Every finding on record at Hospice Preferred Choice, Inc.

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. Corrected on site.

Upon observation, there was no evidence the Emergency Plan communication plan must includes a primary and alternate means for communicating with hospice's employees. Corrected on site.

Upon patient record review 1 of 19 (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: SOC date 10/7/2022, Spiritual assessment occurred on 10/27/2022, Psychosocial assessment occurred on 10/13/2022.

Upon patient record review, 3 of 19 (Patient #5, #6, #7) 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 #5: Medication profile dated 5/20/2024 included Polyethylene Glycol 17Gm oral powder Q8Hr PO PRN Constipation. No evidence of a diluent. Corrected on site. Patient #6: On home visit to pt. in SNF, the hospice medication profile did not match the SNF MAR as oxygen was included on hospice profile but not SNF MAR. SNF was administering the O2. Patient #7: On home visit to pt. in SNF, hospice medication profile contained Atorvastatin however, the SNF had discontinued the medication.

Upon patient record review, 2 of 19 (Patient #13,#17,) 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 #13: SOC date 10/7/2022, bereavement assessment completed 7/21/2023. Patient #17: SOC 12/13/2023, bereavement assessment completed 12/27/2023.

Upon patient record review, 4 of 19 (Patient #4, #5,#17, #18) 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 #4: On SOC assessment MSW identified no identification of funeral arrangements, no evidence on POC for problem/intervention/goals for funeral planning. Corrected on site. Patient #5: On SOC assessment MSW identified no identification of funeral arrangements, no evidence on POC for problem/intervention/goals for funeral planning. Corrected on site. Patient #17: On SOC assessment MSW identified no identification of funeral arrangements, no evidence on POC for problem/intervention/goals for funeral planning. SN on SOC assessment identifies dysphagia and admission after aspiration pneumonia. No evidence on the POC of problem/intervention/goals for dysphagia/risk of aspiration. Patient #18: SN SOC assessment identifies nausea as significantly affects pt. Diagnosis CA Liver, bile duct. No evidence on POC for problem/interventions/goals for nausea.

Upon patient record review, 1 of 19 (Patient #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 medications and treatments. Patient #5: Order dated 5/20/2024 included Polyethylene Glycol 17Gm oral powder Q8 hr. PO PRN Constipation. No evidence of a diluent. Corrected on site.

Upon client record review, 1 of 19 (Patient #4) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #4: Order for SN visits dated 4/28/2024 included SN 3x 8 weeks, week of 4/28/2024 visits occurred 4/29 and 5/2/2024, with no evidence of a missed visit for the 3rd visit ordered.

Upon personnel record review, 1 of 13 (Personnel #9) 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.) ·Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff. ·Reading and recording temperature, pulse, and respiration ·Safe transfer techniques and ambulation. ·Normal range of motion and positioning ·Appropriate and safe techniques in personal hygiene and grooming that include-- ·(A) Bed bath ·(B) Sponge, tub, and shower bath The other subject areas in this section may be evaluated through written examination, oral examination or after observation of a Hospice Aide with a patient. Employee #9: Competency assessment for bed bath, sponge/tub and shower were not observed with a PT or pseudo pt. competency form has "sim" marked for simulation.

Upon patient record review, 1 of 19 (Patient #18) 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 #18: SN at SOC placed fall precautions on full comprehensive POC, no evidence on aide assignment of fall precautions.

Upon observation, there was no evidence the annual report documents the use of volunteers providing day to day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract personnel. Report for 12/2023 equaled 2.89%.

Upon patient record review, 2 of 19 (Patient #6, #8) did not have evidence that the hospice provided the following information: • The most recent hospice plan of care specific to each patient • Hospice election form and any Advance Directives specific to each patient • Physician certification and recertification of the terminal illness specific to each patient • Names and contact information for hospice personnel involved in hospice care of each patient • Instructions on how to access the hospice's 24-hour on-call system • Hospice medication information specific to each patient • Hospice physician and attending physician (if any) orders specific to each patient Patient #6: Last updated POC dated 4/16/2024. Patient #8: Last updated POC dated 4/16/2024