Every finding on record at Lifetime Hospice Care, Inc

Upon patient record review, 1 of 14 (Patient 5) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient #5 - SN visit note 05/30/24 - patient has foley catheter and wound but no assessment of foley or wound documentation.

Upon client record review, 4 of 14 (Patient #8, 9, 11, 12) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #8 - POC dated 02/28/24 - LVN visit frequency 1 x wk but LVN visited 2 x wk week 3 and 4. Patient #9 - POC dated 03/27/24 SC and MSW visit frequency 1 x month but no visit made in month of April. Patient #11 - POC dated 03/06/24 SC and MSW visit frequency 1 x month but no visit made in month of April. Patient #12 - POC dated 03/17/24 SC and MSW visit frequency 1 x month but no visit made in month of April. In addition, Foley catheter changed on 03/25/24 but no order for catheter changes noted on POC dated 03/17/24.

Upon observation, there was no evidence the hospice is in compliance with accepted professional standards and principles for all core services which includes nursing services, medical social services and counseling services as the agency was using contracted personnel.

Upon patient record review 1 of 14 (Patient #8) 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 #8 - Aide visit frequency effective 02/28/24 2 x week - only 1 visit made week 1.

Upon patient record review 1 of 14 (Patient #11) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs. Patient #11 - POC dated 03/06/24 - 06/03/24 - No Aide supervisory visit made during cert period up to date of survey.

Condition of Participation: Organization and Administration of Services.

Upon observation, there was no evidence the hospice is directed by a Board of Directors/governing body which assumes full legal authority and responsibility for the operation of the hospice. There was no evidence the board of directors/governing body appointed an administrator that was an employee of the agency as this employee was contracted (corrected onsite). In addition, core services (nursing, medical social services, and counseling) were provided by employees and contracted staff and core services must be provided by employees only.

Upon patient client record review, 1 of 14 (Patient #12) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient #12 - SN visit note on 04/10/24 LVN documented "wound care rendered per MD orders - did not contain specific care provided and LVN documented on 04/10/24 "foley last changed on 03/25/24 -but no documentation on 03/25/24 that foley catheter was changed.