Every finding on record at Leading Hospice & Palliative Care

Upon patient record review 1 of 14 (Patient #3) did not have evidence that the hospice Registered Nurse must complete an initial assessment within 48 hours after the election of hospice care in accordance with §418.24. Patient #3: There is evidence that the Election of Benefit indicated a start date of 4/5/24. The initial RN assessment was completed on 4/19/24, not within 48 hours.

Upon patient record review 1 of 14 (Patient #3) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient #3: There is evidence that the Election of Benefit indicated a start date of 4/5/24. The nursing comprehensive assessment was completed on 4/19/24. The comprehensive assessment was no completed in 5 days.

Upon patient record review, 1 of 14 (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: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #1: There is evidence in the patient record that Farxiga was on the medication record. The patient caregiver did not have the medication in the box of medications. After the visit, the medical director discontinued the medication. (Corrected on site.)

Upon patient record review, 10 of 14 (Patient #1,2,3,4,5,6,7,8,9,10) 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: There is evidence in the record of significant weight loss prior to admission. The initial plan of care did not include Nutrition. Additionally, the Chaplain had a visit frequency of 1Xmonth, but did not have a Problem/Intervention/Goal open on plan of care. Patient #2: The Chaplain had a visit frequency of 1Xmonth, but did not have a Problem/Intervention/Goal open on plan of care. Patient #3: The Chaplain had a visit frequency of 1Xmonth, but did not have a Problem/Intervention/Goal open on plan of care. Additionally, the patient was had swallowing difficulty and was on aspiration precautions on admission. The initial plan of care did not include Nutrition/Swallowing problem. Patient #4: There is evidence in the medical record the patient was admitted on Coumadin 4 mg daily and ASA 81 mg daily. The initial plan of care did not include Bleeding Risk. In addition the Chaplain had a visit frequency of 1Xmonth, but did not have a Problem/Intervention/Goal open on plan of care. Patient #5: There is evidence in the medical record the patient was admitted on Eliquis daily. The initial plan of care did not include Bleeding Risk. In addition the Chaplain had a visit frequency of 1Xmonth, but did not have a Problem/Intervention/Goal open on plan of care. Patient #6: The Chaplain had a visit frequency of 1Xmonth, but did not have a Problem/Intervention/Goal open on plan of care. Patient #7: The Chaplain had a visit frequency of 1Xmonth, but did not have a Problem/Intervention/Goal open on plan of care. Additionally, the patient was hospitalized for vaginal bleeding. After discharge the Plan of Care was not updated for risk of bleeding. Patient #8: The Chaplain had a visit frequency of 1Xmonth, but did not have a Problem/Intervention/Goal open on plan of care. Patient #9: The Chaplain had a visit frequency of 1Xmonth, but did not have a Problem/Intervention/Goal open on plan of care. Patient #10: The Chaplain had a visit frequency of 1Xmonth, but did not have a Problem/Intervention/Goal open on plan of care.

Upon patient record review, 2 of 14 (Patient #1, #9) 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: There is evidence in the patient record that Farxiga was on the medication record. The patient caregiver did not have the medication in the box of medications. After the visit, the medical director discontinued the medication. (Corrected on site.) Patient #9: There is evidence in the record of an order "cleanse wound area with wound cleanser, cover with self adhesive dressing and change 2xwk". The order does not include location or who will change the dressing.

Upon patient record review, 1 of 14 (Patient #9) 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 #9: There was evidence in the medical record of an order for indwelling catheter. The Plan of Care was not updated to include a problem/interventions/goal for indwelling catheter.

Upon patient record review, 3 of 14 (Patient #3,#5,#6) 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 #3: There is evidence in the medical record the patient was on aspiration precautions. The aide plan of care did not include aspiration precautions. Patient #5: There is evidence in the medical record the patient was on Eliquis 5 mg daily. The aide plan of care did not include bleeding precautions. Patient #6: There is evidence in the medical record the patient was hospitalized for vaginal bleeding. After discharge, bleeding precautions was not added to the aide plan of care.

Upon patient record review, 1 of 14 (Patient #3) 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: There is evidence that the Election of Benefits indicated a start date of 4/5/24. The verbal Certification of Terminal Illness was not received until 4/19/24.

Upon patient record review, 1 of 5 (Patient #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. Patient 3: The medication list, dated 09.29.2021, indicates Voltaren gel 1% bid topical to affected area, but did not specify the location for medication use. (corrected on site)

Upon patient record review, 1 of 5 (Patient #2) 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 2: The comprehensive initial nursing assessment indicates the patient utilizes a bedside commode for management of the terminal illness. However, the bedside commode is not included on the equipment list on the plan of care. (corrected on site)