Every finding on record at Hospice of St Clare

Upon patient record review, 2 of 14 (Patient #5, 6) 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 #5, 6: No documented initial bereavement assessment.

Upon client record review, 1 of 14 (Patient #12) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #12: 2/2/24 Physician order: Left buttocks pressure injury - cleanse with normal saline. Pat dry, apply triple antibiotic ointment, cover with bordered dressing daily. PCG to change dressing in between hospice nurse visits. LVN visit documentation for March 29, April 5, 12, 18, 2024 includes: integumentary assessed no issues. No evidence of wound care provided or coordinated with PCG to ensure performed. 3/25/24 CTI physician documentation notes no change in left buttocks stage II ulcer. 4/12 RN supervisory visit Braden risk assessment documented , but no specific wound description and no mention of wound care. No order to DC wound care. Wound still present according to DC summary.

Upon observation, there was no evidence the hospice that is using contract personnel for core services met the following exception: The hospice may use contracted personnel, if necessary, to supplement hospice personnel in order to meet the needs of patients under extraordinary or other non-routine circumstances. A hospice may also enter into a written arrangement with another Medicare certified hospice program for the provision of core services to supplement hospice personnel to meet the needs of patients. Circumstances under which a hospice may enter into a written arrangement for the provision of core services include: unanticipated periods of high patient loads, staffing shortages due to illness or other short-term temporary situations that interrupt patient care; and temporary travel of a patient outside of the hospice's service area. Patients #2, 3: Patients have active wounds with wound care provided by outside staff of WCWC group, although there is no documented contract. There is no specialized care provided. Hospice nurses, SNF staff and or PCG perform same care other days. Patient #2: 8/12/24 order for Wound care evaluation.... (with progress note to revisit weekly on Thursdays - subsequent visits 8/29, 8/30, 9/5/24.) Patient #3: 9/3/24 order for Wound care evaluation and treatment ... (with subsequent visit 9/6/24 with progress note for WCWC to visit one time weekly.)

Upon personnel record review, 1 of 12 (Personnel #5) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) ·(C) Shampoo, sink, tub, and bed Personnel #5: The form competency form utilized by hospice does not include specifics of sink, tub, bed for shampoo types, but only shampoo.

Upon patient record review, 3 of 14 (Patient #1, 3, 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: Plan of Care includes Oxygen 2L/min prn. There is no reference to this on Hospice Aide assignment sheet. Oxygen section left blank. 8/16/24 SN visit assessment related to altered skin integrity of penis. Hospice Aide assignment not updated to include skin breakdown. Patient #3: POC includes Oxygen 2L/min prn. There is no reference to this on Hospice Aide assignment sheet. Patient #5: Plan of Care includes Oxygen 3L/min prn. There is no reference to this on Hospice Aide assignment sheet.

Upon patient record review 1 of 14 (Patient #6) 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: 6/7/24 order for Hospice Aide 2x/wk. All visits after 7/15/24 are blank with no tasks documented as completed. There was no staff signature. (July 17, 19, 26, 28, Aug 2, 5, 7, 9, 14, 16, 19, 2024). Notes completed, signed and filed by the next day.

Condition of Participation: Organization and Administration of Services.

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. Agency is using outside wound care co. for routine wound care without documentation if wound is or is not related to hospice diagnoses and does not have a contract with this company. Part B Medicare is being billed by wound care co.

Upon contract review, the agency did not have evidence of an agreement with wound care provider 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 The medical record did not contain documentation if wound was unrelated and is being billed to Medicare part B for each patient.

Upon personnel record review, 3 of 12 (Personnel # 2, 6,7 ) did not have evidence that the hospice employees have received orientation on their specific job requirements. Personnel #2: There was no signed job description for Alt DPCS. Personnel #6: There was no signed job description for Bereavement Coordinator. Personnel #7: There was no signed job description for spiritual counselor. All were provided the following day.

Upon personnel record review, 2 of 12 (Personnel # 1, 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 #1: There is no competency for Volunteer Coordinator. Personnel #6: There is no competency for Bereavement Coordinator. Both were provided the following day.

Upon patient client record review, 4 of 14 (Patient #1, 4, 5, 11) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient #1, 4: Effective date of election is blank. Patient #5, 11: Requested notice of non-covered items addendum. The forms were provided but were not completed. Only included "See medication sheet"

Upon patient client record review, 1 of 14 (Patient #8) did not have evidence that each patient record contains Physician certification and recertification of terminal illness. Patient #8: CTI for Benefit #4 (8/18-10/16/24) is not signed by MD within 48 hours and no verbal authorization is documented.

Upon patient client record review, 4 of 14 (Patient #2, 3, 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 #2: Patient/SNF Resident admitted 7/9/24 with Foley catheter in place. The last documented catheter change was noted in 7/25 LVN note as occurring 3 days prior according to patient's report to nurse. Documentation was unclear who changed the catheter- facility or hospice staff. There was no documentation regarding Foley catheter changes month of August by hospice or facility staff. Also, Wound Care Provider notes 9/6/24 for Patient #3 inadvertently uploaded to patient #2 EMR. Patient #3 inadvertently uploaded to patient #2 EMR. Patient #12: RN supervisory visit 3/29/24 “Still noted wound on the left buttock. No signs of infection at this time. Wound care done." Patient #13: The initial bereavement assessment is not signed by any staff.

Upon client record review, 1 of 14 (Patient #2) 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 #2: Patient/SNF Resident admitted with Foley catheter in place. The IDG Care Plan did not delineate responsibility between SNF and hospice staff. (The last documented change was noted 7/25/24 LVN visit, as occurring 3 days prior according to patient's report to nurse. There was no documentation regarding Foley catheter changes month of August by hospice or facility staff.)

Upon observation, there was no evidence the hospice provides orientation to personnel of a SNF/NF or ICF/IID regarding the policies and procedures of the provision of care/service including all required content. The hospice reported providing orientation/training regularly, but were unable to present documented evidence during survey.