Every finding on record at Love and Care Hospice Service Inc.

Upon patient record review, 4 of 14 (Patient #2,5,6,8) 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 #2,5,6: There was evidence in the medical record for an order for Oxygen 2-5L/min via NC with a titration scale. Oxygen is not on the medication profile. Patient #8: There was evidence in the medical record of an order for an oxygen concentrator. Oxygen was not on the medication profile.

Upon patient record review, 2 of 14 (Patient #1,2) 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 is evidence of an order for a foley catheter. The plan of care does not include problems/goals/interventions for foley catheter care. additionally, there is an order for Nephrostomy tube. The plan of care does not include problems/goals/interventions for nephrostomy care. Patient #2: There is evidence of an order for wound care. The plan of care does not include problems/goals/interventions for wound care. Additionally, on the initial nursing assessment, all criteria for imminent death were checked "yes". Imminent death was not on the plan of care.

Upon patient record review, 2 of 14 (Patient #1,8) 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: There is evidence in the medical record of an order for wound care. The order does not include who will complete the daily dressing change. Patient #8: There was evidence in the medical record of an order for an oxygen concentrator. There was no order for oxygen dose, route or frequency. Additionally, there was an order for Stage 3 wound care that does not include who will do the dressing change.

Upon patient record review, 1 of 14 (Patient #4) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient #4: On 1/11/24, the social worker noted mortuary information was needed. The plan of care was not updated to include this information.

Upon patient record review, 10 of 14 (Patient #1,2,3,4,5,6,7,8,9,10) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patients 1-10: The election statement did not have an effective date of election.

Upon SNF/NF contract review, 1 of 3 (Astoria Nursing Center) did not have a delineation of the responsibilities of the hospice and the SNF/NF to provide bereavement services to SNF/NF personnel. There was no evidence of a contract to include delineation of the responsibilities of the hospice and the SNF/NF to provide bereavement services to SNF/NF personnel. This was corrected on site with an addendum signed by both parties.