Every finding on record at In Home Health, LLC

Upon patient record review, 4 of 13 (Patients #1,#2,#8,#11) 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: The medication profile contained lidocaine patch with no area defined for administration. Corrected on site. Patient 2: The medication profile contained duplicative duonebs listed with frequencies of every 6 hours as needed and four times daily as needed. The medication profile also contained oxycodone with no defined frequency. Corrected on site. Patient 8: The medication profile contained a multivitamin oral liquid with no defined dose for administration. Corrected on site. Patient 11: The medication profile contained duplicative morphine listed with doses of 0.25 ml and 1 ml for every four hours as needed for pain and shortness of breath. The medication profile also contained a potassium chloride oral packet with no instructions for a diluent.

Upon patient record review, 1 of 13 (Patient #12) 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 12: There was no evidence of a bereavement assessment. The initial nursing assessment upon admission states bereavement risk was not assessed and there was no additional assessment.

Upon patient record review, 1 of 13 (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 medical record contains nursing documentation 6/19/22 identifying patient had two stage 2 ulcers to coccyx. There was no evidence of wound assessments completed 6/20/22-7/21/22, and 7/21/22-8/10/22 per wound care policy requiring assessments weekly.

Upon patient record review, 3 of 13 (Patients #1,#6,#8) 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 medical record contains nursing documentation 7/19/22 identifying patient issue with chronic pressure injury to coccyx. There was no evidence of problems, goals, and interventions related to skin impairment. Corrected on site. Patient 6: The medical record contains nursing documentation 6/22/22 identifying patient issue with delayed swallowing requiring pureed diet and thickened liquids. There was no evidence of problems, goals, and interventions related to dysphagia or modified diet. Corrected on site. Patient 8: The medical record contains nursing documentation upon admission identifying patient comorbidities of dysphagia and aspiration pneumonia. There was no evidence of problems, goals, and interventions related to dysphagia. Corrected on site.

Upon patient record review, 4 of 13 (Patients #1,#2,#8,#11) 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: The medical record contained an order for a lidocaine patch with no area defined for administration. Corrected on site. Patient 2: The medical record contained an order for oxycodone with no defined frequency. Corrected on site. Patient 8: The medical record contained an order for multivitamin oral liquid with no defined dose for administration. Corrected on site. Patient 11: The medical record contained an order for potassium chloride oral packet with no instructions for a diluent.

Upon patient record review, 2 of 13 (Patients #6,#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 equipment and supply needs. Patient 6: The medical record contains nursing documentation 6/22/22 identifying patient use of a mechanical lift for transfers. There was no evidence of a lift included as DME on the plan of care. Corrected on site. Patient 8: The medical record contains nursing documentation upon admission identifying patient use of hospital bed and 7/27/22 identifying use of wheelchair and walker. There was no evidence of the bed, chair, and walker included as DME on the plan of care. Corrected on site.

Upon client record review, 3 of 13 (Patients #3,#4,#6) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 3: The medical record contains ordered spiritual care frequency of twice every 30 days. There was no evidence of a second visit completed in July. Corrected on site with late entry documentation of missed visit. Patient 4: Spiritual care ordered for one time eval. The medical record contains spiritual care documentation stating the husband wanted spiritual care but not that week of admission and an order would be obtained to complete the initial evaluation the following week. There was no evidence of any visits completed or further communication documented. Corrected on site with documentation of refusal. Patient 6: The medical record contains ordered spiritual care frequency of twice every 30 days. There was no evidence of a second visit completed in July. Corrected on site with late entry documentation of missed visit.

Upon personnel record review, 1 of 1 applicable (Personnel #6) 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 ·(C) Shampoo, sink, tub, and bed ·(D) Nail and skin care ·(E) Oral hygiene ·(F) Toileting and elimination Personnel 6 no evidence of a competency with a patient or pseudo patient.

Upon patient record review 2 of 11 applicable (Patients #5,#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 5: The medical record contained an ordered aide frequency of three times weekly. There was no evidence of a third visit the week of 7/3/22. Corrected on site with late documentation of missed visit. Patient 7: The medical record contained an ordered aide frequency of five times weekly. There was no evidence of a fifth visit the week of 7/3/22. Corrected on site with late documentation of missed visit.

Upon patient client record review, 1 of 13 (Patient #9) 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 9: The medical record contains documentation that the patient representative requested to obtain the Notice of Hospice Non-Covered Items upon admission 4/8/22. There was no evidence of a signed form to show receipt of the notice per agency procedures.

Upon patient client record review, 1 of 13 (Patient #12) 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 12: The medical record contains Face to Face encounter by NP 3/1/22 stating consider discharge for extended prognosis and 4/27/22 recommending to consider decision tree. The medical record also contains CTIs for benefit period starting 3/26/22 stating consider decision tree and 5/25/22 recommending decision tree. IDG notes by the MD 3/30/22 state will send to decision tree. There was no evidence of follow up in IDG until 5/25/22 stating patient went to decision tree and 6/8/22 stating decided to discharge. Agency discharge policy states the process for IDG determination of live discharge is to ensure appropriate actions are taken to facilitate decision making regarding patient's continued eligibility for hospice care and expedited determination is given to Medicare beneficiaries when it is believed that Medicare will deny payment.