Every finding on record at Hospice of Acadiana Inc.

Upon patient record review, 1 of 31 (Patient #9) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient 09: The patient record does not include evidence that the patient chooses or refuses to choose an attending physician for hospice services.

Upon patient record review 2 of 31 (Patient #8, 11) 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 08: The patient was admitted on 4/15/25, the initial comprehensive Spiritual assessment was complete on 4/22/25. Patient 11: The patient was admitted on 3/22/25, the initial comprehensive Spiritual assessment was completed on 3/28/25.

Upon patient record review, 4 of 31 (Patient #2, 4, 7, 21) 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 02: The medication profile includes Miralax 17G powder orally one time a day for bowel regimen, it does not include a diluent. The medication profile includes Voltaren gel, no dose indicated, apply topically 2 times a day as needed for pain, it does not include an application site. (Order corrected on site.) Patient 04: Upon review of the medications in the home, the primary caregiver reports that the patient does not take tamsulosin 0.4mg which remains on the medication profile. Patient 07: The medication profile includes polyethylene glycol 17G powder orally one time a day for bowel regimen, it does not include a diluent. (Order corrected on site.) Patient 21: The medication profile includes polyethylene glycol 17G powder packet, take orally 1 time a day, it does not include a diluent. (Order corrected on site.)

Upon patient record review, 4 of 31 (Patient #4, 6, 7, 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 04: The patient was admitted on 11/5/24 with a primary diagnosis of sarcopenia, he has a secondary diagnosis of epilepsy determined as related to his hospice services, he takes phenobarbital and levetiracetam for epilepsy/seizure management. The plan of care does not include a problem statement with interventions and goals for the management of the epilepsy/seizures or seizure precautions. Patient 06: The patient was admitted on 4/24/25 to General Inpatient level of care with a primary diagnosis of Neurocognitive disorder with Lewy bodies, he is admitted with signs and symptoms of agitation and combativeness and was transferred from the hospital where he exhibited the same behaviors. The plan of care does not include a problem statement with interventions and goals for the management of the agitation. Patient 09: The patient record includes documentation of dysphagia with changes in patients ability to feed herself with noted symptoms of possible aspiration. The patient consumed 3 meals per day one month prior to admission and now eats 1 small meal a day, requires assisted feeding and medications must be crushed and added into pudding. The plan of care does not include a problem statement for nutrition with interventions and goals to include aspiration precautions.

Upon patient record review, 1 of 31 (Patient #3) 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 03: The plan of care includes hospice aide services with frequency orders of a range of 1-2 times per week, effective 1/2/25 and continuing into benefit 2 effective 4/2/25. (Updated and corrected order on site.)

Upon patient record review, 3 of 31 (Patient #2, 7, 21) 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 02: Medication orders on 9/21/24 includes Miralax 17G powder orally one time a day for bowel regimen, it does not include a diluent. Orders on 4/22/24 includes Voltaren gel, no dose indicated, apply topically 2 times a day as needed for pain, it does not include an application site. (Orders updated and corrected on site.) Patient 07: Medication orders on 4/10/25 includes polyethylene glycol 17G powder orally one time a day for bowel regimen, it does not include a diluent. (Orders updated and corrected on site.) Patient 21: The medication orders on 5/23/24 for polyethylene glycol 17G powder packet, take orally 1 time a day, does not include a diluent. (Orders updated and corrected on site.)

Upon patient record review, 4 of 31 (Patient #2, 3, 7, 10) 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 02: The patient documentation on 4/25/25 indicates the patient utilizes a rollator (rolling walker) for ambulatory assistance, this is not included in the plan of care. (Corrected on site.) Patient 03: The patient record indicates that the patient utilizes a rollator (rolling walker) for ambulatory assistance, this is not included in the plan of care. (Corrected on site.) Patient 07: The patient record indicates the patient is non-ambulatory and utilizes a wheelchair to self propel himself for mobility. The plan of care does not include a wheelchair. (Corrected on site.) Patient 10: The patient record upon admission (7/19/24) and onward indicates that the patient is weak and utilizes a wheelchair for ambulation, this is not included in the plan of care. Documentation on 3/5/25 performed by LPN indicates that the patient ambulates with a walker, this is not included in the plan of care. (Corrected on site.)

Upon patient record review, 4 of 31 (Patient #2, 8, 12, 18) 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 02: The patient has declined spiritual care and social work services and visits and denies needs or interventions, the plan of care has not been updated to discharge previous interventions and goals. (Corrected on site.) Patient 08: The patient record includes evidence of significant wounds including stage IV coccyx wound, left hip wound, unstageable right heel wound with eschar and right heel wound with eschar. The plan of care does not include patient specific interventions for the wounds. (Updated on site.) Patient 12: The plan of care includes orders for monthly SW visits, the plan of care does not include problem statements with interventions and goals for SW services. (Updated plan of care on site.) Patient 18: The plan of care includes order for volunteer visits 1-4 times per month starting 2/4/25, the plan of care is not updated to include volunteer services with interventions and goals. The patient/primary caregiver have initiated requests for assistance with nursing home placement with SW visits, interventions and goals that have not been included in the plan of care. (Updated and corrected on site.)

Upon client record review, 4 of 31 (Patient #7, 18, 20) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care.

Upon patient record review, 4 of 31 (Patient #26, 27, 28, 29) 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 26: The patient record does not include a plan of care for bereavement services reflective of the needs of the bereaved following the patient death. Patient 27: The patient record does not include a plan of care for bereavement services reflective of the needs of the bereaved following the patient death. Patient 28: The patient record does not include a plan of care for bereavement services reflective of the needs of the bereaved following the patient death. Patient 29:The patient record does not include a plan of care for bereavement services reflective of the needs of the bereaved following the patient death.

Upon patient record review, 2 of 31 (Patient #5, 6) 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 05: The patient was admitted on 4/22/25 to General Inpatient level of care, the aide task assignment does not specify frequencies for performing oral care, hair care, or bathing. (Updated and corrected on site.) Patient 06: The patient was admitted on 4/24/25 to General Inpatient level of care, the aide task assignment does not specify a frequency of tasks for bathing, hair care/shampooing, and oral care. The assistance level for patient needs is not specified and ranges from fully independent to full assistance, the aide is allowed to determine level of task and the care is not assigned as patient specific. (Updated and corrected on site.)

Upon patient record review 3 of 31 (Patient #13, 15, 16) 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 13: The patient record includes orders for Hospice Aide services for 6 times per week. The patient received 7 visits the week of 3/23/25 - 3/29/25 Patient 15: The patient record includes orders for Hospice Aide services 2 times per week. The patient received 1 visit the week of 3/2/25 - 3/8/25, and 1 visit the week of 4/13/25 - 4/19/25 Patient 16: The patient record includes order for Hospice Aide services 6 times per week. The patient received 5 visits the week of 4/14/25 - 4/19/25 and 5 visits the week of 3/30/25 - 4/5/25.

Upon personnel record review, 1 of 15 (Personnel #5) 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 #5: The employee record does not include evidence of an initial competency assessment.

Upon patient record review, 1 of 31 (Patient #21) 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 21: The patient record dated 1/16/25, 1/26/25 and 1/30/25 includes documentation of a hospice aide supervisory visits performed by the RN, the patient record does not include hospice aide services.

Upon patient record review, 1 of 31 (Patient #25) 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 25: The patient/family elected to revoke the hospice benefit, the record does not include a discharge summary.

Upon patient record review, 2 of 31 (Patient #7, 30) 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 07: The patient was admitted on 4/10/25 with a secondary related diagnosis of Type II diabetes mellitus without complications, the patient is prescribed Humalog twice daily, dose dependent on finger stick blood glucose results. The plan of care does not include a problem statement with interventions and goals for the management of the diabetes. The patient record indicates that he has a history of aggression and anxiety with a diagnosis of Paranoid Schizophrenia, indicated as a related diagnosis. The patient takes sertraline, trazadone, Zyprexa, buproprion, risperidone to control his mood and behavior, the plan of care dose not include a problem statement with interventions and goals for the management of the aggression and anxiety. The patient record includes volunteer services to be provided weekly effective 4/16/25, there is no evidence of volunteer visits being made. Patient 30: The medication profile in the hospice plan of care includes haloperidol 1mg every 4 hours as needed, the patient resides at a skilled nursing facility, this medication is not included in the plan of care at the skilled nursing facility. (Order corrected.)

Upon inspection throughout the facility, it was observed that the penetrations through the ceiling to the attic/roof space were not properly sealed to provide a fire barrier or fire stop. These openings were found in the electrical room, riser room, garage, storage rooms, oxygen storage room and boiler room. In healthcare facilities, unsealed penetrations and gaps in life safety ceilings can compromise fire protection measures, potentially delaying sprinkler or smoke detector activation and increasing the risk of fire spread. CODE REFERENCE: NFPA 101-2012, 8.3.5.1 "Penetrations for cables, cable trays, conduits, pipes, tubes, combustion vents and exhaust vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communication systems that pass through a wall, floor, or floor/ceiling assembly constructed as a fire barrier shall be protected by a firestop system or device. Gaps and holes from unsealed penetrations allow easy access for both fire and smoke to spread quickly throughout the building.

Upon patient record review, 5 of 5 (Patient #1-5) 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 #1-5 No aide task assignment frequency for any task assignments to date on Aide task assignment created by the RN.

Upon patient record review 3 of 5 (Patient #1, 4, 5) 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 on the 4/22/22 and 4/27/22 aide visits Shower, incontinence care and housekeeping were not documented as complete. Patient #4 on the 4/28/22 aide visit hair care and shave were not documented as complete, Patient #5 on the 4/27/22 aide visit note there is no evidence of any task completion to date.

Upon patient record review, 4 of 5 (Patient #2, #3, #4, #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 specific orders for all medications and treatments. Patient #2-The 02/26/22 plan of care includes orders for Foley insert/connect to BSD and change prn leaking or obstruction by hospice staff. The plan of care does not include a Foley size/balloon size. The comprehensive assessments on record indicate the patient is incontinent. Orders are incomplete and/or inaccurate. The plan of care also includes take 100u of Insulin Detimir 100u/3ml by pen as directed. (Incomplete/inaccurate orders). The referral on record indicates the patient is on a sliding scale. The medication list on the plan of care include Dropperette of carboxymethylcellulose sodium (0.5%) by ophthalmic three times a day. The plan of care does not specify Rt/Left or both eyes. Patient #3- The 02/27/22 plan of care includes orders for Nitroglycerin Take 0.4mg SL as directed q5min until chest pain resolved. The maximal allowable doses is not specified on the plan of care. Orders also include comfort kit. Comfort kit orders do not include specific medications and dosages included in the kit. Orders for wound care are incomplete and unclear and read: Patient has a wound to Rt knee and left wrist which they are applying Mepilex dressing once a week which was applied yesterday. Redness to sacrum with foam dressings every 72 hours. Patient #4- The 02/17/22 plan of care includes orders for Comfort Kit. Comfort Kit orders do not include specific medications. Patient #5-The 02/18/22 plan of care has orders for Foley cath insert and connect to BSD. (incomplete order). The patient was admitted with a Mediport and the plan of care does not address management of the Mediport.

Condition of Participation: Hospice Aide and Homemaker Services. L607

Upon personnel record review, 1 of 2 applicable (Personnel # 2) did not have evidence in the personnel file that a complete aide competency assessment was performed by the RN observing the aide with a patient or pseudo patient. Personnel #2- The Aide Competency on record occurred in November 2016 and did not document the following required tasks were observed being performed on a patient or pseudo patient: tub/shower bath, nail and skin care, oral hygiene, shampoo is documented but does not specify it was observed in the sink, tub and bed, and normal range of motioning and positioning was not documented.

Upon patient record review, 3 of 4 applicable (Patient #1, #3, #5) did not have evidence in the patient record that hospice aide assignments and duties include the tasks to be provided and the frequency of those tasks. Patient #1-The Aide care plan 02/24/22 assigns the aide to empty catheter bag, assist with colostomy and assist with meal set up and patient is tube fed. The patient does not have a colostomy, Foley or tube feedings. Patient #3- The Aide Care plan 02/27/22 does not include fall precautions, aspiration precautions and/or Oxygen precautions which are identified in the nursing visit documentation on 02/27/22 and 02/28/22 as applicable to the Aide Care Plan. There is also no visit frequency on the Aide plan of care Patient #5- The Aide Care plan 02/18/22 does not include fall precautions and Oxygen precautions which are applicable to the patient. The patient was admitted on Eliquis and bleeding precautions are not included in the plan of care. The Aide Care plan includes assist the patient to empty colostomy bag, empty catheter bag and catheter care. The patient does not have a catheter or colostomy.

Upon patient record review 4 of 4 applicable (Patient#1, #3, #4, #5) did not have evidence documentation in the patient record that a hospice aide provides services that are ordered by the IDG and included in the plan of care. Patent #1-Beginning 02/24/22 the Aide was ordered to visit 2-3 times weekly. One visit was documented on 3/11/22. The agency's scheduling calendar documented the family had refused care 02/26, 03/01, 03/03, 03/05, 03/08 and 03/10/22 however this was not documented in the patient record. Patient #3- The Aide plan of care 02/27/22 includes assisting the patient with a bed bath, hair care/shampoo, oral hygiene, bathroom assistance, and positioning/turning assistance each visit. On 03/05/22, 03/09/22 and 03/11/22 the Aide only documented full assistance with dressing. On 03/11/22 the Aide documented the patient refused a shave which had not been assigned. Patient #4- The Aide care plan assigns the aide to assist with a bed bath and oral hygiene every visit. On 02/21/22 and 02/28/22 the Aide documented full assist with dressing and did not document bed bath and oral hygiene as assigned. On 03/07/22 the Aide documented full assist with dressing . Oral hygiene and bed bath was not addressed. The Aide also documented the patient did not want her hair washed on 03/07/22. A shampoo/hair wash was not assigned. Patient #5- The Aide assignment includes 25 tasks to be performed. On 02/23/22 and 02/25/22 the Aide only documented partial assistance with dressing. On 03/07/22 the aide documented gave patient bed bath so we did not get in tub. The Aide was assigned to assist with a shower. On 03/11/22 the Aide only documented basic ADLs performed. Partial assistance with dressing. On 03/14/22 the only documentation by the Aide is patient is independent in dressing.

Upon patient record review 1 of 16 (Patient #13) 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 #13 admitted on 9/28/21, spiritual assessment completed on 10/7/21.

Upon patient record review 1 of 16 (Patient #5) 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 #5 admitted on 11/9/21, no evidence of a spiritual assessment as part of the comprehensive assessment.

Upon patient record review, 16 of 16 (Patient #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15 and #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. Patient #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #13, #14 and #16 initial plan of care included orders for Comfort Care Kit, and Bowel Regimen of enemas/laxative of choice, stool softener/suppository of choice. Comfort Kit medications and specific bowel regimen medications are not listed on the medication profile. Patient #11, #12, and #15 initial plan of care included orders for Bowel Regimen of enemas/laxative of choice, stool softener/suppository of choice. Specific bowel regimen medications are not listed on the medication profile. Patient #1 medication profile included oxygen 2-5LPM, no evidence of route of administration on medication profile. Patient #3 medication profile included oxygen 2-4LPM, no evidence of route of administration on medication profile. Patient #6 medication profile included oxygen 2.5-5LPM, no evidence of route of administration on medication profile. Patient #11 medication profile included oxygen 2-5LPM, no evidence of route of administration on medication profile. Patient #13 medication profile included oxygen 2-5LPM, no evidence of route of administration on medication profile. Patient #14 medication profile included oxygen 1-2LPM, no evidence of route of administration on medication profile. Patient #16 medication profile included oxygen 2-5LPM, no evidence of route of administration on medication profile.

Upon patient record review, 1 of 16 (Patient #3) 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 #3 admitted on 12/24/19 bereavement risk assessment completed on 12/30/19.

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

Upon patient record review, 2 of 16 (Patient #2 and #7) 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 #2 admitted with PEG tube. RN visits from 11/18/21-1/10/22 do not provide evidence or an assessment of PEG tube site. RN visit on 1/10/22 documented accessed patient Mediport, no evidence of an assessment of Mediport site. Patient #7 admitted with PEG tube. RN visits from 11/29/21-1/13/22 no evidence of an assessment of PEG tube site.

Upon patient record review, 5 of 16 (Patient #2, #4, #5, #6, and #10) 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 RN visit on 1/10/22 documented accessed Mediport. No evidence of goals and interventions specific to Mediport. Patient #4 terminal diagnosis of cerebral infarct. No evidence of goals and interventions related to neurological diagnosis. Patient #5 terminal diagnosis of heart failure. No evidence of goals and interventions related to cardiac diagnosis. Patient #6 admitted with PEG tube. No evidence of goals and interventions for PEG tube. Patient #10 admitted with diagnosis of anxiety. No evidence of goals and interventions related to anxiety.

Upon patient record review, 16 of 16 (Patient #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15 and #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 #1, #2, #3, #4, #5, #6, #7, #8, #9. #10, #13, #14 and #16 initial plan of care included orders for Comfort Care Kit, foley insert/connect to BSD prn, may irrigate with NS prn change every 30 days and prn, and Bowel Regimen of enemas/laxative of choice, stool softener/suppository of choice. Comfort Kit orders did not include specific medications, foley order did not include size, and bowel regimen did not include specific medications. Patient #11, #12, and #15 initial plan of care included orders for foley insert/connect to BSD prn, may irrigate with NS prn change every 30 days and prn, and Bowel Regimen of enemas/laxative of choice, stool softener/suppository of choice. Patient #2 medications ordered via PEG and order for PEG feedings. No evidence of order for PEG site care. Patient #6 medications ordered via PEG and order for PEG feedings. No evidence of order for PEG site care. Patient #11 RN visit on 1/4/22 documented 18G peripheral IV LFA and 16Fr foley in place. No evidence of orders for management of IV or foley. Patient #12 initial plan of care included IV ok to start IV and flush every shift. No evidence of specific orders for size and management of IV. RN visit on 1/8/22 documented foley in place, no evidence of orders for size and management of foley. Patient #14 order for oxygen 1-2LPM prn dyspnea, no evidence of route. Patient #15 RN visit on 7/16/21 documented foley in place, no evidence of an order for management and size of foley.

Upon patient record review, 13 of 16 (Patient #1, #2, #3, #4, #5, #6, #7, #8, #10, #13, #14, #15 and #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 equipment and supply needs. Patient #1 initial plan of care stated DME as needed. RN visit 7/27/21 identified Oxygen, wheelchair, Nebulizer, and suction in use. No evidence of specific orders for identified DME. Patient #2 initial plan of care stated DME as needed. RN visit on 1/21/21 identified wheel chair, hospital bed, shower chair, cough assist, and suction in use. No evidence of specific orders for identified DME. Patient #3 initial plan of care stated DME as needed. RN visit on 12/24/19 identified hospital bed, bed side commode, wheel chair, walker and oxygen in use. No evidence of specific orders for identified DME. Patient #4 initial plan of care stated DME as needed. RN visit on 10/21/21 identified hospital bed, oxygen, and bedside table in use. No evidence of specific orders for identified DME. Patient #5 initial plan of care stated DME as needed. RN visit on 1/18/22 identified suction and nebulizer in use. No evidence of specific orders for identified DME. Patient #6 initial plan of care stated DME as needed. RN visit on 6/1/21 identified oxygen, trilogy, wheel chair, bariatric hospital bed, lift, nebulizer, and trapeze in use. No evidence of specific orders for identified DME. Patient #7 initial plan of care stated DME as needed. RN visit on 1/13/22 identified kangaroo pump in use. No evidence of specific orders for identified DME. Patient #8 initial plan of care stated DME as needed. RN visit on 12/6/21 identified oxygen in use. No evidence of specific orders for identified DME. Patient #10 initial plan of care stated DME as needed. RN visit on 1/18/22 identified wheel chair and walker in use. No evidence of specific orders for identified DME. Patient #13 initial plan of care stated DME as needed. RN visit on 9/29/21 identified oxygen, nebulizer, suction, wheel chair, bedside commode, and rollator in use. No evidence of specific orders for identified DME. Patient #14 initial plan of care stated DME as needed. RN visit on 12/12/21 identified kangaroo pump, suction for purewick, and hospital bed in use. No evidence of specific orders for identified DME. Patient #15 initial plan of care stated DME as needed. Order for vapotherm oxygen for home use. No evidence of specific orders for identified DME. Patient #16 initial plan of care stated DME as needed. RN visit on 5/20/21 identified hospital bed, bed side table, oxygen, nebulizer, and suction in use. No evidence of specific orders for identified DME.

Upon patient record review, 6 of 13 (Patient #1, #2, #3, #6, #9, and #10) 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 last documented update noting progress toward identified goals and interventions was 12/30/21. Patient #2 last documented update noting progress toward identified goals and interventions was 12/28/21. Patient #3 last documented update noting progress toward identified goals and interventions was 12/23/21. Patient #6 last documented update noting progress toward identified goals and interventions was 12/14/21. Additionally, plan of care order dated 11/10/21 declined social work support. Social work IDG notes dated 10/27/21, 11/3/21, 11/17/21, 11/24/21, 12/22/21 and 1/5/22 documented provided support via telehealth the last 2 weeks MSW will continue to f/u and provide support, assist with any psychosocial issues or resources needed, MSW visit 1xm and prn. records. This plan of care update documentation was incorrect as this patient was not receiving MSW services. Patient #9 last documented update noting progress toward identified goals and interventions was 11/30/21. Patient #10 last documented update noting progress toward identified goals and interventions was 12/20/21.

Upon client record review, 4 of 16 (Patient #1, #2, #6 and #16) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1 plan of care dated 10/25/21 included spiritual care visit frequency of 1-2month and 3-4prn. Spiritual care visits were made on 12/5/21, 12/12/21 and 12/30/21. Patient #2 RN visit on 1/10/22 documented accessed Mediport using sterile technique blood return noted patient tolerated well. No evidence of an order for care of or accessing Mediport. Patient #6 plan of care orders dated 11/10/21 and 1/9/22 included RN visit frequency of 1-2week and 3-5prn. RN visits made on 12/21/21, 1/4/22, and 1/18/22. Patient #16 initial plan of care included foley insert/connect to BSD prn. May irrigate with NS prn. Change every 30 days and prn. RN visit on 5.21.21 documented inserted 16Fr foley cath per sterile technique patient tolerated well. RN visit on 6.2.21 documented new 20Fr placed without issue. No evidence of an order for 16 or 20Fr foley.

Condition of Participation: Hospice Aide and Homemaker Services. L607

Upon personnel record review, 1 of 1 applicable (Personnel #7) did not have evidence a complete aide competency in the personnel record. Personnel #7 aide competency assessment performed on 10/19/21 included several tasks however did not include bed bath, sponge, tub and shower bath, shampoo (sink, tub and bed), nail and skin care, and toileting and elimination. The aide competency assessment did not include evidence that the competency was performed with a patient or a pseudo patient.

Upon patient record review, 5 of 7 applicable (Patient #2, #3, #4, #5 and #16) did not have evidence in the patient record that hospice aide assignments and duties include all tasks to be completed by the aide including precautions to be taken. Patient #2 identified as high risk for falls and aspiration, no evidence of fall or aspiration risk on aide care plan. Patient #3 identified as high risk for falls and aspiration, no evidence of fall or aspiration risk on aide care plan. Patient #4 identified as high risk for falls and aspiration, no evidence of fall or aspiration risk on aide care plan. Patient #5 identified as high risk for falls, no evidence of fall risk on aide care plan. Patient #16 identified as high risk for falls and aspiration, no evidence of fall or aspiration risk on aide care plan.

Upon patient record review 2 of 7 applicable (Patient #4 and #16) did not have evidence documentation in the patient record that a hospice aide provides services that are ordered by the IDG and included in the plan of care. Patient #4 initial plan of care included aide visit frequency of 5-7 week. Aide visits made only on 12/17/21, 12/20/21, 12/29/21, and 1/5/22. No evidence of refusal of other ordered visits. Patient #16 initial plan of care included aide visit frequency of 2-3 week. Aide visits made on 6/1/21, 6/2/21, 6/3/21, 6/4/21, 6/7/21, 6/8/21, 6/9/21, 6/10/21, 6/11/21, 6/14/21, 6/15/21, 6/16/21, 6/17/21, and 6/18/21.

Upon client record review, 4 of 5 applicable (Patient #7, #8, #9, and #14) 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 #7 initial plan of care dated 11/24/21 included spiritual care frequency of 1-2m and 3-4prn. No evidence of spiritual care visit for November. Patient #8 initial plan of care included bereavement visits 1-2 month. No evidence of bereavement visits made. Patient #9 plan of care order dated 11/26/21 included spiritual care frequency of 1-2month and 3-4prn. No evidence of spiritual care visit for the month of December. Patient #14 plan of care order dated 11/11/21 declined spiritual services. Spiritual care visit made on 12/16/21.

Upon client record review, 3 of 5 applicable (Patient #7, #10 and #14) 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 #7 admitted with PEG tube. No evidence of an order for site care and who is responsible for providing the PEG site care. Patient #10 RN visits document 18Fr suprapubic in place. No evidence of an order for 18Fr suprapubic foley and who is managing catheter. Patient #14 admitted with purewick catheter. No evidence of an order detailing who is managing catheter.

Upon personnel record review, 3 of 4 applicable (Personnel #15, #16 and #17) 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.