Every finding on record at Legacy Healthcare, LLC

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 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 on the medication record 11/22/24 Polyethylene Glycol 17 gm Powder daily there are not instructions to mix with diluent. Additionally, there is an order on the plan of care for "oxygen concentrator at 2-4 lpm via nasal cannula as needed for shortness of breath". Oxygen does not appear as a medication on the medication list. Patient #2,3,4,5,6,7,8,9,10: There is an order on the plan of care for a treatment "oxygen concentrator at 2-4 lpm via nasal cannula as needed for shortness of breath". Oxygen does not appear as a medication on the medication list.

Upon patient record review, 1 of 14 (Patient #4) 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 #4: There is evidence in the medical record of an MSW visit monthly to assist with funeral planning and provide supportive counseling. There is not a problem/intervention/goal for the psychosocial problems.

Upon patient record review, 2 of 14 (Patient #1,2) 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 medications and treatments. Patient #1: There is evidence on the plan of care, 11/22/24 Polyethylene Glycol 17 gm Powder daily there are not instructions to mix with diluent. COS. Patient #2: There is evidence of an order for "right upper back, cleanse area, pat dry, apply thin layer Calmoseptine, cover with foam dressing. The frequency of dressing change and who will change the dressing is not indicated. COS.

Upon inpatient contract review, 1 of 3 (contract The Vineyards Healthcare Center) did not have evidence that the hospice patient's inpatient clinical record includes a record of all inpatient services furnished and events regarding care that occurred at the facility; that a copy of the discharge summary be provided to the hospice at the time of discharge; and that a copy of the inpatient clinical record is available to the hospice at the time of discharge.

Upon SNF/NF contract review, 1 of 3 (contract The Vineyards Healthcare Center) did not have evidence that specifies the provision of hospice services in the facility, including: A provision that the SNF/NF or ICF/IID immediately notifies the hospice if: • A significant change in a patient's physical, mental, social or emotional status occurs • Clinical complications appear that suggest a need to alter the plan of care • When a need to transfer a patient from the SNF/NF or ICF/MR arises, and the hospice makes arrangements for, and remains responsible for, any necessary continuous care or inpatient care necessary related to the terminal illness and related conditions • A patient dies Contract #1: There is evidence the following was missing from the contract: Clinical complications appear that suggest a need to alter the plan of care; When a need to transfer a patient from the SNF/NF or ICF/MR arises, and the hospice makes arrangements for, and remains responsible for, any necessary continuous care or inpatient care; necessary related to the terminal illness and related conditions; patient dies

Upon SNF/NF contract review, 1 of 3 (contract The Vineyards Healthcare Center) did not have a provision stating that the hospice reports all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by anyone unrelated to the hospice to the SNF/NF administrator within 24 hours of the hospice becoming aware of the alleged violation.

Upon SNF/NF contract review, 1 of 3 (contract The Vineyards Healthcare Center) did not have a delineation of the responsibilities of the hospice and the SNF/NF to provide bereavement services to SNF/NF personnel.

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as hand hygiene. This standard was not met as evidenced by home visit observation and document review. In 1 of 3 (33%) home visit observations, the hospice did not ensure staff performed hand decontamination in accordance with agency Hand Hygiene policies and procedures. Record #98296: SOC 3/14/22; Benefit Period #5; Diagnosis Senile Degeneration of the Brain. During the home visit the RN was observed donning gloves after handwashing. The RN removed assessment tools from the nursing bag and placed the items on a clean barrier. The RN removed his gloves and donned new gloves multiple times while assessing the patient at her bedside, using each assessment tool and returning it to the barrier, and documenting assessment findings in a notebook and the patient's hospice home folder. The RN did not consistently sanitize his hands after direct contact with the patient or inanimate objects in the immediate vicinity of the patient or after removing gloves and donning new gloves prior to the next task. The agency's policy, Hand Hygiene, states in part, "...Hand decontamination using an alcohol-based hand rub should be performed after contact with a patient's intact skin (when taking a pulse, blood pressure, or lifting a patient); ...after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient;...after removing gloves.