Every finding on record at La Paz Hospice Inc

Upon patient record review 1 of 7 (Patient #2) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient #2: The initial spiritual care assessment was not completed. "SC assessment” in the system, however it was blank and the narrative said left message with no further SC contacts.

Upon patient record review, 2 of 7 (Patient #2, 3) 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 #2: The patient has oxygen ordered as needed. There is no evidence of oxygen being on the medication profile. Patient #3: The patient has oxygen ordered as needed. There is no evidence of oxygen being on the medication profile.

Upon patient record review, 2 of 7 (Patient #2, 3) 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 #2: There is no evidence of an initial bereavement assessment being completed on this patient. Patient #3: There is no evidence of an initial bereavement assessment being completed on this patient.

Upon patient record review, 1 of 7 (Patient #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 #3: The patient has a diagnosis of diabetes. The hospice is providing lancets and has ordered glucose testing at home. There are no interventions or goals on the POC related to diabetes.

Upon patient record review, 3 of 7 (Patient #1, 2, 3) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient #1: The patient records shows that aide visits are ordered 2 days per week and prn. The aide has not performed any prn visits. The aide cannot decide when prn visits are to be performed. Patient #2: The patient has orders for MSW every 7 days as needed, and SC every 7 days as needed. There are no set frequencies. Prn visits cannot stand alone. The aide is ordered 2 days per week and prn. The aide has not performed any prn visits. The aide cannot decide when prn visits are to be performed. Patient #3: The patient has orders for MSW 1 every 30 days as needed, and SC one every 30 days as needed. There are no set frequencies. Prn visits cannot stand alone. In addition, the aide is ordered 1 day per week prn. The aide has not performed any visits, however, the aide cannot decide when prn visits are to be performed and must have a set frequency if being utilized per POC. This patient declined Aide services. If the patient needs aide services, the RN must assess and create an aide assignment for the visits.

Upon personnel record review, 1 of 12 (Personnel #10) 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.) Personnel #10: In the competency assessment, the method for assessing the following was marked as assessed through interview. ·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 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.

Upon patient record review, 2 of 7 (Patient #1, 2) 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: The Aide assignment lists "Complete bed bath or shower each visit if patient allows" and "Shampoo hair if patient allows" The aide assignment cannot list two different choices for the aide to determine. It must be written without using permission of patient or per patient choice, or giving the aide choice in tasks to be performed. Patient #2: The aide assignment lists "Complete bed bath or shower each visit if patient allows" and "Shampoo hair if patient allows" The aide assignment cannot list two different choices for the aide to determine. It must be written without using permission of patient or per patient choice, or giving the aide choice in tasks to be performed.

Upon patient record review, 1 of 7 (Patient #4) did not have evidence that the hospice forwarded a summary and a copy of the patient record, if requested, to a facility when transferring the patient to that facility. Patient #4: There was no evidence of a transfer summary in the record. There is no evidence of records being sent to receiving organization.

Upon patient record review, 3 of 7 (Patient #5, 6, 7) did not have evidence that the discharge summary includes all required information. Patients #5, 6, 7: There is no evidence in the record of a discharge summary that includes: • A summary of the patient's stay, including treatments, symptoms and pain management • The patient's current plan of care • The patient's latest physician orders • Any other documentation that will assist in post-discharge continuity of care or that is requested by the attending physician or receiving facility

Upon observation, there was no evidence a copy is provided of the hospice written policies and procedures on the management and disposal of controlled drugs to the patient or patient representative and family. Patients #1, 2, 3: Although there was documentation provided and discussed with families regarding the management and disposal of medications, the agency did not provide the patient/family with the actual policy. COS-all active patients received this policy and the policy was added to admission materials.

Upon patient record review 4 of 5 (Patient #2, 3, 4, 5) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient #2: There was no evidence that a psychosocial assessment was completed. Patient #3: There was no evidence that the Spiritual assessment was completed. Patient #4 and 5: There was no spiritual or psychosocial comprehensive assessment completed.

Upon client record review, 1 of 5 (Patient #3) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #3: Orders upon admission states for the Skilled Nurse to visit 2 times the first week, then re-evaluate the frequency; however there were no orders for the continued frequency (nurse visits 2 times a week).

Upon patient record review 1 of 3 applicable (Patient #2) 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 #2: Aide frequency orders were for 1 time a week. However the aide consistently visits 2 times a week.