Every finding on record at Hospicio De San Miguel Inc.

Upon patient record review, 5 of 14 (Patient #1, #2, #3, #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. 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 #1: There is evidence on the aide note of 7/8/24 stating, "Calmoseptine was applied to protect skin" There is no order for Calmoseptine Patient #2: There is evidence on the aide note of 6/28, 7/2, 7/6/24, stating, "applied lidocaine patch for pain on the back of the neck". There is no order for Lidocaine patch. Patient #3: There is a duplicate order on the medication record. The same order is written for Acetaminophen and Tylenol. Patient #5: There is evidence on the medication record of an incorrectly written medication order: Ofloxacin eye drop, apply to both eyes twice daily until resolution of possible ear infection. AEB foul ear drainage is resolved. Patient #6: There is evidence on the medication record of an order on for Bactrim DS oral tab 800-160mg twice daily X 7 days. The medication was still on the medication record however, should have been removed as more than 7 days passed since written.

Upon patient record review, 3 of 15 (Patient #2, #4, #5) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual's attending physician, if any) • Changes that have taken place since the initial assessment • Information on the patient's progress toward desired outcomes • Reassessment of the patient's response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days Patient #2: There is no documentation in the chart of RN visits every 15 calendar days to update the comprehensive assessment. There is an RN visit on 2/12/24, 4/21/24, 5/7/24 and 6/1/24. In between those date the patient was seen by an LPN according to the frequency. Patient #4: There is no documentation in the chart of RN visits every 15 calendar days to update the comprehensive assessment. There is an RN visit on 1/24/24, 3/2/24 and 4/21/24. In between those date the patient was seen by an LPN according to the frequency. Patient #5: There is no documentation in the chart of RN visits every 15 calendar days to update the comprehensive assessment. There is an RN visit on 1/24/24, 3/2/24 and 4/21/24. In between those date the patient was seen by an LPN according to the frequency.

Upon patient record review, 3 of 14 (Patient #1, #2, #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 #1: On 7/8/24, the aide note states: "Calmoseptine was applied to protect skin". There is no documentation on the Plan of care to apply Calmoseptine to protect skin. Patient #2: There is evidence on the aide note of 6/28, 7/2, 7/6/24, stating, "applied lidocaine patch for pain on the back of the neck". There is no documentation on the Plan of Care for Lidocaine patch. Patient #5: There is evidence on the plan of care of an incorrectly written medication order: Ofloxacin eye drop, apply to both eyes twice daily until resolution of possible ear infection. AEB foul ear drainage is resolved.

Upon patient record review, 1 of 14 (Patient #7) 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 #7: There is evidence in the note of 3/20/24 stating: "4 cm X 4cm with mild clear exudate on the right foot. Wound care performed." The plan of care was not updated with problems/interventions/goals for wound.

Upon patient record review, 4 of 14 (Patient #1, #2, #3, #8) 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: There is evidence in the Plan of Care the patient has dysphagia, is on thickened fluids and is a high risk for falls. The aide plan of care does not contain aspiration precautions or fall precautions. Patient #2: There is evidence in the Plan of care the patient has risk of bleed and fall risk, The aide plan of care does not contain bleeding or fall precautions. Patient #3: There is evidence in the Plan of care the patient has risk of falls and is at risk of aspiration. The aide plan of care does not contain aspiration or fall precautions. Patient #8: There is evidence in the aide plan of care of PRN tasks. The aide care plan states: shave, as needed.

Upon patient record review 3 of 14 (Patient #1, #2, #7) 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 7/8/24 there is a note by the aide:"pt. bottom left side wound about 2 3/4 w. Calmoseptine was applied to protect skin". There is no documentation on the aide plan of care to apply Calmoseptine. Patient #2: There is evidence in the 2/12, 2/14, 2/16/24 aide notes "completed wound care to left heel". The aide plan of care does not include wound care. In addition, on the aide note of 6/28, 7/2, 7/6/24, states "applied lidocaine patch for pain on the back of the neck". The aide plan of care does not include applying patch and this is out of the aide's scope. Patient #7: There is evidence in the note of 3/20/24 stating: "4 cm X 4cm with mild clear exudate on the right foot. Wound care performed." however, this is not listed on the plan of care and would be out of the aide scope of practice.

Upon patient record review 2 of 14 (Patient #1, #2) did not have evidence in the patient record that the hospice aides report: • Changes in the patient's medical, nursing, rehabilitative, and social needs to a registered nurse, as the changes relate to the plan of care and quality assessment and improvement activities • Hospice aides must also complete appropriate records in compliance with the hospice's policies and procedures Patient #1: There is evidence in the chart of a aide reported to the family a change in skin condition. aide note: "pt. bottom left side wound about 2 3/4 w. Calmoseptine was applied to protect skin. There is no evidence skin changes or skin protectant application were reported to the RNCM. Patient #2: There is evidence on the aide of 6/28, 7/2, 7/6/24, stating, "applied lidocaine patch for pain on the back of the neck". There is no order for Lidocaine patch. There is no evidence in the patient record the aide reported pain or the use of Lidocaine patch to the RNCM and this is out of aide's scope.

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. There is evidence the hospice provided 0 hours of administrative or direct care volunteer hours.