Every finding on record at Hospice of the Plains, Inc

Upon patient record review, 1 of 14 (Patient #1) 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 Patient 1: The medication list indicates lidocaine patch 4% apply daily for 12 hours; however, there is no site/location indicated for this transdermal medication. (corrected onsite)

Upon client record review, 4 of 14 (Patient #1, 2, 4, 7) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 1: SN visits are ordered for 1 x weekly. However, during the week of 07.23.2023, both the RN and the LPN made a visit to the patient on 07.28.2023. There is no evidence of an order for the additional nursing visit. Patient 2: SN visits are ordered for 2 x weekly. However, during the week of 06.18.2023, the RN and LPN made a visit to the patient on 06.19.2023 and the RN made a visit to the patient on 06.22.2023. During the week of 07.23.2023, the RN made a visit to the patient on 07.25.2023 and the RN and LPN made a visit to the patient on 07.27.2023. There was no evidence of orders for the additional nursing visits. Patient 4: SN visits are ordered for 1 x weekly. However, during the week of 06.18.2023, both the RN and the LPN made a visit to the patient on 06.21.2023. There is no evidence of an order for the additional nursing visit. Patient 7: SN visits are ordered for 1 x weekly. However, during the week of 06.25.2023, both the RN and the LPN made a visit to the patient on 06.27.2023. There is no evidence of an order for the additional nursing visit.

Upon observation, there was no evidence of contracts/agreements with other facilities/agencies/hospices to receive patients in the event the hospice cannot provide care to their patients during an emergency.

Upon patient record review, 6 of 14 (Patient #1, #2, #3, #4, #5, #6) 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- On 05/01/23 the nurse documents receiving an order that the patient could take Oxycodone 10 mg q3h prn pain. The medication profile was not updated with the new frequency. (corrected on site) Patient #2-The medication profile includes OTC antacid of choice prn dyspepsia per directions on package. (not specific). The medication profile also includes multiple prn medications for constipation without differentiation for administration. Milk of magnesia, Glycerin suppositories and Fleets enema are all ordered prn for constipation. (corrected on site) Patient #3- The medication profile includes multiple prn medications for constipation without differentiation for administration. Milk of magnesia, Miralax and Fleets enema are all ordered prn for constipation. MiraLax is listed on the medication profile as MiraLax 17 gm oral powder once daily prn constipation. A diluent is not included. Omeprazole is listed on the profile as Omeprazole 20 mg 1 cap bid for dyspnea. The correct symptom is dyspepsia. (corrected on site) Patient #4-The patient is on Oxygen and Oxygen is not included in the profile. The medication profile includes multiple prn medications for constipation without differentiation for administration. Milk of Magnesia, Glycerin suppositories, Fleets enema and Bisacodyl suppository are all ordered prn for constipation. The medication profile lists Hydromorphone 2mg 1 q4h prn moderate pain and Oxycodone 5mg 1 tab q6h prn moderate pain. The orders do not include differentiation for administration. (corrected on site) Patient #5- The medication profile includes Oxygen 0-10 liters continuous via NC. The profile does not include specific guidelines for titration. (corrected on site) Patient #6-The patient is on Oxygen and Oxygen is not on the medication profile. The medication profile includes multiple prn medications for constipation without differentiation for administration. Milk of magnesia, Glycerin suppositories, Fleets enema and Bisacodyl suppository. OTC antacid of choice prn dyspepsia per directions on package is on the profile. On 05/26/23 the nurse documents the family is giving Loperamide for loose stools. Loperamide is not listed on the profile. (corrected on site).

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

Upon patient record review, 6 of 14 (Patient #1, #2, #3, #4, #5, #6) did not have evidence the plan of care 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 #1- Nursing is ordered 1-2X week and 12 prns. Chaplain is ordered as 12 prn, SW is ordered 1-3X/mo with 9 prn visits. Must have a visit frequency with the PRN visits, not PRN stand alone visits. (corrected on site) Patient #2, #3, #6 - Nursing is ordered 1-2X week and 12 prns. Chaplain is ordered as 6 prn. SW is ordered 1-3X/mo with 6 prn visits. Aide is ordered 1-2 times a week with 6prn (The Aide can not decide ranges and prn visits). (corrected on site) Patient #4- Nursing is ordered 1-2X week and 12 prns. Chaplain is ordered as 6 prn and SW is ordered 1-3X/mo with 6 prn visits. (corrected on site) Patient #5- Nursing is ordered 1-2X week and 12 prns. Chaplain is ordered as 12 prn and SW is ordered 1-3X/mo with 8 prn visits. (corrected on site).

Upon patient record review, 6 of 14 (Patient #1, #2, #3, #4, #5, #6) did not have evidence the plan of care includes all services necessary for the palliation and management of the terminal illness including specific orders for all medications and treatments. (corrections made on site) Patient #1- On 05/01/23 the nurse documents receiving an order that the patient could take Oxycodone 10 mg q3h prn pain. The plan of care was not updated with the order. Patient #1, #2-The plan of care includes orders to insert Foley cath prn as needed for retention/incontinence and change as needed for maintenance and infection prevention. The orders are not specific for size, balloon size, and frequency of changes. The orders also include: May irrigate with normal saline prn to maintain patency. The orders are not specific for the amount of irrigant to be used. Patient #2-The plan of care includes orders which read the patient may take an OTC antacid of choice prn dyspepsia per directions on package. Orders also include nursing may initiate wound care protocols for skin breakdown. The orders are not specific for the actual wound care to be performed. The plan of care includes multiple prn medications for constipation without differentiation for administration. Milk of magnesia, Glycerin suppositories and Fleets enema are all ordered prn for constipation. Patient #3- The plan of care includes multiple prn medications for constipation without differentiation for administration. Milk of magnesia, Miralax and Fleets enema are all ordered prn for constipation. MiraLax is listed on the plan of care as MiraLax 17 gm oral powder once daily prn constipation. A diluent is not included in the order. Omeprazole is listed as Omeprazole 20 mg 1 cap bid for dyspnea. The correct symptom is dyspepsia. Orders also include nursing to cleanse wound with soap and water and may initiate wound care protocols for skin breakdown. The orders are not specific for the actual wound care to be performed. Patient #4-The plan of care includes multiple prn medications for constipation without differentiation for administration. Milk of magnesia, Glycerin suppositories, Fleets enema and Bisacodyl suppository are all ordered prn for constipation. The plan of care includes orders to insert Foley cath prn as needed for retention/incontinence and change as needed for maintenance and infection prevention. The orders also include may irrigate with normal saline prn to maintain patency. Orders also include nursing may initiate wound care protocols for skin breakdown. The orders are not specific for the actual wound care to be performed. The patient was admitted with a port a cath and the plan of care does not address maintenance of the port. The plan of care lists Hydromorphone 2mg 1 q4h prn moderate pain and Oxycodone 5mg 1 tab q6h prn moderate pain. The orders do not include differentiation for administration. Patient #5- The plan of care includes Oxygen 0-10 liters continuous via NC. The plan does not include specifics for titration. The plan of care includes orders to insert Foley cath prn as needed for retention/incontinence and change as needed for maintenance and infection prevention. Patient #6-The plan of care includes multiple prn medications for constipation without differentiation for administration. Milk of magnesia, Glycerin suppositories, Fleets enema and Bisacodyl suppository. OTC antacid of choice prn dyspepsia per directions on package is on the plan of care On 05/26/23 the nurse documents the family is giving Loperamide for loose stools. Loperamide is not included in the plan of care. Foley catheter orders are not specific and wound care orders are written as per protocol.

Upon patient record review, 4 of 14 (Patient #1, #4, #5, #6) 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 05/11/23 the nurse documents instructing the patient to take Kaopectate for persistent loose stools. The record does not contain orders for Kaopectate. Patient #4- On 05/26/23 the nurse documents we decided to hold Lasix for now as the patients blood pressure remains low. Furosemide is ordered as one tab qd for edema. There are no orders on record to hold the medication. (late entry orders corrected on site) Patient #5 On 05/18/23 the nurse documents the Foley was discontinued and the plan of care was not updated with orders to discontinue the Foley. Patient #6- The nurse documents the patient's family was instructed to administer 1/2 tab of Oxycodone as 1 tab is too sedating. There are no orders on record for 1/2 tab. Orders on record are for Oxycodone 5 mg 1-2 tab q4h prn moderate pain. The nurse also documents we will switch to Motrin 200mg and if needed 400 mg to assist with fever. There are no orders on record for Motrin.

Upon patient record review, 5 of 14 (Patient #10, #11, #12, #13, #14) did not have evidence the hospice offers bereavement counseling that includes: • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery Patient #10, #11, #12, #13, #14-The Bereavement plans of care on record do not include interventions and frequencies for mailings and/or phone contacts following death.

Upon patient record review 1 of 12 (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- On 05/22/23 the Aide documented the patient wanted to get in the shower so a shower visit was performed. The Aide assignment included the patient was on bedrest and a bath was to be performed.

Upon personnel record review, 1 of 12 (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-The personnel file does not contain a competency for the volunteer.

Upon patient record review, 9 of 14 (Patient #1, #2, #3, #4, #5, #6, #7, #8, #9) did not have evidence that each patient record contains: • A Signed election statement in accordance with 418.24 Patient #1, #2, #3, #4, #5, #6, #7, #8, #9-The records did not contain the updated requirements for the election statement that went into effect on October 2020. Notification of the beneficiary’s right to request in writing, the “Patient Notification of Hospice Non-Covered Items, Services, and Drugs” addendum that includes information and rationale for why the hospice has determined items, drugs, or services are unrelated to the terminal illness and that immediate advocacy is available through the Beneficiary and Family-Centered Care Quality Organization (BFCCQIO) if the beneficiary disagrees with the Hospice's determination.

Upon personnel record review, 1 of 12 (Personnel #12) did not have evidence that all Speech Therapy Services are provided by a qualified licensed Speech-Language Pathologist (SLP) or Audiologist in accordance with the state's Speech-Language Pathology Practice Act and the hospice's policies and procedures and/or job descriptions. Personnel #12-The agency does not have a professional license for a Speech Language Pathologist from the contract agency.

Upon personnel record review, 1 of 12 (Personnel #11) did not have evidence all Occupational Therapy Services are provided by a qualified licensed Occupational Therapist (OT) in accordance with the state's Occupational Therapy Practice Act and the hospice's policies and procedures and/or job descriptions. Personnel #11-The agency does not have a professional license for an Occupational Therapist from the contract agency.

Upon personnel record review, 3 of 12 (Personnel #10, #11, #12) 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 #10, #11, #12-The records do not contain criminal background checks for the contracted employees.

Upon personnel record review, 1 of 12 (Personnel #6) did not have evidence of criminal background checks being obtained in accordance with state requirements for direct patient care personnel. 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 #6 -The file does not contain criminal background checks.

Upon personnel record review, 4 of 12 (Personnel #6, #7, #11, #12) did not have evidence that all personnel have been fully vaccinated for COVID-19. Personnel #6, #7, #11, #12-The personnel files do not contain evidence of vaccinations or approved exemptions.