Every finding on record at Light House Hospice Care Services

Upon observation, there was no evidence the Emergency Plan communication plan includes all of the following: • Names and contact information for the following: • Hospice employees • Entities providing services under arrangement • Patients' physicians • Other hospices

Upon patient record review, 2 of 6 (Patients #1,#6) 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: The medication profile contained Nitrostat sublingual tablets every 5 minutes as needed without instructions for a maximum allowable times for consecutive administration. Patient 6: The medication profile contained Glycolax oral powder without instructions for a diluent. The profile also contained morphine, reglan, phenol, benzocaine, and bisacodyl medications with PRN frequencies and no indications identified.

Upon patient record review, 2 of 6 (Patients #1,#3) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual's attending physician, if any) • Changes that have taken place since the initial assessment • Information on the patient's progress toward desired outcomes • Reassessment of the patient's response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days Patient 1: There was no evidence of RN visits between the dates of 7/12/22, 8/4/22, 8/23/22, and 9/11/22 to complete a comprehensive assessment every 15 days. Patient 3: There was no evidence of RN visits between the dates of 7/11/22 and 8/3/22 to complete a comprehensive assessment every 15 days.

Upon patient record review, 6 of 6 (Patients #1,#2,#3,#4,#5,#6) 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 was no evidence of problems, goals and interventions related to psychosocial and spiritual care. Patient was receiving social work and spiritual care services once monthly. Patient 2: The medical record contained nursing documentation identifying patient is a fall risk. There was no evidence of problems, goals, and interventions related to patient safety. There was also no evidence of problems, goals and interventions related to psychosocial and spiritual care. Patient was receiving social work and spiritual care services once monthly. Patient 3: The patient has a hospice primary diagnosis of heart failure. There was no evidence of problems, goals, and interventions related to cardiac dysfunction. There was also no evidence of problems, goals and interventions related to psychosocial and spiritual care. Patient was receiving social work and spiritual care services once monthly. Patient 4: There was no evidence of problems, goals and interventions related to psychosocial and spiritual care. Patient was receiving social work and spiritual care services once monthly. Patient 5: The medical record contained an order for an indwelling catheter. There was no evidence of problems, goals, and interventions related to urinary dysfunction. There was also no evidence of problems, goals and interventions related to psychosocial and spiritual care. Patient was receiving social work and spiritual care services once monthly. Patient 6: There was no evidence of problems, goals and interventions related to psychosocial and spiritual care. Patient was receiving social work and spiritual care services once monthly.

Upon patient record review, 6 of 6 (Patients #1,#2,#3,#4,#5.#6) 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 the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patients 1,2,3,4,5,6: The medical records contained an initial frequency for nursing once weekly and PRN, social work once monthly and PRN, and spiritual care once monthly and PRN. There is not a quantity of how many PRN visits can be completed for any discipline.

Upon patient record review, 3 of 6 (Patients #4,#5,#6) 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 4: The medical record contained orders for gabapentin and tramadol without routes identified and oxygen without a delivery method. Patient 5: The medical record contained a foley order without identified balloon size, maintenance and change frequency. Patient 6: The medical record contained an order for glycolax oral powder without instructions for a diluent. The record also contained orders for PRN morphine, reglan, phenol, benzocaine, bisacodyl without defined indications.

Upon patient record review, 1 of 6 (Patient #4) did not have evidence in the patient record that hospice aide assignments and duties are: • 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 4: The aide care plan contained task frequencies of PRN for skin care and back massage.

Upon patient record review 1 of 6 (Patient #4) 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 4: The aide care plan contained tasks for shampoo and comb hair every visit, aide visits were 3x/week. There was evidence of tasks completed once weekly for the weeks of 8/28/22, 9/4/22, and 9/11/22.

Upon patient record review, 6 of 6 (Patients #1,#2,#3,#4,#5,#6) 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 Patients 1,2,3,4,5,6: There was no evidence the medical director composed a narrative based on patient chart review as part of the certification of terminal illness order upon admission.

Upon patient record review, 4 of 6 (Patients #1,#3,#4,#5) did not have evidence that before the recertification period for each patient, the medical director or physician designee must review the patient's clinical information and provide written documentation that it is anticipated that the patient's life expectancy is 6 months or less. Patients 1,3,4,5: There was no evidence the medical director composed a narrative based on patient chart review as part of the certification of terminal illness order upon recertification for patients 1 and 3 this was for the 2nd and 3rd benefit period and for patients 4 and 5 this was for the 2nd benefit period. Patient 1: The benefit period dates identified on the recertification orders 9/5/22-12/2/22 and 11/30/22-2/2/23 did not match the period dates identified on the certification of terminal illness 9/5/22-12/4/22 and 12/2/22-2/2/23. Patient 3: The benefit period dates identified on the recertification orders 9/22/22-12/20/22 and 12/19/22-2/20/23 did not match the period dates identified on the certification of terminal illness 9/20/22-12/18/22 and 12/18/22-2/16/23.

Upon patient client record review, 1 of 6 (Patient #1) did not have evidence that each patient record contains signed election statement in accordance with 418.24 Patient 1: The medical record contained an election form identifying patient requested the Notice of Hospice Non-Covered Items upon admission. There was no evidence the patient received the notice.

Upon patient client record review, 3 of 6 (Patients #2,#3,#5) 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 2: The medical record contained an election form identifying patient declined to receive the Notice of Hospice Non-Covered Items and a separate consent form specific to the addendum in which the patient elected to received the Notice of Hospice Non-Covered Items. Patient 3: The medical record contained an election form identifying patient declined to receive the Notice of Hospice Non-Covered Items and a separate consent form specific to the addendum in which the patient elected to received the Notice of Hospice Non-Covered Items. Patient 5: The benefit period dates identified on the recertification orders signed 9/5/22 did not match the period dates identified on the certification of terminal illness which was correct.

Upon inpatient contract review, 1 of 4 (West Houston) did not have evidence that the hospice retains responsibility for ensuring that the training of personnel who will be providing the patient's care in the inpatient facility has been provided and that a description of the training and the names of those giving the training are documented. The GIP/respite contract did not include a provision explaining that hospice will retain and document a description of facility personnel training and names of those giving the training.

Upon SNF/NF contract review, 1 of 4 (West Houston) did not have evidence of the manner in which the SNF/NF and the hospice are to communicate with each other and how each will document such communications to ensure that the needs of patients are addressed and met 24 hours a day.

Upon SNF/NF contract review, 1 of 4 (West Houston) 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

Upon SNF/NF contract review, 1 of 4 (West Houston) did not have evidence that it is the SNF/NF's responsibility to continue to furnish 24 hour room and board care, meeting the personal care and nursing needs at the same level of care that would have been provided by the family at the facility before hospice care was elected.

Upon SNF/NF contract review, 1 of 4 (West Houston) did not have evidence that it is the hospice's responsibility to provide services at the same level and to the same extent as those services would be provided if the SNF/NF resident were in his or her own home.

Upon SNF/NF contract review, 1 of 4 (West Houston) did not have a delineation of the hospice's responsibilities, which include, but are not limited to the following: providing medical direction and management of the patient; nursing; counseling (including spiritual, dietary and bereavement); social work; provision of medical supplies, durable medical equipment and drugs necessary for the palliation of pain and symptoms associated with the terminal illness and related conditions; and all other hospice services that are necessary for the care of the resident's terminal illness and related conditions.

Upon SNF/NF contract review, 1 of 4 (West Houston) did not have a delineation of the responsibilities of the hospice and the SNF/NF to provide bereavement services to SNF/NF personnel.