Every finding on record at Judson Home Care

Upon patient record review, 1 of 5 (Patient #1) 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: Patient #1 Polyethylene Glycol order with no diluent Ordered on 7/5/23, Corrected on Site

Upon review of policy and procedure, the Emergency Plan did not define procedures to follow up with on duty staff and patients to determine services that are needed, in the event that there is an interruption in services during or due to an emergency. The hospice must inform state and local officials of any on-duty staff and patients that they are unable to contact. Emergency Plan did not contain evidence of the hospice must inform state and local officials of any on-duty staff they are unable to contact.

Upon review of policy and procedure, the Emergency Plan did not include the development of arrangements with other hospices and other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to hospice patients.

Upon patient record review, 2 of 14 (Patient 13,14) did not have evidence that the patient chooses a health care provider, including an attending physician. Patients 13 & 14: The medical record does not contain evidence the patient was given a choice of a health care provider including attending physician.

Condition of Participation: Initial and Comprehensive Assessment of the Patient.

Upon patient record review, 12 of 14 (Patient 1,2,3,4,5,6,7,8,9,10,11,12) did not have evidence in the patient record that the comprehensive assessment takes into consideration the imminence of death.

Upon patient record review, 11 of 14 (Patient 1,2,3,4,5,7,8,9,10,12,13) 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: Patient 1: Nurse documents 6-6-22 "Pt using O2 2L nasal cannula." No O2 on medication profile. Nurse documents 6/6/22 "Metoprolol,Torsemide,midodrine all have parameters discussed with pt". There are no parameters for these meds on the medication profile. Medication profile contains Metoprolol 50mg daily, the POC contains Metoprolol 50mg BID. Corrected on site. Patient 2: Oxygen with humidity found in home, no order for O2 on medication profile. Corrected on site. Patient 3: The medication profile contains order for polyethylene glycol with no diluent and Cetirizine 1mg/ml with no dose or frequency, Bisacodyl 10mg suppository prn no frequency and Wheat Dextrin daily and not on the medication profile. Corrected on site. Patient 4: The medication profile contains Meloxicam 7.5mg/5ml 7.5mg prn, no frequency or reason, Metformin 1000mg give 100mg BID incorrect dose, Trazodone 50mg give 25mg prn no frequency or reason. Corrected on site. Patient 5: The medication profile contains order for Guaifenesin 10mg/ml prn with no frequency, Sennosides 2 tabs prn no frequency. Corrected on site. Patient 7: The medication profile contains Dextromethorphan 10ml PRN no frequency, Polyethylene Glycol no diluent. Corrected on site. Patient 8: The RN documents in the comprehensive assessment 3/23 "back pain continues, continue with lidocaine spray". There is no order for lidocaine spray on the medication profile. Medication profile contains Acetaminophen 325mg prn no frequency. Corrected on site. Patient 9: Medication profile contains Robitussin prn with no frequency. Patient 10: Medication profile with Haloperidol with no dose, Morphine prn no reason. Patient 12: Physician's initial order contains Lorazepam and Hyoscyamine with no frequencies it is not on the medication profile. Care coordination note nurse documents "Pt on O2 4l continuous" There is no order for oxygen on the medication profile. Patient 13: Medication profile contains Miralax no diluent, morphine prn with no reason, acetaminophen prn no reason.

Upon patient record review, 8 of 14 (Patient 2,3,4,5,6,7,8,9) did not have evidence in the patient record that the comprehensive assessment is updated including and by: Patients 2,3,4,5,7,8,9: There is no evidence nursing is performing a comprehensive assessment every 15 days. They are documenting on a routine clinical note that does not include changes since the initial assessment, pt progress toward desired outcomes, reassessment of response to care. IDG notes restate the goals and interventions and no progress toward goals documented. Patient 6: The patient was recertified by the physician on 4/3/23, there was no comprehensive assessment update or IDG completed until 5/2/23. Patient 7: The medical record contains evidence of IDG/comprehensive assessment completed 5/17/23 and the next one was 6/9/23. Patient 9: The medical record contains evidence pt was admitted 03/03/23, there is no evidence of an IDG or updated comprehensive assessment until 05/01/23. Administrator provided written photo copied IDG notes to surveyor for evidence of IDG meeting, though they contain no evidence of being signed or authenticated.

Condition of Participation: Interdisciplinary Group, Care Planning, and Coordination of Services. L536

Upon client record review, 3 of 14 (Patient 10,12,14) did not have evidence that the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions as identified in the comprehensive assessment. Patient 10: The medical record does not contain a POC for the certification period 7/31/22-10/28/22 or certification period 10/29/22-12/27/22. There is no evidence in the patient record that the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions as identified in the comprehensive assessment. Patient 12: The medical record does not contain a POC. There is no evidence in the patient record that the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions as identified in the comprehensive assessment. Patient 14: The medical record does not contain a POC. There is no evidence in the patient record that the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions as identified in the comprehensive assessment.

Upon patient record review, 11 of 14 (Patient 1,2,3,4,5,7,8,10,12,13,14) 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: Nurse documents 6-6-22 "Pt using O2 2L nasal cannula." No O2 on POC. Nurse documents 6/6/22 "Metoprolol,torsemide,midodrine all have parameters discussed with pt". There are no parameters for these meds on the POC. POC contains Metoprolol 50mg daily, the medication profile contains Metoprolol 50mg BID. Patient 2: Oxygen with humidity found in home, no order for O2 on POC. Corrected on site. Patient 3: The POC contains order for Polyethylene Glycol with no diluent corrected on site, and Cetirizine 1mg/ml with no dose or frequency. Patient 4:The POC contains Meloxicam 7.5mg/5ml 7.5mg prn, no frequency or reason, Metformin 1000mg give 100mg BID incorrect dose, Trazodone 50mg give 25mg prn no frequency or reason. Corrected on site. Patient 5: The POC contains order for Guaifenesin 10mg/ml prn with no frequency, Sennosides 2 tabs prn no frequency. Corrected on site. Patient 7: The POC contains Dextromethorphan 10ml PRN no frequency, Polyethylene Glycol no diluent. Corrected on site. Patient 8: The RN documents in the comprehensive assessment 3/23 "back pain continues, continue with lidocaine spray". There is no order for lidocaine spray on the POC. POC contains Acetaminophen 325mg prn no frequency. Corrected on site. Patient 10: POC with Haloperidol with no dose, Morphine prn no reason. Patient 12: Physician's initial order contains Lorazepam and Hyoscyamine with no frequencies. Care coordination note nurse documents "Pt on O2 4l continuous" There is no order for oxygen. Physician's initial order contains Lorazepam and with no frequencies. Care coordination note nurse documents "Pt on O2 4l continuous" There is no order for oxygen. Patient 13: Medical record contains an order for miralax no diluent, morphine prn with no reason, acetaminophen prn no reason. Patient 14: Medical record contains an order for bisacodyl prn no reason,miralax no diluent,oxycodone prn no reason,sennosides prn no reason.

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 equipment and supply needs. Patient 1:No DME supplies listed on POC. There is evidence pt has a hospital bed and incontinence supplies. Patient 2:No DME supplies listed on POC. There is evidence upon home visit, pt has a hospital bed ,OBT,raised toilet seat. Corrected on site. Patient 5: The nurse documents 5/10 pt has a Broda chair. There is no DME documented on the POC.

Upon client record review, 1 of 14 (Patient 10) did not have evidence that the IDG in collaboration with the attending physician reviewed, revised and documents the individualized plan as frequently as the patient's condition requires but no less frequently then every 15 calendar days. Patient 10: The medical record does not contain a POC for the certification period 7/31/22-10/28/22 or certification period 10/29/22-12/27/22. There is no evidence in the patient record that the IDG in collaboration with the attending physician reviewed, revised and documents the individualized plan as frequently as the patient's condition requires but no less frequently then every 15 calendar days.

Upon client record review, 9 of 14 (Patient 1,2,3,4,5,6,7,8,9) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 1: Nurse documents 6/5/23 "increased O2 from 2 to 3 liters". No evidence of order to increase. POC 6/2/23 nurse visits 3x a week starting 6/5/23, pt seen 6/5,6/7,no 3rd visit that week, no missed visit documentation or refusal. POC order for nurse visits 1x a week starting 6/2/23, nurse visited 6/2 and 6/3, there is no order for the second visit and no evidence the visit was prn, it was documented as a "follow up visit". Clinical note completed on 6-3-23 visit as per Devero EMR pt face page. The actual note when opened does not contain the date the visit was done just shows time of visit 2:30-5:00pm. The note time stamps the date when the nurse completed the note on 6-6-23 @3:50pm. The same happened with 6/5/23, 6/7/23 visits. Agency is unable to provide evidence of when the actual visit was performed. Patient 2: POC contains order MSW 1x every other week starting 4/29, the first MSW visit was not until 5/4. No visit made the week of 4/23-4/29. POC contains order for SC 2x a month starting 4/19. The first visit was 4/24 there was no second visit made in April, no missed visit documentation or evidence of refusal. Clinical note completed 4/21 per Devero EMR face page. The note time stamps the date when the nurse completed the note on 4/24/23. The same happened with 5/3 visit signed 5/6 and 5/10 visit signed 5/12. Agency is unable to provide evidence of when the actual visit was performed. Patient 3: The medical record contains an order for SN visits 7 days a week starting 4/30. There were no visits made on 5/1,5/17,5/20,5/21. There was no missed visit documentation. RN documents wound care on 5/9,5/14,5/18 but does not document applying Zinc oxide to perimeter of wound as ordered. POC 4/17 RN documents "coccyx wound evaluated by wound care doctor, dressing changes 3x a week." There is no evidence of directives for the wound care. Patient 4: The medical record contains an order for MSW starting 5/1 for visits 1x a week for 9 weeks. Pt not seen the week of 5/7-5/13,5/21-5/27,5/28-6/30. 3/29 there is an order for PT evaluation. This has not been completed. No evidence of refusal. Patient 5: Medical record contains order for nursing visits starting 4/3 twice weekly. The nurse saw pt on 4/3 and did not complete a second visit the week of 4/2-4/8. No missed visit documentation. MSW order starting 4/29 for 1x a week for 9 weeks. There were no visits made by MSW 4/23-4/29, 5/7-5/13,5/21-5/27. SC order for visits starting 3/21 for 1x per week. No vs made week 3/26-4/1 and 4/16-4/22. On 5/17 the RN documented her wound care though did not document applying the zinc oxide as ordered around the perimeter of wound. Patient 6: Medical record contains a nursing order 3/28 for nursing 1x per week, there was no nursing visits the week of 3/27-4/27/22. Patient 7: The medical record contains an order for MSW visits starting 4/27 for 1x a week. There were no MSW visits made the week of 5/21-5/27. Patient 8: Nurse documents 4/2/23 and 4/3/23 "cleansed wound with wound cleanser applied Allevyn". There is no evidence nurse followed the order to apply ATB cream, Telfa, ABD and wrap with kerlix. Patient 9: The POC order for nursing starting 3/7 is 1 time a week. There was no visit 5/28-6/3 and no missed visit documentation. MSW order for every other week start 5/15, There was no visit completed the week of 5/28-6/3 as ordered.

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: The RN carried her equipment in her nursing jacket pockets. Her stethoscope around her neck. She has her thermometer in a small bag with a BP cuff and pulse oximeter no antimicrobial wipes, no designated clean/dirty sides. RN lays BP cuff bag on pt's bed with no barrier. She removes BP cuff, pulse ox, and thermometer for use and does not cleanse prior to use or after use. She did drip some hand sanitizer on the pulse oximeter and placed it in the bag with the dirty Bp cuff and thermometer. Per agencies Healthcare Bag Technique Policy: All nursing staff will have a healthcare bag that has at least 3 compartments two compartments will be designated clean and one dirty, the bag will have antimicrobial wipes, the bag will be placed on an impervious barrier on the surface prior to laying bag down, clean reusable items with antimicrobial wipes before placing back in bag.

Upon patient record review 5 of 14 (Patient 1,2,5,8,9) did not have evidence documentation in the patient record that a hospice aide provides services that are: Patient 1:POC 6/2/23 Aide 2x a week for 12 weeks starting 6/5. Aide did not see until 6/12. There is no evidence of missed visit documentation for the week of 6/4-6/10 or for missed 2nd visit week of 6/11-6/17. Aide did not follow aide POC on 6/12 aide did not give a shower, prepare a meal, prepare a snack, offer laundry as ordered by the nurse. There is no documentation why the orders were not followed, no communication with RN. Patient 2: POC contains orders 4/19/22 for aide 2x a week start 4/20, aide visited 4/20 with no second visit week of 4/16-4/22. The week of 4/30-5/6 aide saw pt 5/4 only no second visit, No aide visits made week of 5/21-5/27 or 5/28-6/3. No missed visit documentation or refusal. Patient 5: The aide on 4/4,5/8,6/12 did not complete cleaning/filing nails as ordered. No documentation of why the order was not followed. No communication with RN. Medical record contains order for aide visits starting 3/21/23 twice weekly there was no aide visits made the week of 3/19-3/25, no missed visit documentation. Patient 8: The medical record contains an order for aide visits 1x per week starting 3/30/23. The aide did not see pt until 4/6. The next visit was 4/8 and there are no further aide visits documented. No evidence of an order to DC or refusal by pt. Aide visit 4/8 the only intervention documented that was ordered was tidy area, the rest of the ordered tasks were not completed and no documentation of why or communication with nurse. Patient 9: The medical record contains aide visits on 5/1/23,5/2,5/8 aide documents assisted with ambulation, assisted to toilet, transferred to chair. These items were not ordered on the aide POC.

Upon patient record review, 3 of 14 (Patient #3, 7, 9) did not have evidence that the medical director or physician designee provides written certification that it is anticipated that the patient's life expectancy is 6 months or less if the illness runs its normal course. The physician must consider the following when making this determination: • The primary terminal condition • Related diagnosis • Current subjective and objective medical findings • Current medication and treatment orders • Information about the medical management of any of the patient's conditions unrelated to the terminal illness Patient 3: The medical record does not contain a CTI from the medical director with narrative. The record has only a CTI from the Attending physician. The medical record contains a CTI 4/14/23 by the medical director with no narrative. Patient 7: The medical record contains a CTI 4/14/23 by the medical director with no narrative. Patient 9: The medical record contains a CTI 7/23 by the medical director with no narrative.

Upon patient record review, 1 of 14 (Patient #10) 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 10: The medical record contains a recertification document on 10/26/22 that does not contain a physician name or a verbal order. The form is blank.

Upon patient client record review, 2 of 14 (Patient #13 and 14) 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 Patients 13 & 14: The medical record does not contain evidence the patient was given a choice of a health care provider including attending physician.

Upon patient client record review, 12 of 14 (Patient 1,2,3,4,5,6,7,8,9,10,11,12) 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. Patients 1,2,3,4,5,6,7,8,9,10,11,12: The form the agency uses for patients right to choose and attending physician does not have any patient identifiers on it. The form the agency uses for Hospice items non-covered does not have any patient identifiers. Patient 1: The POC contains nursing goals/interventions for teaching s/sx of infection for catheter. The nurse reports "pt does not have a catheter". Nurse documents STML, this is not an approved abbreviation per agency policy. Patient 2-8: The RN's signature authentication contains the RN's name and then "RN/PT" after her name documented on all visit notes. The RN is not a physical therapist and the administrator does not know why system does that. Patient 3: The chaplain documents "ch" on 4/18 visit note. There is no evidence this is an approved abbreviation per agency policy. Patient 5: The medical record contains a blank physician order on 5/25. Patient 7: The POC contains a nursing goal "Pt/Cg goals: pain rating ___/10 will be maintained by 5/5/23."

Upon client record review, 2 of 14 (Patient 9,10) did not have evidence that the discharge summary includes all required information. Patient 9 & 10: No current POC or latest physician orders were documented on the discharge summaries.

Upon patient record review, 1 of 14 (Patient #7) did not have evidence that if a drug order is verbal or given via an electronic transmission, it is given to a Registered Nurse, Nurse Practitioner, pharmacist, physician or other licensed individuals as designated by state regulations. The person receiving the order records and signs it immediately and has the prescribing person sign it in accordance with state and federal regulations. Patient 7: RN documents 6/1 "Dr assessed wounds ordered Triad wound care to left hip with Allevyn, skin prep QOD right heel". There is no evidence of an order written in medical record.

Upon personnel record review, 1 of 11 (Personnel #4) did not have evidence the hospice obtained a criminal background check on all contracted individuals who have direct patient care and access to patient records. Personnel 4: Did not have a criminal background check completed.