Every finding on record at Keepers of Hope

Upon patient record review, 2 of 14 (Patient #1,#3) 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 plan of care includes an order for pureed diet. There is no evidence that the plan of care includes problems, goals and interventions for the management of the risk of aspiration. Patient 3:The diet ordered as pureed and the patient is at risk for falls. There is no evidence that the plan of care includes problems, goals and interventions for the management of the risk of aspiration and falls.

Upon client record review, 1 of 14 (Patient #8) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 8:The plan of care included an intervention to check size and integrity of skin cancer to right lateral face every 2 weeks. No evidence in record of documentation of size and integrity from 10/15/24 through 11/13/24.

Upon patient record review, 2 of 14 (Patient #1,#3) 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 and 3:The medical record includes nursing documentation that the patient is at risk of aspiration. The aide plan of care does not include aspiration precautions.

Upon patient record review, 1 of 5 (Patient #4) 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 Patient Record #4. There is no evidence that initial bereavement assessment was completed. There is no separate bereavement assessment form completed as compared to other records and the bereavement section of the RN Comprehensive Assessment is missing.

Upon Client Record Review, 2 of 5 records (#3, 5) did not have evidence that the hospice provided spiritual counseling in accordance with the patient/family's desires. Patient Record #3, 5: (10/28/21 and 10/3/21 respectively) Comprehensive Assessment - Regarding Spiritual Assessment section - For questions "Was spiritual care declined. Answer marked was no. Will SC service be provided? Answer checked was Yes. However, no evidence that SC was provided. There was no additional documentation in the record that SC was in fact, declined.

Upon personnel record review, 1 of 1 applicable (Personnel #4 ) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (C) Shampoo, sink, tub, and bed 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. Personnel File #4: There was no differential in the shampoo competency as evidence of sink, tub and bed shampoo competency demonstration by the Hospice Aide

Upon contract review, 1 of 4 (Complete Rehab Therapy) did not have evidence the agreement to furnish any services under arrangement included that the hospice must retain administrative and financial management, and oversight of staff and services for all arranged services, to ensure the provision of quality care. Arranged care/services are supported by written contract/agreement that requires all care/services are: • Authorized by the hospice • Furnished in a safe and effective manner by qualified personnel • Delivered in accordance with the patient's plan of care

Upon client record review, 3 of 5 (Patient #3, 4, 5) 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. #3-10/28/21 POC IDG Summary included statement "Admitted 81 y.o. to Swift Care Hospice under routine level of care". The agency being surveyed was Keepers of Hope Hospice. #4-10/3/21 RN Prognosis Summary of CTI included statement : "Admitted 86 y.o. male to Swift Care Hospice services under routine level of care." Patient was being admitted to Keepers of Hope Hospice. POC Summary missing bereavement assessment section. Hospice Aide Notes - Shampoo provided task had hole punch so unable to ascertain if task completed 10/7/21, 10/10/21 # 5: Hospice Aide Notes - Shampoo provided task had hole punch so unable to ascertain if task completed 10/7/21, 10/9/21 10/12/21.