Every finding on record at Hospice Holdings Dfw, LLC

Upon patient record review, 1 of 14 (Patient #2) 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. Patient#2-The medication profile lists Ondansetron 4mg ordered q8h prn for nausea with special instructions listed as take q4h prn for nausea. (discrepancy in frequency). (corrected on site)

Upon patient record review, 5 of 14 (Patient #1, #2, #3, #4, #5) 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. (corrected on site) Patient #1, #2, #3, #4, #5-On each of the plans of care the intervention for spiritual care services read: Hospice Chaplain developed a plan of care. The goal is listed as the Hospice Chaplain will meet the patient/family/caregiver needs. The spiritual portion of the plan of care does not reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. Patient #3-The plan of care on record only includes Social Worker frequency and orders to eval and develop a plan of care. The psychosocial portion of the plan of care does not reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. (corrected on site)

Upon patient record review, 4 of 14 (Patient #2, #4, #6, #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 medications and treatments. Patient #2-The medication profile lists Ondansetron 4mg ordered q8h prn for nausea with special instructions listed as take q4h prn for nausea. (discrepancy in frequency). (corrected on site) Patient #4-The plan of care includes goals and interventions for Oxygen therapy. This is an error as the patient is not on Oxygen. (corrected on site) Patient #6- The plan of care includes orders for the nurse to DC the patients PICC line on 03/20/24. (This is an error as the patient was not admitted with a PICC line). 04/23/24 orders to update the plan of care read: hospice nurse to cleanse wound with dermal wound cleanser. Pat dry with gauze and cover with bordered dressing. The location of the wound is not included in the orders. (corrected on site) Patient #8-The 03/07/24 plan of care includes orders to assess the patients cardiopulmonary symptom relief including Oxygen treatment. This is an error as the patient is not on Oxygen. (corrected on site)

Upon patient record review, 3 of 14 (Patient #1, #2, #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 #1-The patient was admitted on 03/13/24 and is receiving Chaplain services. The revised plans of care 04/04/24 and 04/18/24 do not include findings from the patients spiritual assessment and or progress towards outcome/goals from the plan of care. The revised plans of care only documents the Chaplain will help with patients grief and facilitate a supportive environment in the spiritual assessment documentation. The documentation does not address religious affiliation, and/or findings from initial assessment to include spiritual needs and interventions. In addition, On 03/29/24 the nurse documents the patient has a signed DNR on record. The plan of care is not updated with the DNR status. (corrected on site) Patient #2- The patient was admitted on 03/30/24 and is receiving Chaplain services. The revised plans of care 04/04/24 and 04/18/24 do not include findings from the patients spiritual assessment and or progress towards outcome/goals from the plan of care. The revised plans of care only documents the Chaplain will help with patients grief and facilitate a supportive environment in the spiritual assessment documentation. The documentation does not address religious affiliation, and/or findings from initial assessment to include spiritual needs and interventions. Patient #8-The Chaplain evaluated the patient on 04/16/24. The 04/18/24 revised plan of care/IDG documentation does not include findings from the patients spiritual assessment. The revised plan of care only documents the Chaplain will help with patients grief and facilitate a supportive environment in the spiritual assessment documentation. The documentation does not address religious affiliation, and/or findings from initial assessment to include spiritual needs and interventions.

Upon patient record review, 3 of 14 (Patient #1, #5, #8) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1-On 03/13/24 the Chaplain is ordered to visit monthly. Then Chaplain visited twice in March on 03/14/24 and 03/29/24. Patient #5-On 03/08/24 the Chaplain is ordered to visit twice monthly for one month. The Chaplain visited three times in March on 03/11/24, 03/22/24, and 03/28/24. Patient #8- Effective 03/07/24 the Chaplain was ordered monthly to evaluate the patient spiritual needs. A Chaplain visit is not on record for March 2024.

Upon patient record review 1 of 14 (Patient #2) did not evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group and included in the plan of care Patient #2-The Aide is assigned to perform a shampoo weekly. The week of 04/07/24 and 04/14/24 the Aide documented a shampoo was not performed on all visits. Effective 04/07/24 the Aide is ordered three times weekly. The week of 04/07/24-04/13/24 the aide visited twice on 04/10/24 and 04/11/24. There is no documentation on record regarding the reason for a missed visit during this timeframe.

Upon patient record review, 2 of 14 (Patient #1, #4) did not have evidence that all entries are accurate. Patient #1-On 03/29/24 and 04/12/24 the nurse documents performing an Aide Supervisory visit. This is a documentation error as the patient does not receive Aide Services. Patient #4- On 03/25/24, 04/01/24, 04/08/24, and 04/15/24 the nurse documents performing an Aide Supervisory visit. This is a documentation error as the patient does not receive Aide Services.

Upon patient record review, 1 of 14 (Patient #8) did not have evidence that the hospice plan of care identifies the care and services that are needed and specifically identify which provider (nursing facility or hospice) is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care. Patient #8-The patient resides in a Skilled Facility. On 03/07/24 wound care orders on record read: hospice nurse to perform/teach pt/caregiver wound care to L coccyx and L buttock. Cleanse wound with NS/wound cleanser , pat dry, apply Santyl, calcium alginate and cover with foam dressing daily. On 03/19/24 the nurse received orders which read: Cleanse scabbed area to L shin once daily with wound cleanser or saline, pat dry, and leave open to air. The orders do not specify provider (nursing facility or hospice) is responsible for performing the wound care. (corrected on site)