12,#14) 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 medical record contained nursing documentation 4/23/24 oxygen in home. There was no evidence of an order for oxygen dose, frequency, and delivery method. The medical record also contained an order for wound supplies 5/21/24. There was no evidence of an order for wound care. Patient 7: The medical record contained nursing documentation since admission identifying patient use of an indwelling catheter. There was no evidence of an order for catheter type, size, change frequency, and maintenance. Patient 8: The medical record contained orders for ciclopirox and silicone topical cream no area defined for administration, and orders for PRN fleet enema and Tussin DM with no time allowance determined between PRN dose administration. Topical creams and fleet enema were corrected on site. Patient 12: The medical record contained nursing documentation identifying patient use of Tylenol and Salonpas patches for pain 4/24/24 and 6/10/24, and Miralax 6/10/24. There was no evidence of orders for the Tylenol, Salonpas, and Miralax. Patient 14: The medical record contained nursing documentation upon admission and 5/6/24 identifying patient use of oxygen. There was no evidence of an order for oxygen dose, frequency, and delivery method.

Upon patient record review, 3 of 19 (Patients #1,#4,#14) 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 since 4/23/24 identifying patient possession of an oxygen concentrator. There was no evidence of an order for the equipment included in the plan of care. Patient 4: The medical record contained nursing documentation since admission identifying patient use of a nebulizer, hospital bed, bedside table, wheelchair, and specialty mattress. There was no evidence of orders for the equipment included in the plan of care. Corrected on site. Patient 14: The medical record contained nursing documentation since admission identifying patient use of oxygen. There was no evidence of an order for the oxygen concentrator included in the plan of care.

Upon patient record review, 2 of 19 (Patients #1,#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 1: The medical record contained nursing documentation 5/21/24 identifying patient developed a wound. There was no evidence the plan of care was updated to include problems, goals, and interventions related to skin breakdown. Patient 11: The medical record contained nursing documentation 5/13/24 identifying patient has history of falls, unsteady gait, and high risk for falls. There was no evidence the plan of care was updated to included problems, goals, and interventions related to fall safety.

Upon patient record review, 3 of 19 (Patients #15,#16,#17) did not have evidence the hospice offers bereavement counseling that includes: • Making bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. Bereavement counseling also extends to residents of a SNF/NF or ICF/IID when appropriate and identified in the bereavement plan of care • Ensuring that bereavement services reflect the needs of the bereaved • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery Patient 15: There was no evidence the bereavement care plan tasks for sending sympathy card, letters at 1 month, 3 months, 6 months, and 9 months, memorial service invitation, support group invitation, and holiday letter were completed as assigned. Patient 16: There was no evidence the bereavement care plan tasks for sending memorial service invitation, support group invitation, and holiday letter were completed as assigned. Patient 17: There was no evidence the bereavement care plan tasks for sending sympathy card, letters at 3 months, 6 months, and 9 months, memorial service invitation, support group invitation, and holiday letter were completed as assigned.

Upon observation, there was no evidence the hospice ensures that Speech-Language Pathology is provided to hospice patients and their families according to applicable laws and regulations. The agency had a national contract that stated SLP is able to be provided, however the agency confirmed that the local providing agency does not have any employed speech pathologists and they did not have a waiver or contract with another individual or agency.

Upon personnel record review, 1 of 19 (Personnel #7) did not have evidence in the personnel file that the hospice aide had received at least l2 hours of in-service training during each 12-month period. In-service training may occur while an aide is furnishing care to a patient. Personnel 7: There was evidence of 9 hours of in-service training provided within the last 12 months. There was no evidence of training provided in October 2023, November 2023, and May 2024 and no evidence of additional training completed to make up for the missing months.

Upon patient record review, 5 of 19 (Patients #3,#4,#8,#11,#14) did not have evidence in the patient record that hospice aide assignments and duties are specific to meet patient needs. Patient 3: The aide care plan did not contain instructions for transfer assistance needed. Patient 4: The aide care plan did not contain instructions for transfer and ambulation assistance needed. Patient 8: The aide care plan did not contain instructions for ambulation assistance needed. Corrected on site. Patient 11: The aide care plan did not contain instructions for ambulation assistance needed. Patient 14: The aide care plan did not contain instructions for ambulation assistance needed.

Upon patient record review 5 of 19 (Patients #4,#7,#8,#9,#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 4: The medical record contained an ordered aide frequency of twice weekly. There was no evidence of second visits completed the weeks of 5/12/24 and 5/19/24. Patient 7: The medical record contained an ordered aide frequency of twice weekly. There was no evidence of visits completed the week of 5/26/24. Patient 8: The medical record contained an ordered aide frequency of twice weekly. There was no evidence of a second visit completed the week of 5/26/24. Patient 9: The medical record contained an ordered aide frequency of twice weekly. There was no evidence of a second visit completed the week of 5/26/24. Patient 12: The medical record contained an ordered aide frequency of four times weekly. There was no evidence of a fourth visit completed the week of 5/19/24.

Upon personnel record review, 2 of 15 (Personnel #14,#15) did not have evidence the hospice employees and contract employees have received orientation on the hospice philosophy. Personnel 14,15: There was no evidence of orientation on the hospice philosophy.

Upon personnel record review, 1 of 15 (Personnel #6) did not have evidence that the hospice employees have received orientation on their specific job requirements. Personnel 6: There was no evidence of orientation to the employee's job requirements.

Upon personnel record review, 1 of 15 (Personnel #6) did not have evidence that a skills competency assessment, specific to each discipline had been conducted for all personnel including volunteers initially during orientation. Personnel 6: There was no evidence of an initial skills competency.

Upon patient client record review, 2 of 19 (Patients #18,#19) did not evidence that each patient record contains physician orders. Patient 18: There was no evidence of an order to discharge due to transfer per agency policy. Patient 19: There was no evidence of an order to discharge due to extended prognosis.

Upon client record review, 1 of 19 (Patient #18) did not have evidence that the hospice forwarded a summary and a copy of the patient record, if requested, to a facility when transferring the patient to that facility. Patient 18: There was no evidence the agency forwarded a transfer summary to the receiving hospice agency.

Upon patient record review, 2 of 19 (Patients #3,#4) did not have evidence that the hospice provided the following information: • Hospice election form • Physician certification and recertification of the terminal illness specific to each patient Patient 3: There was no evidence of a signed hospice election form at the facility. Patient 4: There was no evidence of a signed hospice election form and CTI at the facility.

Upon personnel record review, 2 of 15 (Personnel #14,#15) 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 14,15: There was no evidence of a criminal background check.

Upon personnel record review, 1 of 15 (Personnel #5) did not have evidence of criminal background checks being obtained in accordance with state requirements. In the absence of state requirements, criminal background checks are obtained within three months of the date of employment for all states that the individual has lived or worked in the past 3 years. Personnel 5: There was no evidence of a criminal background check.