Every finding on record at Maka Hospice

Upon patient record review, 1 of 14 (Patient #1) 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 nursing comprehensive and physician CTI had documentation which showed patient was a diabetic (unrelated diagnosis). There was no evidence of problems, goals or interventions related to endocrine system. There was record of Maxi-Strips to test blood glucose supplies, Glucerna supplemental nutrition and last lab reading of A1c @ 8.8.

Upon patient record review, 2 of 14 (Patients #1, 3) 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: This patient had a bedside commode. This item was not included on the Plan of Care. Patient #3: This patient had a front wheeled walker. This item was not included on the Plan of Care.

Upon personnel record review, 1 of 11 (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 Aide's Initial Competency had verbal verification for range of motion and not observed/demonstrated as required.

Upon patient record review, 3 of 14 (Patients #3,6,12) did not have evidence that each patient record contains: • Signed election statement in accordance with 418.24 Patients #3 and #12: The hospice election statement did not have date of election/start of care in space provided on the form. Patient #6: The hospice election statement witness signature was not followed by date. The space provided for the date was left blank,

Upon patient record review, 2 of 14 (Patients #7, 8) did not have evidence that the discharge summary includes all required information. Patient #7: The discharge summary did not have all required CMS items listed on form as follows- • A summary of the patient's stay, including treatments, symptoms and pain management • The patient's current plan of care Patient #8: The discharge summary did not have all required CMS items listed on form as follows- • The patient's current plan of care

Upon observation, there was no evidence all the patient records, whether hard copy or in electronic form, were made readily available on request. Patient charts #1,2,3,4,5 were not readily available. Some charts were readily available while others needed to be printed due to recent EMR issues with Hospice MD. The final chart was ready for review in the afternoon of the second survey day.

Upon observation, there was no evidence the hospice discussed the policies and procedures for managing the safe use and disposal of controlled drugs with the patient or representative and the family in a language and manner that they understand to ensure that these parties are educated regarding the safe use and disposal of controlled drugs. Patients #1,2,3,4,5,7,12: The documentation for controlled drugs (admission checklist) in patient file was left blank and unchecked. The patient handbook distributed to all patients did have agency policy for disposal of controlled drugs (page 93).

Upon patient record review, 7 of 14 (Patients #1,2,3,4,5,7,12) did not have evidence that the written policies and procedures for managing controlled drugs was provided and discussed. Patients #1,2,3,4,5,7,12: The documentation for controlled drugs (admission checklist) in patient file was left blank and unchecked. The patient handbook distributed to all patients did have agency policy for disposal of controlled drugs (page 93).

Observed in Record Review. In 2 of 2 resident records reviewed, It was noted in review of BR-RR# 1-2 , the goals were not measurable and did not have time frames for achieving those goals. For example in BR-RR# 1, Caregiver/Family will receive emotional support to adequately cope with patient's death. Caregiver/Family will exhibit functional coping skills. Caregiver/Family will express feelings of grief and loss. This was discussed with the Administrator.

Observed in Record Review. In 1 of 3 patient records reviewed, where the patient had hospice aide services ordered, the hospice surveyor found that the aide had not followed the aide plan of care. The aide plan of care instructed the aide to shave the patient every visit, aide frequency is 2 times a week. In RR #4 , The Hospice Aide has not been shaving the patients as documented in the aide plan of care. HHA documented that Shaving not done, shaving is due once a week. The aide care plan was not updated to reflect the above. This was discuss with the Administrator.