Every finding on record at Hospice of Yavapai County, LLC

Upon patient record review 1 of 11 (Patient #9) 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 9: SOC date 9/3/2022. The MSW SOC assessment occurred on 9/16/2022.

Upon patient record review 1 of 11 (Patient #3) 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 3: The HIS questions are answered, along with the verbiage Part of faith based or spiritual community "No", Do you have any spiritual beliefs that need to be in the care we provide? "No", What is important to you at time of death? "none" SC was ordered, pt refused, so no SC assessment done. MSW and RN assessment did not cover spiritual care assessment components that were identified per the agency process with the remaining patients.

Upon patient record review, 2 of 11 (Patient #4, #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. 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: Medication profile dated 10/26/2022 includes Lidocaine patch to affected area as needed for topical pain. There was no evidence of an area identified for application. Corrected on site. Patient 6: Medication profile dated 8/17/2022 includes Capsaicin topical cream 0.25% apply topically to pain area 2x day as needed for pain. There was no evidence of an area to apply.

Upon patient record review, 1 of 11 (Patient #9) 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 9: SOC date 9/3/2022. The Bereavement SOC assessment occurred on 9/16/2022, there was no evidence of occurring within the required time frame.

Upon patient record review, 2 of 11 (Patient #2, #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. Patient 2: On service with Alzheimer's primary, seizure disorder as comorbidity, there was no evidence of a neuro care plan with problem/interventions. Corrected on site. Patient 5: Patient with comorbidities of CVA and Seizures. There was no evidence on the POC of a neuro problem/ interventions for CVA. Corrected on site.

Upon patient record review, 2 of 11 (Patient #4, #6) 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 4: Order dated 10/26/2022 includes Lidocaine patch to affected area as needed for topical pain. There was no evidence of an area identified for application. Corrected on site. Patient 6: Order dated 8/17/2022 includes Capsaicin topical cream 0.25% apply topically to pain area 2x day as needed for pain. There was no evidence of an area to apply.

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 2: Upon entering home, placed bag on barrier, opened bag and removed items without washing hands/use of sanitizer. After using equipment on patient, cleaned all equipment without removing dirty gloves/cleansing hands.

Upon patient record review, 4 of 8 applicable (Patient #6, #8, #10, #11) 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 6: Patient is on supplemental O2. There was no evidence of Oxygen safety or precautions on the Aide POC/assignment list. Patient 8: Patient is on supplemental O2. There was no evidence of Oxygen safety or precautions on the Aide POC/assignment list. Patient 10: Patient is on supplemental O2. There was no evidence of Oxygen safety or precautions on the Aide POC/assignment list. Patient 11: Patient is on supplemental O2. There was no evidence of Oxygen safety or precautions on the Aide POC/assignment list.