Every finding on record at Lighthouse Hospice, Inc.

Upon patient record review 4 of 14 (Patient #1, 2, 6, 8) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient 01: The patient was admitted on 10/10/23, the initial comprehensive psychosocial assessment was completed on 10/16/23, the comprehensive spiritual care assessment was completed on 10/19/24. Patient 02: The patient was admitted on 11/16/24, the initial comprehensive psychosocial assessment was completed on 12/2/24. Patient 06: The patient was admitted on 7/25/24, the initial comprehensive spiritual care assessment was completed on 7/31/24. Patient 08: The patient was admitted on 10/10/24, the initial comprehensive spiritual care assessment was completed on 10/18/24.

Upon patient record review 2 of 14 (Patient #5, 10) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and 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 05: The patient was admitted on 11/15/24, the comprehensive spiritual care assessment has not been completed to date. Patient 10: The patient was admitted on 11/21/24 and revoked the hospice benefit on 12/4/24, the initial psychosocial comprehensive assessment was not completed, the initial spiritual care comprehensive assessment was not completed.

Upon patient record review, 3 of 14 (Patient #2, 8, 12) 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 02: The medication profile for the hospice agency does not include Lactase tablets 3000 units, take 3 pills, 3 times daily as compared in the SNF medication profile. (Corrected on site.) Patient 08: The medication profile includes Miralax 17G daily PO, it does not include a diluent or instructions for mixing. (Corrected on site.) Patient 12: The medication profile includes Xalatan Opthalmic Solution 0.005%, drop at bedtime, does not include how many drops, and does not specify which eye to instill the medication. The profile includes Cosopt PF Opthalmic Solution 2-0.5% 1% drop daily, it does not include how many drops, and does not specify which eye to instill the medication. The medication profile includes Lidocaine External Patch 4%, 1 patch daily, apply to affected area, 12 hours on 12 hours off, and does not include an application site. (All corrected on site.)

Upon patient record review, 3 of 14 (Patient #5, 8, 10) 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 05: The patient has a secondary condition of diabetes mellitus and takes Levemir and Lantus for diabetes management, the plan of care does not include a problem statement with interventions and goals for the management and monitoring of the diabetes. (Corrected on site.) Patient 08: The patient is admitted to hospice services with a primary diagnosis of heart failure with evidence of 3+ and 4+ pitting edema upon admission, the plan of care does not include interventions and goals for the management of the edema. (Corrected on site.) Patient 10: The patient is admitted to hospice services for cerebrovascular disease with a history of seizures and a stroke, she also has a gastrostomy tube, the plan of care does not include a problem statement for the management of the neurological conditions with interventions and goals. The plan of care does not include interventions and education for the patient/caregiver for the prevention of aspiration. (Corrected on site.)

Upon patient record review, 1 of 14 (Patient #2) 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. Patient 02: The plan of care includes interventions and goals for Volunteer services, there are no frequency orders for volunteers.

Upon patient record review, 2 of 14 (Patient # 8, 12) 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 08: The medication orders on 10/10/24 for Miralax 17 G scoop, PO daily do not include a diluent or instructions for mixing. (Corrected on site.) Patient 12: Medication orders on 2/21/24 for Xalatan Opthalmic Solution 0.005%, drop at bedtime, does not include how many drops, and does not specify which eye to instill the medication. Medication orders on 2/21/24 for Cosopt PF Opthalmic Solution 2-0.5% 1% drop daily, it does not include how many drops, and does not specify which eye to instill the medication. Medication orders on 2/21/24 for Lidocaine External Patch 4%, 1 patch daily, apply to affected area, 12 hours on 12 hours off, and do not include an application site. (Corrected on site.) Oxygen orders are written as 2L nasal cannula daily for shortness of breath, the patient record includes documentation on 6/10/24 that the patient was receiving oxygen 3L via nasal cannula. Additional documentation on 6/11/24 and 6/13/24 indicated the patient was receiving oxygen 4L via nasal cannula and on 6/17/24 documentation indicated the patient was receiving oxygen 5L via nasal cannula. There were no updated orders for oxygen and specific parameters for oxygen titration.

Upon patient record review, 1 of 14 (Patient #8) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 08: The plan of care includes orders for Spiritual Care visits 1 time per month, there is no visit made in the month of November.

Upon patient record review 6 of 14 (Patient #1, 3, 4, 5, 6, 9) 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 01: The hospice aid task assignment includes orders to shampoo the patients hair on Tuesday and Friday of each week, the aide did not shampoo that patients hair on 11/12/24, 11/15/24, 11/19/24, 11/22/24, 11/26/24, 11/29/24, 12/3/24, 12/6/24 or 12/10/24. The task is marked NV in the patient record on these dates, indicating "not required." Patient 02: The patient received hospice aide services 5 days per week, the aide was providing hair care but the aide plan of care does not include task assignments to perform shampooing or hair care for the patient. (Corrected on site.) Patient 03: The patient receives hospice aide services with task assignment to perform shampooing once a week. Shampooing was not performed the weeks of 12/1/24 - 12/7/24, 11/10/24 - 11/16/24, and 10/27/24 - 11/2/24, the task is marked NV which indicates "not required at this visit." Patient 04: The patient record includes orders for hospice aide services 3 times per week with showers to be performed at each visit. Aide services started on 11/22/24, the patient has received 7 visits with one shower performed on 12/2/24 only, the record indicates "not required at this visit" for all other visit entries. Patient 05: The patient was admitted on 11/15/24 and the plan of care includes hospice aide orders for 2 times a week visit to include providing a shower and shampooing (hair care) at each visit. The patient has received 7 visits over the past 4 weeks with no shower or hair care provided. The document is marked NV, indicating the service is not required. Patient 06: The patient record includes orders for hospice aide visits 3 times a week to include linen changes 1 time a week, the documentation does not show evidence of linen changes prior to 10/2/24. The aide was providing hair care but the aide plan of care does not include task assignments to perform shampooing or hair care for the patient. (Corrected on site.) Patient 09: The patient record includes hospice aide task assignments for shampooing 1 time per week on Wednesday. The patient did not receive a shampoo during the week of 11/10/24 or 11/17/24.

Upon patient record review, 2 of 13 (Patient #5,8) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient #5,8: On the election statements, the patient's physician choice is written in and marked thru with a straight line and initials, with another physician name written over the initial name. It is unclear that the physician was the choice of the patient or representative.

Upon patient record review, 2 of 13 (Patient #3, 5) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component. Patient #3, 5 did not have evidence of a bereavement assessment.

Upon personnel record review, 1 of 9 applicable (Personnel #6 ) did not have evidence of receipt of the job description at the time of orientation and whenever the job description changes. Personnel File #6: Following a staffing change, there was no Job Description signed when Bereavement Counselor was added to responsibilities of the spiritual counselor.

Upon personnel record review, 1 of 9 applicable (Personnel #6) did not have evidence that a skills competency assessment had been conducted. Personnel #6: Missing evidence of a competency for the role of bereavement counselor.

Upon patient client record review, 2 of 13 (Patient #5, 8) did not have evidence that each patient record contains a signed election statement in accordance with 418.24 including the identification of the attending physician. Patient Records #5, 8: On the election statements, the patient's physician choice is written in and marked thru with a straight line and initials, with another physician name written over the initial name. It is unclear when the change was made and that the patient or representative was aware of change and that it was actually patient's choice.

Upon personnel record review, 1 of 8 applicable (Personnel #3) did not have evidence of criminal background checks being obtained in accordance with state requirements. Personnel File #3: Name misspelled for criminal background check at hire. Error was not identified when logging report. Correction was made and resubmitted with results available to surveyor before end of survey.