Every finding on record at Hospice Family Care, Inc.

Upon patient record review, 1 of 5 (Patient #5) 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 5: The medical record contained an order for wound care 7/30/24. There was no evidence of a frequency included in the wound care instructions. Corrected on site.

Upon client record review, 1 of 5 (Patient #2) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 2: The medical record contained nursing documentation identifying removal of catheter. There was no evidence of an order for the removal in the chart. Through agency investigation, the nurse stated the patient had discharge instructions for the removal, however, there was no copy or confirmation of an order in the hospice medical record.

Upon patient record review, 5 of 19 (Patient #4, 8, 12, 15, & 16) 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 4 & 16: Colace 100mg daily PRN "bowel care" on medication list with no further instructions to further explain "bowel care" or indications for use of medication. Patient 8: SN documentation reveals report from patient on 4/24/24 of use of Milk of Magnesia for relief of constipation. There is no evidence the medication list was updated to include this medication at that time. Patient 12: Medication list reflects Lorazepam 0.5mg tablets every 4 hours as needed anxiety. Lorazepam 2mg/ml oral concentrate 0.25ml every 4 hours as needed agitation is also present. There are no further instructions on when it is appropriate to administer which medication related to pill versus liquid, to prevent overdose, or whether they can or cannot be utilized in conjunction with each other. Patient 15: Medication list contains both Hydrocodone 5-325 every four hours as needed "pain" and Tylenol 325mg 2 tablets every 6 hours as needed "pain or fever". There are no further indications on when to administer one medication versus the other for pain.

Upon patient record review, 1 of 19 (Patient #13) 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 13: SOC date 2/20/24. No evidence of initial Bereavement assessment until 4/4/24.

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

Upon patient record review, 2 of 19 (Patient #7 & 13) 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 7: SN visit 6/4/24 documents no BM x 4 days, 5/30/24, with "Dulcolax suppository given" on 6/4/24. There is no evidence of follow up before next SN visit on 6/7/24 of effectiveness of bowel regimen. Patient 13: Wounds present to Left and Right Heels and Coccyx. No wound measurements obtained for 4 weeks, from 5/21/24 - 6/12/24. Agency policy states wound measurements to be obtained no less than weekly.

Upon patient record review, 2 of 19 (Patient #5 & 8) 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: RN and MSW documentation reveal pt. is unable to make needs known due to aphasia with this causing "extreme frustration." No evidence found of communication problem, interventions or goals r/t this need on the plan of care. Patient 8: Oxygen utilized since initiation of hospice services. No interventions or goals found on plan of care relating to oxygen precautions/safety.

Upon patient record review, 1 of 19 (Patient #8) 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 8: Recertification order effective 4/23/24 indicates a number of PRN visits for the SN, MSW, and SC but does not further clarify the scope/indication for PRN need.

Upon patient record review, 8 of 19 (Patient #2, 4, 8, 9, 12, 13, 15, & 16) 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 2: Nursing documentation 5/23/24 indicates "wounds" under integument assessment with DTI to left heel with hydrocolloid in place. No evidence found of any wound care treatment/orders present on medication/treatment record. Patient 4 &16 : MD order for Colace 100mg 1-2 capsules daily PRN "bowel care" with no further instructions to further explain "bowel care" or indications for use of medication. Patient 8: SN documentation reveals report from patient on 4/24/24 of use of Milk of Magnesia for relief of constipation. There is no evidence of an MD order to include this medication on the plan of care at that time. Patient 9: Wound care orders on 4/29/24 & 5/8/24 are incomplete and do not contain method for securing dressing or any PRN change/indications, only stating for the nurse to change at each visit. Also, wound inactivated at 6/3/24 visit but no evidence of order found to discontinue wound care. Patient 12: MD orders reflect Lorazepam 0.5mg tablets every 4 hours as needed anxiety. Lorazepam 2mg/ml oral concentrate 0.25ml every 4 hours as needed agitation is also present. There are no further instructions on when it is appropriate to administer which medication related to pill versus liquid, to prevent overdose, or whether they can or cannot be utilized in conjunction with each other. Patient 13: MD order 5/21/24 is incomplete. Buttocks wound care lacks indication for PRN application and does not specify who is to perform care. Right Heel order lacks the frequency of wound care and any PRN change order or indications. Left Heel fluid blister order states, "Cover with foam. Monitor for open skin." it lacks when foam is to be removed, who is to monitor for open skin and if foam is to be removed to monitor site is it to be reapplied and at what frequency. 5/30/24 MD order states, "Skin tear to right heel. Clean and dry, apply Silvasorb gel and cover with foam, wound care to be provided by RN until resolved." Order lacks what agent to cleanse with, method for drying, how foam is to be secured or if it is a bordered foam dressing, how often wound care is to be performed and any prn indication for change. These wounds were inactivated 6/12/24 with no orders found to discontinue wound care. Patient 15: Medication list contains both Hydrocodone 5-325 every four hours as needed "pain" and Tylenol 325mg 2 tablets every 6 hours as needed "pain or fever". There are no max dose instructions or further indications on when to administer one medication versus the other for pain.

Upon patient record review, 2 of 19 (Patient #4 & 12) 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 4: DME: Oxygen Concentrator, e-tanks, & nebulizer are not present on plan of care. Patient 12: Nursing documentation and aide instructions indicate the use of a walker. This DME is not listed on plan of care. Nursing documentation also states there is a hospital bed and BSC present in home. These are not listed on plan of care.

Upon patient record review, 1 of 19 (Patient #8) 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 8: Diagnosis of insomnia was added on 5/13/24 to pt. plan of care with patient utilizing PRN medications for sleep. SN documentation reveals this is a current, ongoing concern for the patient. The plan of care contains no evidence of related problem, interventions, or goals.

Upon client record review, 6 of 19 (Patient #1 2, 3,5, 6, & 10) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 1: Recertification Plan of Care order lists SC frequency of 2m2, 1m1 effective 5/7/24. There is no evidence of a second visit conducted in May 2024 or any documentation found of a missed visit. Patient 2: Initial assessment on 1/13/24 through current nursing documentation 6/20/24 indicate presence of Foley catheter. 6/6/24 nursing documentation reveals 16Fr/10ml catheter was changed. No evidence found of any catheter orders since the time of admission to present date. Patient 3: Initial assessment on 1/16/24 through current nursing documentation 6/20/24 indicate presence of Foley catheter. 6/6/24 nursing documentation reveals 16Fr/10ml catheter was changed. No evidence found of any catheter orders since the time of admission to present date. Patient 5: Add-on MSW order states frequency effective 6/12/24, "1M1, 2M2..." The initial MSW assessment was completed 6/14/24 with another MSW visit 6/20/24. The visit frequency followed does not match 1M1 as plan of care indicates. Patient 6: Recertification Plan of Care order lists calendar frequency effective 5/29/24 SN 1w1, 2w8. Week 1 begins 5/29/24-6/1/24. There is no evidence of the 1w1 visit being completed or a missed visit note. Patient 10: Supplemental order completed 4/30/24 reflects MSW frequency of 3M1, 5M1, 4M1, 1M1 effective 4/4/24. MSW visits completed on 4/5/24, 4/9/24, 4/17/24, & 4/23/24. There is no evidence of change in frequency for the month of April for the 4th completed visit.

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. Patient 4: During home visit there were several instances where bag technique policy number 6-013 was not followed. The nurse utilized gloved hands to document on the tablet. The tablet surface was not cleaned prior to placing back into bag. The nurse had a designated "dirty" side where she stored equipment. Each item was accessed from the dirty side one by one to utilize during patient care. She then returned (with gloved hands) each item upon use to this compartment without disinfecting/cleansing. The policy specifies there should be no "dirty" side as no dirty items should be placed in the bag, supplies should be removed from the bag and placed on a clean, dry surface or barrier, do not reenter the bag with gloves on, clean equipment upon patient use.

Upon patient record review, 6 of 19 (Patient #2, 6, 7, 12, 13, & 14) 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 2: Oxygen utilized by patient. No Oxygen precautions listed on aide instructions. Patient 6: Nursing documentation indicates use of WC further indicating patient is chair bound. NP face-to-face documents pt. is non-ambulatory. Physician CTI narrative states increased assistance now needed with transfers. Aide instructions contain "stand-by assistance with ambulation". Aide instructions do not contain patient use of WC/chair bound status, need for transfer assist, or need for glasses as nursing documentation reveals. Patient 7: Nursing documentation 6/4/24 reveals pt. requires wheelchair with max. assist with transfers. 6/7/24 nursing documentation indicates transfers, "sometimes 2 person." The aide instructions do not reflect the use of a WC, need for transfer , or need to obtain 2nd person assist for safe transfers. Patient 12: Aide instructions Contain both bed bath and shower. Detail listed states, "Bed bath if pt. too weak to shower." There is no further instruction on who is to determine if patient is too weak or if patient is cognitively and functionally able to make this determination. Also, nursing documentation states, "extensive help needed" with transfers. Transfer assist is not contained in aide instructions. Patient 13: Nursing documentation reveals pt. is chair bound, utilizes WC, and is a high fall risk. The aide instructions do not contain fall precautions, the use of a wheelchair, and does not reflect chair bound status stating, " stand by assist with ambulation" Patient 14: Aide plan of care does not reflect need for SC and Walker related to patient decline effective 6/18/24. Aide instructions also do not contain Fall precautions or that pt. is HOH in both ears.

Upon patient record review 2 of 19 (Patient #6,7) 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 6: Recertification Plan of Care order lists calendar frequency effective 5/29/24 SN 1w1, 2w8. Week 1 begins 5/29/24-6/1/24. There is no evidence of the 1w1 visit being completed or a missed visit note. CNA visit frequency effective 5/29/24 1w1, 2w8. There is no evidence of the 1w1 visit being completed or documented as missed. Patient 7: CNA visit on 6/24/24 indicates bed bath was given. Shower is bath type included on aide instructions. No evidence found of RN notification of need for/request for bed bath or of pt. decline warranting bed bath be performed. In addition, Recertification Plan of Care order lists calendar frequency effective 5/24/24 for CNA 1w1, 2w8. There is no evidence of the 1w1 visit being completed or documented as missed.

Upon observation, there was no evidence the hospice is directed by a Board of Directors/governing body which assumes full legal authority and responsibility for the operation of the hospice. There are 2 Delegation of Authority for physicians found with both of these forms dated 1/15/24. The Delegation of Authority for Hospice Physician found in the survey readiness binder with the Governing Body meeting minutes reflects the physician listed on the organizational chart as "Hospice Physician" as the designee. The contract signed by this physician does not designate him as alternate, but only as a hospice physician. The Delegation of Authority form that is framed and displayed in the foyer of the agency lists a different MD as designee. The MD listed as designee on the framed display in the foyer does have a properly executed contract delineating him as the alternate.

Upon patient client record review, 6 of 19 (Patient #1, 5, 6, 8, 12, & 13) 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 1: Election statement contains an incorrect correction to the effective date of hospice services. The date is written as 7/11/23 then marked over to indicate 7/12/23. The SOC is noted as 7/12/23. Patient 5: SC initial assessment note indicates a visit frequency discussed with pt./cg. of 1 x week for 2 weeks then twice monthly. The Add-on order to the plan of care states SC frequency of 2M1, 3M1. There is no evidence of a conversation with pt./cg. to warrant a desired frequency change. The correct needed frequency is unclear. Patient 6: NP face-to-face visit on 5/14/24 indicates patient is non-ambulatory. CTI narrative on 5/16/24 documents, increased assist needed with transfers. RN documentation on 6/4/24 & 6/6/24 indicate pt. is chairbound. RN visits 6/18/24 indicates "steady gait with or without assistive devices." Patient 8: Nursing documentation on 5/8/24, 5/22/24, 5/29/24, 6/12/24, & 6/19/24 all state Oxygen in utilized continuously. The MD order and medication list states PRN. Patient 12: Recert assessments dated 4/29/24 & 6/25/24 indicate Oxygen concentrator present in pt. home. There is no Oxygen listed under DME on the plan of care, there are no problem, interventions, or goals related to Oxygen use open and subsequent visit documentation states pt. is not on Oxygen. Patient 13: 5/1/24 recert visit note indicates "+2 assist for transfers" in the Eligibility Criteria section. In the same note under Mobility assessment findings the nurse documents, "Transfer bed to chair with minimal assist." It is unclear what pt. true functional status and safety needs are. Further, 5/16/24, 5/23/24 nurse documentation reflects teaching on Oxygen precautions. No evidence found of Oxygen in home.

Upon client record review, 1 of 19 (Patient #16) 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 16: No evidence found of discharge summary being sent when patient revoked services.