Every finding on record at Liberty Healthcare Group, LLC

Upon patient record review, 2 of 11 (Patient #10, #11) did not have evidence in the patient record that the comprehensive assessment identifies the 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 10 and 11: There was no evidence of a spiritual assessment.

Upon patient record review, 9 of 11 (Patient #1, #3, #4, #5, #6, #7, #8, #10, #11) 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 1: The care plan from start of care includes an order for O2 2-4 LPM inhalation for shortness of breath PRN. There was no evidence of a route. Corrected on site. Patient 3: The care plan dated 2/4/2022 includes an order for Sarna topical cream 1 application every 4 hours PRN for skin irritation. There was no evidence of an application site. Corrected on site. Patient 4: The care plan for start of care includes O2 2-4L inhalation PRN shortness of breath. There was no evidence of a route. Corrected on site. Patient 5: The care plan dated 2/8/2022 includes an order for O2 2-4 L for comfort as needed PRN. There was no evidence of a route. A medication order dated 2/22/2022 includes Zinc cream 1 application every 2 hours for skin care PRN. There was no evidence of an application site. Both items corrected on site. Patient 6: The care plan dated for 1/27/2022 includes O2 2-4 L inhalation continuous for shortness of breath. There was no evidence of a route. Corrected on site. Patient 7: The care plan dated for 10/26/2021 includes an order for O2 2-4 L/M inhalation for shortness of breath PRN. There was no evidence of a route. Corrected on site. Patient 8: The care plan dated dated 11/9/2021 includes O2 2-4 L/M inhalation PRN for shortness of breath. There was no evidence of a route. Corrected on site. Patient 10: The care plan for start of care includes an order for O2 2-4 L inhalation PRN shortness of breath. There was no evidence of a route. Patient 11: The care plan dated 9/17/2021 includes an order for O2 2-4 L inhalation PRN for comfort as needed. There was no evidence of a route. Dated 9/23/2021 an order includes Miralax 17 GMs once a day PRN constipation. There was no evidence of a route or diluent.

Upon patient record review, 1 of 11 (Patient #10) 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. Patient 10: There was no evidence of a bereavement assessment.

Upon patient record review, 3 of 11 (Patient #2, #3, #8 ) 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. Patient 2: Patients terminal diagnosis at admission was Alzheimer's with epilepsy. The CTI at start of care documents 3 grand mal seizures prior to admission, which sent patient to the Emergency Department. There was no evidence of a Neuro care plan in the record. Corrected on site. Patient 3: Patient terminal diagnosis was Unspecified Protein caloric malnutrition. Patient has been prescribed Remeron for appetite. There was no evidence of a care plan for nutrition/hydration. Corrected on site. Patient 8: Patients terminal diagnosis at admission was Heart Failure with Cardiomyopathy. There was no evidence of a Cardiac care plan. Corrected on site.

Upon patient record review, 9 of 11 (Patient #1, #3, #4, #5, #6, #7, #8, #10, #11) 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: The care plan from start of care includes an order for O2 2-4 LPM inhalation for shortness of breath PRN. There was no evidence of a route. Corrected on site. Patient 3: A medication order dated 2/4/2022 includes Sarna topical cream 1 application every 4 hours PRN for skin irritation. There was no evidence of an application site. Corrected on site. Patient 4: A medication order dated 12/13/2021 includes O2 2-4L inhalation PRN shortness of breath. There is no evidence of a route. Corrected on site. Patient 5: A medication order dated 2/8/2022 includes an order for O2 2-4 L for comfort as needed PRN. There was no evidence of a route. A medication order dated 2/22/2022 includes Zinc cream 1 application every 2 hours for skin care PRN. There was no evidence of an application site. Both items corrected on site. Patient 6: A medication order dated 1/27/2022 includes O2 2-4 L inhalation continuous for shortness of breath. There was no evidence of a route. Corrected on site. Patient 7: A medication order dated 10/26/2021 includes O2 2-4 L inhalation PRN for shortness of breath. There was no evidence of a route. Corrected on site. Patient 8: A medication order dated 11/9/2021 includes O2 2-4 L/M inhalation PRN for shortness of breath. There was no evidence of a route. Corrected on site. Patient 10: A medication order dated 7/17/2021 includes O2 2-4 L inhalation PRN shortness of breath. There was no evidence of a route. Patient 11: A medication order dated 9/17/2021 includes O2 2-4 L inhalation PRN for comfort as needed. There was no evidence of a route. Dated 9/23/2021 an order includes Miralax 17 GMs once a day PRN constipation. There was no evidence of a route or diluent.

Upon observation, there was missing evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient #4: Visit made with HHA. HHA did not wear goggles per agency policy as they don't fit over glasses. Policy provided states goggles or face shield to be used, personal prescription lens' do not provide optimal eye protection and should not substitute PPE required.

Upon patient record review, 2 of 8 applicable (Patient #1, #10) 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 Patient 1: On HHA noted dated 2/1/2022 aide charted gave bed bath instead of shower, he requested. There was no evidence the aide notified the RN. Patient 10: Aide ordered frequency was 2x week, for week of 7/25/2021 one visit was documented. There was no evidence of a missed visit.

Upon patient client record review, 1 of 11 (Patient #10) did not have evidence that each patient record contains Physician certification and recertification of terminal illness. Patient 10: On start of care patient chose an attending physician. There was no evidence of a verbal or written certification from the attending physician.

Upon patient client record review, 1 of 11 (Patient # 9) did not evidence that each patient record contains physician orders. Patient 9: Discharged from service as no longer met eligibility requirements. There was missing evidence of a discharge order.