Every finding on record at Loving Care Hospice Inc.

Upon patient record review, 1 of 7 (Patient #1) 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 Patient 1: The medication list indicated oxygen 2-4L/min via nasal canula continuously for COPD. The medication list also included an order for PRN oxygen as a part of the standard comfort kit. This is a duplicate drug order as the patient already requires the use of oxygen continuously per the terminal diagnosis. (corrected onsite)

Upon patient record review, 1 of 7 (Patient #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 2: On initial assessment by the chaplain, ongoing SC visits were ordered for 1 x monthly. After the SC visit on 02.17.2023, the family declined further SC visits; however, the care plan was not updated to reflect this request. (corrected onsite)

Upon patient record review, 7 of 7 (Patient #1, 2, 3, 4, 5, 6, 7) 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, 2, 3, 4, 5, 6, 7: All DME required by the patient for management of the terminal illness must be included on the plan of care; there was no DME included on the plans of care for any of the hospice's patients. (corrected onsite for all active patients)

Upon patient record review 3 of 7 (Patient #2, 4, 6) 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 Patient 2, 4: The hospice aide care plan indicates the hospice aide is to shampoo the patient's hair 1 x weekly. Documentation by the aide demonstrates that the aide is shampooing the hair on every visit at each of the 3 weekly visits, ongoing since the initiation of aide visits. Patient 6: The hospice aide care plan indicates the hospice aide is to provide a bed bath and shampoo the patient's hair every Monday. Documentation by the aide demonstrates that the aide performed these tasks on Wednesday 06.08.2022, Friday 06.10.2022, Wednesday 06.15.2022, and Thursday 06.16.2022.

Upon patient client record review, 1 of 7 (Patient #1) 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 1: Treatment orders on the plan of care indicated the patient has a condom catheter; however, per the documentation and direct observation during the home visit, this is a female patient. The standard order per the options on the documentation template did not include an option for an external female catheter, however the condom catheter option is not appropriate for use. (corrected on site)

Upon observation, there was no evidence of contracts/agreements with other facilities/agencies/hospices to receive patients in the event the hospice cannot provide care to their patients during an emergency.

Upon patient record review, 1 of 7 (Patient #2) did not have evidence that the hospice informed and provided written information to the patient concerning its policies on advance directives, including a description of applicable state law. Patient #2 was admitted to the hospice on 10/17/22. There was no evidence that the patient/family received written information of Advance Directives at time of admission.

Condition of Participation: Initial and Comprehensive Assessment of the Patient.

Upon patient record review 1 of 7 (Patient #4) did not have evidence in the patient record that the hospice conducted and documented in writing a patient-specific comprehensive assessment that identifies the patient's need for hospice care and services, and the patient's need for physical, psychosocial, emotional, and spiritual care. This assessment includes all areas of hospice care related to the palliation and management of the terminal illness and related conditions. Patient #4- Admitted on 11/8/22. There was no evidence that the registered nurse completed the initial assessment within 48 hours of election. There was no evidence of an initial assessment having been completed that included: the physical, psychosocial or emotional needs of the patient, complications and risk factors that affect care planning, patient's functional status including the patient's ability to understand and participate in their own care, imminence of death or severity of symptoms.

Upon patient record review 1 of 7 (Patient #2) 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 #2 was admitted to hospice on 10/17/22. There was no evidence in the record of an initial comprehensive assessment that included the psychosocial or spiritual needs of the patient.

Upon patient record review, 1 of 7 (Patient #2) 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 there was no evidence in the record of a review of medications as there was no medication profile on record.

Upon patient record review, 1 of 7 (Patient #2) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient #2 there was no evidence of an initial bereavement assessment having been completed.

Condition of Participation: Interdisciplinary Group, Care Planning, and Coordination of Services. L536

Upon patient record review, 1 of 7 (Patient #2) 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 #2- There was no evidence of an order for comfort medications used by the patient.

Upon patient record review, 1 of 7 (Patient #2) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #2 was admitted to the hospice on 10/17/22. Plan of care included orders for SN 1 x week with 2 PRN's. There was no evidence that a visit was made during the weeks of 10/30/22 and 11/6/22.

Condition of Participation: Hospice Aide and Homemaker Services. L607

Upon patient record review, 1 of 7 (Patient #2) did not have documented evidence in the patient record of an aide plan of care that specified the tasks to be done by the aide, and the frequency of these tasks. Patient #2 was admitted to the hospice on 10/17/22. There was no evidence the RN had developed an aide care plan.

Upon patient record review 1 of 7 (Patient #2) did not have evidence documentation in the patient record that a hospice aide provides services that are: Ordered by the interdisciplinary group and Included in the plan of care. Patient #2 Aide performed tasks such as bathing, dressing, feeding and linen changes. There was no evidence of an aide care plan.

Upon patient record review, 1 of 7 (Patient # 2) did not evidence that each patient record contains physician orders. Patient #2 was admitted to the hospice on 10/17/22 with a diagnosis of Senile Degeneration of Brain. There was no evidence of an order to admit.