Every finding on record at In Good Hands Hospice Inc

Upon patient record review, 1 of 14 records reviewed (Patient #8) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient #8: The consent form regarding the patients choice to choose an attending was marked yes I wish to chose but the name of the physician was blank. COS.

Upon patient record review, 3 of 14 records reviewed (Patient #3, #5, #8) 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 #3: During the home visit the medication profile had Carvedilol 3.125mg po BID HTN, the patient and his wife confirmed he was not taking this medication, this medication was also not in the home at the time of the survey. COS. Patient #5: The record indicated the patient was on Tylenol 500g po TID prn for pain 2-5/out of 10 and fever greater than 100 degrees Fahrenheit and had Tylenol Suppositories 650mg PR Q6hours prn fever greater than 101, there was no evidence of not exceeding 4gm in a 24 hour period. COS. During the home visit the medication profile had the following medications: ketoconazole, tylenol tablets, mycozyl AP 2%,ketoconazole shampoo,milk of magnesia, buspirone, quetiapine fumarate, aspirin, tylenol suppository, levsine, morpine sulfate liquid, and zofran listed but not available at the board and care center. In addition, the lorazepan prescription label read lorazepam 2mg/ml 0.25ml SL Q6hours as needed for anxiety /agitation /restlessness. The medication profile had the medication listed at Q4hours prn. COS. Patient #8: The record indicated Miralax Powder 17 grams 1 scoop oral once per day constipation, there was no diluent listed. COS.

Upon patient record review, 1 of 14 records reviewed (Patient #7) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient #7: The record indicated the nurse documented on 02/22/25 the family reported increased agitation and pain. The patient caregiver expressed concerns about symptom management. A comfort kit was ordered. There was no continuous assessment and or follow up until 03/01/25.

Upon patient record review, 5 of 14 records reviewed (Patient #1, #2, #3, #4, #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 #1: The nursing assessment on 02/15/25 supported the patient was imminent evidenced by decreased LOC, decreased/absence of bowel/bladder function, decreased food and fluid intake, increased fatigue, increased agitation and increased sleeping. There was no evidence of an individualized plan of care to reflect the patient/family goals and interventions based on this problem. COS. Patient #2: Upon admission on 01/04/25 there was no individualized written plan to reflect the patient/family goals and interventions for a full code status and or naming the mortuary of choice. COS. Patient #3: Upon admission on 02/20/25 the patient was taking Eliquis 5mg po BID, there was no individualized written plan to reflect the patient/family goals and interventions for bleeding precautions. COS. Patient #4: Upon admission on 05/13/24 the patient was taking Farxiga 10mg po daily, Jardiance 10mg po daily and Lantus 100U 50Usq daily QHS. There was no evidence of an individualized plan of care to reflect the patient/family goals and interventions based on this diabetic management. In addition, the patient was taking Eliquis 5mg po BID, there was no bleeding precautions in the plan of care. All COS. Patient #5: Upon admission on 08/02/23 there was no individualized written plan to reflect the patient/family goals and interventions regarding their mortuary of choice, there was no mortuary listed at the time of the survey. COS.

Upon patient record review, 6 of 14 records reviewed (Patient #3,#4,#5,#6,#7,#8) 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 #3,4,6,7: The patient had Glucerna ordered. There was no specific order i.e. 2 cans per day. COS. Patient #5: The record indicated an order for Tylenol 500g po TID prn Pain 2-5/out of 10 and Fever greater than 100 degrees Fahrenheit and Tylenol Suppositories 650mg PR Q6hours prn fever greater than 101 degrees Fahrenheit, there was no evidence of not exceeding 4gm in a 24 hour period. COS. In addition, the patient had Glucerna ordered. There was no specific order i.e. 2 cans per day. COS. Patient #8: The order indicated Miralax Powder 17 grams 1 scoop oral once per day constipation, there was no diluent listed. COS.

Upon patient record review, 3 of 14 chart reviewed (Patient #2, #4, #8) 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 #2: The patient had a platelet count of 52 on 02/21/25 and a WBC of 2 on 02/21/25. There was no revised plan of care based off the comprehensive assessment with any progress towards the outcome/goals for high risk bleeding precautions or an infection prevention plan of care. COS. Patient #4: On 01/28/25 the doctor documented Atrial Fibrillation uncontrolled with increased dizziness and increased fall risk. There was no revised plan of care based off the comprehensive assessment with any progress towards the outcome/goals for fall risk. COS. Patient #8: There was an order on 01/20/25 and 01/21/25 for a foley, there was no evidence of a revised plan of care based on the comprehensive assessment with any progress toward the outcome/goals for the foley catheter. COS.

Upon patient record review, 1of 14 records reviewed (Patient #2) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #2: The record indicated an order for MSW 1 X M. There was no evidence of a MSW visit in the month of February 2025. COS.

Upon patient record review, 1 of 14 (Patient #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 #8: A hoyer lift was ordered on 01/14/25, there was no evidence the hospice aide care plan was updated to use this equipment. COS.

Upon patient record review 1 of 14 charts reviewed (Patient #8) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs. Patient #8: The aide made the first visit on 12/20/24, the first supervisory visit was on 01/17/25, therefore the aide supervision was not met in 14 days.

Upon patient record review, 2 of 14 charts reviewed (Patient #6, #7) did not have evidence that before the recertification period for each patient, the medical director or physician designee must review the patient's clinical information and provide written documentation that it is anticipated that the patient's life expectancy is 6 months or less. Patient #6: The record indicated the patient was in their second benefit period 02/02/25-05/05/25, there was no evidence the medical director reviewed the patients clinical information and provided written documentation that it is anticipated that the patient's life expectancy is 6 months or less. COS. Patient #7: The record indicated the patient was in their second benefit period 02/07/25-05/07/25, there was no evidence the medical director reviewed the patients clinical information and provided written documentation that it is anticipated that the patient's life expectancy is 6 months or less. COS.

Upon patient record review, 6 of 14 records reviewed (Patient #1, #2, #4, #6, #7, #8, #10) 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 #1,2,4,6,7,10: The patient elected to receive a copy of non covered items at the time of admission. There was no evidence they received this at the time of the survey. COS. Patient #8: The Hospice Election Statement regarding the patients choice to choose an attending was marked yes I wish to chose but the name of the physician was blank. COS.

Upon patient record review, 1 of 14 records reviewed (Patient #5 ) did not have evidence that each patient record contains Advance Directives. Patient #5: The patient's POA signed legals at the time of the admission on 08/02/23. There was no POA document on the chart at the time of the survey. COS.

Upon patient record review, 1 of 14 (Patient #8) 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 #8: There were orders on 01/20/25 for a foley placement once per month or prn and another order on 01/21/25 to insert a foley cath 14 french to gravity drainage for urinary retention. There was no evidence of the amount or type of solution to inject in the balloon. COS.

Upon patient record review, 1 of 14 (Patient #5) did not have evidence that all drugs and biologicals are labeled in accordance with currently accepted professional practice and include appropriate usage and cautionary instructions, as well as an expiration date, if applicable. Patient #5 During the home visit at the board and care one of the staff member's who administered the medications could not read to the surveyor the English directions on the bubble pack for a prn medication, all prescriptions were in English.

Upon observation, there was no evidence the hospice discussed the policies and procedures for managing the safe use and disposal of controlled drugs with the patient or representative and the family in a language and manner that they understand to ensure that these parties are educated regarding the safe use and disposal of controlled drugs. Upon observation there was not evidence the hospice discussed appropriate storage of controlled substances to ensure safe and appropriate usage, the liquid ativan was being stored in the freezer at the board and care without a thermometer and stored with food.

Upon patient record review, 2 of 14 records reviewed (Patient #8, #10) did not have evidence that a written hospice plan of care is established and maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided is in accordance with this hospice plan of care. Patient #8: There was no evidence the plan of care is established and maintained in consultation with the SNF. COS. Patient #10: There was no evidence the plan of care is established and maintained in consultation with the SNF. COS. In addition, the IDT order for spiritual care on 2/11/25 was noted the spiritual care was declined, the Chaplain made a visit on 2/13/25 without an order.

Upon patient record review, 2 of 14 records reviewed (Patient #8,10) 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 #8, 10: There was no evidence in the plan of care that identified interventions that the facility would provide; only hospice interventions listed on the plan of care. COS.

Observed in Individual Tracer. In 2 of 11 patient records reviewed, the hospice plan of care did not reflect the medications that the patient was taking. RR#3 resided in a SNF and the medication administration record of the SNF reflected that the patient received a medication to manage muscle pain. Per review of the hospice record and discussions with the director, this medication was discontinued upon admission to the hospice which was several months ago. Per the significant other of RR#5 the patient had not been taking a blood pressure medications for over two weeks. This medication was still reflected on the hospice medication profile/comprehensive care plan. These observations were discussed with the director.

Observed in Individual Tracer. In 1 of 11 patient records reviewed, the hospice did not provide care based on the individualized care plan. RR#6 had a Foley catheter in place however the comprehensive care plan (and updates to the care plan) did not include orders to change the Foley. Based on documentation review the hospice nurse changed the Foley monthly. This observation was discussed with the QA RN.

Observed in Individual Tracer. In 2 of 3 patient records reviewed, the hospice aide care plan did not reflect all of the services required based on the assessed needs of the patient. RR#5 was wheelchair dependent and transferred with maximal assistance. The hospice aide care plan reflected that the patient received a shower without any further qualification. Based on discussions with the RN and the significant other the patient actually received shower seated in a chair. RR#6 had a Foley catheter and the home health aide care plan reflected that the patient had a condom catheter. These observations were based on record reviews and were confirmed by the Q.A. RN.

Observed in Individual Tracer. In 1 of 11 patient records reviewed, the hospice did not ensure appropriate authenticated documentation. The medical director signed attendance for multiple IDT(s) for RR#5 on the wrong dates. Per the director, IDT(s) were only held Tuesdays. The medical director signed attendance at four consecutive IDT(s) for dates that coincided with Wednesdays. This observation was discussed with the QAPI coordinator.

Observed in Leadership Session. In 2 of 3 contracts reviewed, the contracts did not include a stipulation that the contracted entities are responsible for obtaining the criminal background checks. This stipulation was not in a nursing home contract and a DME contract. This observation was discussed with QAPI coordinator.

Observed in Leadership Session. In 2 of 2 patient records reviewed, the hospice did not comply with applicable Federal regulations as it related to patients that were no longer hospice appropriate. Based on a review of RR#7 and RR#10 the hospice completed the Advance Beneficiary Form versus the Notice of Non Coverage form. These observations were confirmed with the QAPI coordinator.