Every finding on record at Loving Soul Home Health Inc

Upon patient record review, 5 of 5 (Patient #1, 2, 3, 4, 5) 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: The POC does not include interventions or goals for the GU system, including interventions and goals for urinary incontinence. There are no interventions or goals for the use of a cane. Patient #2: The POC does not include interventions or goals for bleeding or use of anticoagulants. The patient is currently on Eliquis. There are no interventions or goals for the GU system including interventions and goals for urinary incontinence. There are no interventions or goals for the use of a cane. Patient #3: The patient was assessed to have moderate dyspnea with labored, diminished breath sounds and positive for cough for which the patient is prescribed benzonatate. There were no interventions or goals related to the respiratory system. The patient is on Aspirin, however, there are no interventions of goals for bleeding and education of anticoagulants. There are no interventions or goals on the POC related to the use of a cane. There are no interventions or goals for the GU system including interventions and goals for urinary incontinence. The pain POC should include interventions and goals related to use of narcotics for pain relief. Patient #4: The patient is on Aspirin. There are no interventions or goals regarding bleeding and use of anticoagulants. Patient #5: There are no interventions or goals for the GU system including interventions and goals for urinary incontinence. The patient is on Aspirin. There are no interventions or goals regarding bleeding and use of anticoagulants.

Upon patient record review, 1 of 5 (Patients #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 equipment and supply needs. Patient #2: The medical record lists a cane. the patient is ambulating with a walker. Walker is not included on the POC.

Upon personnel record review, 1 of 10 (Personnel #8) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) ·Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff. ·Reading and recording temperature, pulse, and respiration ·Safe transfer techniques and ambulation. ·Normal range of motion and positioning ·Appropriate and safe techniques in personal hygiene and grooming that include-- ·(A) Bed bath ·(B) Sponge, tub, and shower bath ·(C) Shampoo, sink, tub, and bed ·(D) Nail and skin care ·(E) Oral hygiene ·(F) Toileting and elimination The other subject areas in this section may be evaluated through written examination, oral examination or after observation of a Hospice Aide with a patient. Personnel #8: The personnel record did not have proof that the following were performed with a patient or pseudo patient: Tub bath, shower, use of bedpan, transfers from chair to stand, and use of a cane. The record listed that the method of orientation was verbal.

Upon patient record review, 1 of 5 (Patient #5) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • 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 #5: The Aide assignment orders that ambulation every visit is with cane and walker, however does not specify when each would be used. This should be simplified to either one or given further explanation.