Every finding on record at Madrona Hospice Care Inc

Upon patient record review 1 of 4 records, (Patient #3) 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 #3: The record indicated the patient was admitted on 1/17/24, the Spiritual Assessment was completed on 1/25/24. The Spiritual Assessment was not completed within 5 calendar days after the election of hospice.

Upon patient record review, 3 of 4 (Patient #1,2,3) 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 caregiver was instructed by the nurse to stop taking Amlodipine and Losartan. In addition, the caregiver stated he gave the patient Ibuprofen which was not on the medication profile. Corrected on site. Patient #2: The caregiver has not given the patient Docusate Sodium as listed on the medication profile and it was not available in the home. Corrected on site. Patient #3: Medications were on the medication profile, Lorazepam, Morphine and Haloperidol, but not available in the home. Corrected on cite.

Upon patient record review, 2 of 4 records, (Patient #1, #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 #1: Upon observation home visit, the caregiver stated he was giving the patient Ibuprofen. There was not an order for ibuprofen. Patient #2: The record indicated an order on 4/30/24, "May change Foley catheter every 1 and PRN for leaking and complication". There was not evidence of a specific frequency or specifics for catheter change (size, amount to inflate bulb) in the order.

Upon client record review, 1 of 4 records (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: The record indicated on 2/16/24 the order stated change Foley every month. There is no evidence in the record that the Foley was changed until 5/3/24.

Upon home visit observation, 1 of 3 home visits, (Patient#2), there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient #2, the RN cleaned dirty equipment with patient wipes. The wipes did not contain the appropriate percentage of alcohol for cleaning equipment.

Upon contract review, 1 of 2 contracts (Access Therapy) did not have evidence that the agreement to furnish any services under arrangement includes that the hospice must retain administrative and financial management, and oversight of staff and services for all arranged services, to ensure the provision of quality care. Arranged care/services are supported by written contract/agreement that requires all care/services are: • Delivered in accordance with the patient's plan of care •Any additional requirements as out lined in the Social Security Act section 1861(w) •There are copies of professional liability insurance certificates on file for any contract personnel providing direct patient care. Corrected on site.

Upon patient client record review, 2 of 4 records, (Patient #1, #2) did not have evidence that each patient record contained Advance Directives. Patient #1, #2: The record indicated that the patient had an advanced directive. There was not evidence that an advanced directive was a part of the chart. Corrected on site.

Upon patient client record review, 1 of 4 records, (Patient #4) 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 #4: The Bereavement Coordinator documentation indicated the patient's date of death was 2/22/24. A Bereavement condolence call was placed on 2/21/24. The Agency staff indicated the patient's date of death was 2/20/24.

Upon inpatient contract review, 1 of 2 contracts (Smith Ranch Care) did not have evidence of a provision that the hospice supplies the inpatient provider with a copy of the patient's plan of care and specifies the inpatient services to be furnished. Corrected on site.

Upon inpatient contract review, 1 of 2 contracts (Smith Ranch Care ) did not have evidence of a provision that the inpatient provider has established patient care policies consistent with those of the hospice and agrees to abide by the palliative care protocols and plan of care established by the hospice for its patients. Corrected on site.

Upon inpatient contract review, 1 of 2 contracts (Smith Ranch Care) did not have evidence of a provision that the hospice patient's inpatient clinical record includes a record of all inpatient services furnished and events regarding care that occurred at the facility; that a copy of the discharge summary be provided to the hospice at the time of discharge; and that a copy of the inpatient clinical record is available to the hospice at the time of discharge. Corrected on site.