Every finding on record at Life Care Hospice Services LLC

Upon patient record review, 3 of 5 (Patient #2, 4, 5) 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 2, 4, 5: The patient's oxygen was not included on the medication list. (corrected for active patient #2)

Upon patient record review, 1 of 5 (Patient #2) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient which includes all problems identified in the initial and/or comprehensive assessments. Patient 2: On the comprehensive initial assessment, dated 08.05.2021, it was noted that the patient had difficulty swallowing and choked frequently; thin liquids and a finely chopped soft diet were ordered. It was also noted in the summary that the patient had dysphagia. There is no evidence of a care plan related to aspiration risk or swallowing status. (corrected on site)

Upon patient record review, 5 of 5 (Patient #1, 2, 3, 4, 5) 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 a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs. Patient 1, 2, 3, 4, 5: The MSW and SC evaluated the patient and completed the comprehensive initial assessments timely. The patients and/or caregivers declined ongoing support and services. For all patients and both disciplines, MSW and SC, visit orders were written for ongoing PRN visits only.

Upon patient record review, 3 of 5 (Patient #1, 2, 5) 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 1: The patient utilizes a wheelchair and shower chair which was not on the plan of care. Patient 2: The patient utilizes a cane and walker which was not on the plan of care. Patient 5: The patient utilizes a walker and has an oxygen concentrator and back up tanks in the home which was not on the plan of care.

Upon observation and client record review, there was no evidence the hospice investigates all adverse events, incidents, accidents, variances or unusual occurrences that involve patient care and develops a plan of correction to prevent the same or similar event from occurring again. Patient 2: Communication logs indicate the patient was found on the floor on both 08.11.2021 and 08.12.2021, with the fire department having to be called both days to assist the patient back into bed. There was no evidence of these safety incidents being recorded onto the fall log reports for further investigation and trending. (corrected on site)

Upon patient record review, 3 of 3 applicable (Patient #1, 3, 4) did not have evidence in the patient record that hospice aide assignments and duties include the tasks to be provided and the frequency of those tasks. Patient 1,3,4: The hospice aide care plan, dated 07.29.2021, does not specify the frequency of the tasks the HA is to perform (bathing via the shower chair, shampoo, brush teeth). (#1 and #3 corrected on site)