Every finding on record at Magic Touch Hospice

Upon patient record review, 2 of 5 (Patient #4, 5) 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 4, 5: The patient has an oxygen concentrator ordered as DME and the RN confirms is present in the home; however, there is no treatment order present for the PRN use of oxygen. (corrected onsite)

Upon patient record review 6 of 14 (Patient #2,8,10,11,13,14) 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. Patients 2,10,11: No evidence of initial spiritual or psychosocial assessment in patients’ medical record. Patient 8: No evidence of initial psychosocial assessment in patient’s medical record. Patients 13,14: No evidence of initial spiritual assessment in patients’ medical record.

Upon patient record review, 5 of 14 (Patient #2,4,5,6,8) 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: Patient’s medication list with order for Voltaren gel 1%. Order instructions state to apply one thin layer topical twice daily as needed for pain. There is no evidence of application site for this medication. COS Patient 4: Patient’s medication list with order for muscle rub cream 10-15%. Order instructions state to apply to affected area twice daily as needed for pain. There is no evidence of application site for this medication. Patient has oxygen concentrator on plan of care. There is no evidence of physician’s order for oxygen on patient’s medication list. COS Patient 5: Patient has oxygen concentrator on plan of care. There is no evidence of physician’s order for oxygen on patient’s medication list. COS Patient 6: Patient has oxygen concentrator on plan of care. There is no evidence of physician’s order for oxygen on patient’s medication list, it is instead listed as a treatment. COS Patient 8: Patient has oxygen concentrator on plan of care. There is no evidence of physician’s order for oxygen on patient’s medication list. COS

Upon patient record review, 6 of 14 (Patient #2,8,9,10,13,14) 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.

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

Upon patient record review, 5 of 14 (Patient #1,2,5,7,8) 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 no evidence of care planning for skin breakdown precautions, despite Braden score of 9. Patient 2: There is no evidence of care planning for falls precautions or skin breakdown precautions despite documented fall on 5/8/24 and Braden score of 11. Patient 5: There is no evidence of care planning for edema, oxygen, or aspiration risk. This is despite evidence of oxygen in the home; patient with pitting edema present; and patient with aspiration precautions. Patient 7: There is no evidence of care planning for skin breakdown precautions despite Braden score of 12. Patient 8: There is no evidence of care planning for falls precautions despite terminal diagnosis of Parkinson's. There is no evidence of aspiration precautions despite puree diet with nectar thick liquids.

Upon patient record review, 8 of 14 (Patient #1,3,4,5,6,7,8,9) 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 1,9: Ordered visit frequency for MSW and SC is recertification and as needed. Ordered visit frequency for BC is as needed. There is no evidence of quantifiers for any of these visit frequency orders. COS Patient 3,6: Ordered visit frequency for MSW and SC is recertification and as needed. There is no evidence of quantifiers for any of these visit frequency orders. COS Patient 4,5: Ordered visit frequency for BC is as needed. There is no evidence of quantifiers for this visit frequency order. COS Patient 7: Ordered visit frequency for MSW is recertification and as needed. Ordered visit frequency for SC is one as needed and recertification, need quantifiers as needed. Ordered visit frequency for BC is as needed. There is no evidence of quantifiers for these visit frequency orders. COS Patient 8: Ordered visit frequency for SC is once monthly, as needed and recertification. Need quantifiers for as needed. COS

Upon patient record review, 5 of 14 (Patient #2,4,5,6,8) 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 2: Patient’s plan of care with order for Voltaren gel 1%. Order instructions state to apply one thin layer topical twice daily as needed for pain. There is no evidence of application site for this medication. COS Patient 4: Patient’s plan of care with order for muscle rub cream 10-15%. Order instructions state to apply to affected area twice daily as needed for pain. There is no evidence of application site for this medication. Patient has oxygen concentrator on plan of care. There is no evidence of oxygen medication order on patient’s plan of care. COS Patient 5: Patient has oxygen concentrator on plan of care. There is no evidence of oxygen medication order on patient’s plan of care. COS Patient 6: Patient has oxygen concentrator on plan of care. There is no evidence of oxygen medication order on patient’s plan of care, oxygen is instead listed as a treatment. COS Patient 8: Patient has oxygen concentrator on plan of care. There is no evidence of oxygen medication order on patient’s plan of care. COS

Upon patient record review, 10 of 14 (Patient #1,2,3,4,5,6,7,8,9,10) 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: Assessed DME needs: walker and air mattress. There is no evidence of this DME on the plan of care. COS Patient 2: Assessed DME needs: walker, hospital bed, bedside commode. There is no evidence of: walker, hospital bed on the plan of care. COS Patient 3: Assessed DME needs: walker, wheelchair, shower chair, nebulizer. There is no evidence of these DME on the plan of care. COS Patient 4: Assessed DME needs: hospital bed, air mattress, overbed table, wheelchair, oxygen concentrator, oxygen e-tanks, nebulizer. There is no evidence of: hospital bed, air mattress, overbed table, wheelchair, oxygen e-tanks, nebulizer on the plan of care. COS Patient 5: Assessed DME needs: hospital bed, air mattress, overbed table, wheelchair, walker, shower chair, bedside commode, egg crate mattress, oxygen concentrator, oxygen e-tanks, nebulizer, suction. There is no evidence of: hospital bed, overbed table, wheelchair, walker, shower chair, bedside commode, egg crate mattress on the plan of care. COS Patient 6: Assessed DME needs: walker, shower chair, oxygen concentrator, oxygen e-tanks, nebulizer, suction. There is no evidence of: walker, shower chair on the plan of care. COS Patient 7: Assessed DME needs: hospital bed, walker, bedside commode, wheelchair. There is no evidence of hospital bed or walker on the plan of care. COS Patient 8: Assessed DME needs: hospital bed, overbed table, wheelchair, oxygen concentrator, nebulizer, suction. There is no evidence of: hospital bed, overbed table on the plan of care. COS Patient 9: Assessed DME needs: bedside commode, nebulizer, overbed table, oxygen concentrator, shower chair, suction, walker. There is no evidence of: walker on the plan of care. COS Patient 10: Assessed DME needs: hospital bed, air mattress, hoyer lift, oxygen concentrator, oxygen e-tanks, high back reclining wheelchair. There is no evidence of: hospital bed, hoyer lift on the plan of care. COS

Upon patient record review, 4 of 14 (Patient #3,5,6,7) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 3: Ordered visit frequency for MSW is recertification and as needed. There is no evidence of MSW visit made during certification period 03/19/2024-06/16/2024. There is a communication note dated 03/19/2024 that MSW was unable to reach patient/caregiver. Notification was added to IDG for 09/13/2024that MSW was unable to reach patient/caregiver. Notification was added to IDG on 09/13/2024. Patient 5: Ordered visit frequency for MSW and SC is once a recertification and once as needed. There is no evidence of a MSW visit during certification period dated 04/01/2024-05/30/2024. There is no evidence of a SC visit during certification period dated 05/31/2024–07/29/2024. There is not documentation of missed visit. Patient 6: Ordered visit frequency for SC is recertification and as needed. During certification period 08/05/2023-11/02/2023, SC visited 10/26/2023 and 11/01/2023. Both of these visits were documented as recertification visits. There is no evidence that either of these visits were PRN. Patient 7: Ordered visit frequency for MSW is recertification and as needed. Ordered frequency for BC is as needed. There is no evidence of a MSW visit made during the certification period 07/13/2024-09/10/2024. There is no documentation of a missed visit. BC follow up is documented every certification period. There is no evidence documenting that these visits are PRN.

Upon patient record review, 3 of 14 (Patient #3,5,7) did not have evidence that the IDG documents the sharing of information between all disciplines providing care and services in all settings, whether the care and services are provided directly or under arrangement. Patient 3: Ordered visit frequency for MSW is recertification and as needed. There is no evidence of MSW visit made during certification period 03/19/2024-06/16/2024. There is a communication note dated 03/19/2024 that MSW was unable to reach patient/caregiver. There is no evidence that MD was notified of missed visit. Patient 5: Ordered visit frequency for MSW and SC is once a recertification and once as needed. There is no evidence of a MSW visit during certification period dated 04/01/2024-05/30/2024. There is no evidence of a SC visit during certification period dated 05/31/2024–07/29/2024. There is no evidence that MD was notified of missed visit. Patient 7: Ordered visit frequency for MSW is recertification and as needed. There is no evidence of a MSW visit made during the certification period 07/13/2024-09/10/2024. There is no evidence that MD was notified of missed visit.

Upon patient record review, 5 of 14 (Patient #1,2,5,7,8) 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 All COS: Patient 1: No evidence of frequencies on aide care plan: chair to bed; turn and reposition; record bowel movement; dressing pajama/gown; dressing street clothes; feeding assistance; encourage fluids; change linens. No evidence of precautions despite being on POC: bleeding, oxygen. No evidence of vital signs parameters despite ordered frequency of every visit. Patient 2: No evidence of frequencies on aide care plan: transfer; record bowel movement; dressing pajama/gown; change linens. No evidence of vital signs parameters (blood pressure, pulse, temperature) despite ordered frequency of every visit. Patient 5: No evidence of frequencies on aide care plan: turn and reposition; 1-person transfer; record bowel movement; dressing pajama/gown; encourage fluids; change linens. Patient 7: No evidence of frequencies on aide care plan: turn and reposition; 1-person transfer; encourage fluids; change linens; feeding assistance; dentures. There is a warning in aide care plan that states that patient uses oxygen. Do not use petroleum products. Patient does not have an order for oxygen in the plan of care. Patient 8: No evidence of frequencies on aide care plan: turn and reposition; record bowel movement; encourage fluids; change linens. No evidence of precautions despite being on POC: oxygen.

Upon patient record review 3 of 14 (Patient #4,7,9) 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 4: Visit frequency order for aide is twice weekly. This physician’s order written on admission, 10/01/2023. Patient has been seen three times weekly, beginning on the Monday at the start of the current certification period, 08/05/2024. COS. Patient 7: Patient with ordered aide task of dentures. There is no evidence of documentation that this task has been completed since the first aide visit of the current certification period, 07/16/2024. There is also no documentation of why the task is not completed. Patient 9: The following aide tasks have been ordered. On the noted dates for the tasks in the current certification period, there is no documentation that the tasks have been completed. There is also no documentation of why the tasks were not completed. Safety razor/shave: 07/16/2024, 07/23/2024, 08/08/2024, 08/15/2024, 08/22/2024, 09/03/2024, 09/05/2024. Objects in reach and Bed in lowest position: 07/16/2024, 08/13/2024, 08/15/2024, 08/29/2024, 09/03/2024. Oxygen: 07/16/2024, 07/18/2024, 07/23/2024, 07/25/2024, 07/30/2024, 08/01/2024, 08/06/2024, 08/08/2024, 08/13/2024, 08/15/2024, 08/20/2024, 08/22/2024, 08/27/2024, 08/29/2024, 09/03/2024, 09/05/2024.

Upon patient record review 3 of 14 (Patient #4,5,8) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs. Patient 4,5: There is no evidence of aide supervisory visit after 08/26/2024. Patient 8: There is no evidence of aide supervisory visit between 07/25/2024 and 09/05/2024.

Upon patient record review, 2 of 14 (Patient #6,9) did not have evidence that the medical director or physician designee provides written certification that it is anticipated that the patient's life expectancy is 6 months or less if the illness runs its normal course. The physician must consider the following when making this determination: • The primary terminal condition • Related diagnosis • Current subjective and objective medical findings • Current medication and treatment orders • Information about the medical management of any of the patient's conditions unrelated to the terminal illness Patient 6: In certification period 1, there is no evidence of a physician’s narrative including patient's individual clinical circumstances and a clinical justification narrative: There is only evidence of patient’s comorbid conditions. Certification period dates 08/05/2023-11/02/2023. Patient 9: In certification period 1, there is no evidence of a physician’s narrative including patient's individual clinical circumstances and a clinical justification narrative: There is only evidence of patient’s comorbid conditions, KPS, PPS, and a single sentence that states, “increased weakness and dyspnea with moderate exertion.” Certification period dates 04/16/2024-07/14/2024

Upon patient record review, 2 of 14 (Patient #6,9) did not have evidence that before the recertification period for each patient, the medical director or physician designee must review the patient's clinical information and provide written documentation that it is anticipated that the patient's life expectancy is 6 months or less. Patient 6: In certification period 2 and 6, there is no evidence of a physician’s narrative including current subjective and objective medical findings; Current medication and treatment orders; Information about the medical management of any of the patient's conditions unrelated to the terminal illness. There is only evidence of patient’s comorbid conditions. Certification period 2 dates 11/03/2023-01/31/2023. Certification period 6 dates 07/30/2024-09/28/2024. Patient 9: In certification period 2, there is no evidence of a physician’s narrative including current subjective and objective medical findings; Current medication and treatment orders; Information about the medical management of any of the patient's conditions unrelated to the terminal illness. There is only evidence of patient’s comorbid conditions, KPS, PPS, and a single sentence that states, “increased weakness, tires easily, edema and episodes of shortness of breath.” Certification period dates 07/15/2024-10/12/2024.

Upon client record review, 1 of 14 (Patient #13) did not have evidence that if a patient revokes the election of hospice care or is discharged from hospice in accordance with §418.26, the hospice must forward to the patient's attending physician: • A copy of the hospice discharge summary • The patient's clinical record, if requested