Every finding on record at Medical Services of America Inc,

Based on policy clinical record review and staff interview, the chaplain failed to include a comprehensive spiritual assessment on 1 of 9 patients that received chaplain services (#9). Findings included: --- A policy, ";Spiritual Care Services HC.14" (revised 12/22) was provided by RN #7 on 9/20/23 at 10:18 a.m. The policy stated, ";...Hospices provides spiritual counseling to meet the needs of the patient and/or family in a manner consistent with their beliefs and desires and in accordance with the patients plan of care...The Chaplain provided services to the patient and/or caregiver in accordance to the plan of care by identifying appropriate spiritual problems, interventions, and goals for the patient..." A policy, ";Comprehensive Assessment HC.28" (revised 6/23) was provided by RN #7 on 9/20/23 at 10:18 a.m. The policy stated, ";The hospice RN consults with the Medical Director or hospice physician and attending physician and coordinates the comprehensive assessment based on the initial assessment to ensure the immediate physical, emotional, psychosocial, spiritual, and bereavement needs are assessed related to the terminal illness and related conditions to promote the patients well-being, comfort, and dignity...The comprehensive assessment consists of discipline specific assessments..." Patient #9 had a hospice election date of 8/21/23 and a diagnosis of senile degeneration of the brain. The Plan of Care (POC) for 8/21/23-11/18/23 included orders for skilled nursing weekly for 13 weeks; medical social worker monthly for four months; and chaplain monthly for four months. The Chaplain POC goal stated, ";PT [patient] will find hope and coping through her chosen spiritual beliefs and practices." The chaplain conducted the spiritual assessment on 8/21/23. The visit note stated that the patients primary religion was unknown. The assessment of spiritual needs stated that the patient had ";adequate coping" and ";poor spiritual resources." The chaplain visited on 9/8/23. The visit note stated that the patients primary religion was unknown. The note also revealed the patients perspectives: ";My spirituality is a significant part of my life: Strongly agree..." An interview with Chaplain #14 was conducted on 9/19/23 at 4:17 p.m. The interview confirmed the chaplain was not aware of the patients primary religion and had not asked the patients family about religion (the patient was not able to verbalize).

Based on home visits, agency policy, clinical record review, caregiver and staff interviews, the Plan of Care [POC] failed to include correct medications/dosages for 1 of 4 patients that received a home visit [#1]. The findings included: --- The policy, Plan of Care [revised 6/2023], was provided by the agency administrator on 9/19/23 at approximately 2:25 pm. The policy stated, ";...The plan of care includes, but not limited to, medications including dose/route/frequency..." Patient # 1 had a Start of Care date of 7/28/22 and a terminal diagnosis of COPD [chronic obstructive pulmonary disease-lung disease]. Review of the Plan of Care [POC] for the certification period 7/20/23-9/20/23 included orders for SN [skilled nursing] 1 time a week for 9 weeks and 3 PRN [as needed] for symptom management. On 9/18/23 at approximately 3 pm a joint home visit was made with RN # 10. During the visit, a medication review was conducted using the POC provided by the agency. The follow discrepancies were noted: The POC listed Losartan Potassium [blood pressure] 50 mg. Take 1 ½ tablets daily. The start date for this medication was listed as 2/13/23. During the medication review, the caregiver presented a bottle of Losartan Potassium 50 mg [date on bottle was 8/22/23] with the following directions: Give 1 tablet on days blood pressure is greater than 150/90. During an interview with the caregiver, the caregiver stated the patient was receiving the medication as instructed with the date of 8/22/23 on the medication bottle. Hydralazine [blood pressure] 10 mg. Take 1 tablet 3 times per day as needed for blood pressure greater than 160/90. The start date was listed as 8/2/22. The caregiver giver presented a bottle of Hydralazine 10 mg with the instructions to take 1 tablet twice a day as needed for blood pressure greater than 160/90 [date on this bottle was 10/3/22]. During an interview with the caregiver, the caregiver stated the patient was receiving the medication as instructed with the date of 10/3/22 on the medication bottle. An interview was conducted with RN # 10 during the visit. The RN confirmed the POC did not include the correction medication/dosage the patient was taking.

Based on policy review, clinical record review, and staff interview the agency failed to follow up on advanced directives for 2 of 14 current patients (#3 and 12); follow up on a request for therapy for 1 of 1 patient that requested physical therapy (#12); and to assess and update the plan of care related to redness and order of abdominal fold for 1 of 14 active patients (#8). Findings included: --- 4. Patient # 8 had a Start of Care date of 9/1/23 and a terminal diagnosis of Alzheimers Disease. Review of the Plan of Care for the certification period 9/1/23 to 11/29/23 included orders for SN [skilled nursing] 1 time a week for 13 weeks and 5 PRN [as needed] for symptom management and hospice aide 1 time a week for 12 weeks. During of the clinical record revealed hospice aide # 11 documented the following information during a visit on 9/7/23, ";...Patient had redness on fold of her stomach. Has a [sic] odor. Clean [sic] area and applied protective cream. Notified _______ [RN # 8]. Further review of the clinical record revealed the RN failed to assess the patients stomach until 9/13/23. The RN obtained an order for Nystatin [used to treat fungal infections] to be used to the abdominal fold on 9/13/23. During an interview with RN # 8 on 9/19/23, the RN stated, ";I assessed it my next visit. The family and the aide knew [sic] to keep it clean until I made the next visit. The aide told the family to keep using the barrier ointment". A policy, ";Coordination of Hospice Services HC.20" (revised 6/23) was provided by the administrator on 9/19/23 at 2:25 p.m. The policy stated, ";The patients plan of care is coordinated and communicated by the RN Case Manager with the contracted facilities, attending physician, vendors, [interdisciplinary group], and other healthcare providers who provide services related to the terminal illness." 1. Patient #3 was admitted on 7/12/23 with a diagnosis of Alzheimers disease. The Plan of Care 7/12/23-10/9/23 included orders for medical social work (MSW) one time per month for three months. The MSW note for 7/12/23 stated, ";The spouse desires the patient to be a DNR [do not resuscitate] and RN [name] will have the medical director sign the DNR next week...The patients legal guardian was given a MOST [Medical Order Scope of Treatment] for during todays visit and the MSS [medial social services] will follow up with him during their next visit if he has any questions or needs assistance filling it out." The MSW note for 8/3/23 revealed the patients daughter was not familiar with the MOST form. The MSW reviewed that form with the daughter. The daughter said she would discuss it with the patients spouse. The next MSW visit was conducted on 9/1/23. There was no evidence of follow up related to the MOST form. An interview was conducted with MSW #3 on 9/20/23 at 9:12 a.m. The MSW stated that the focus of the 9/1/ visit was caregiver fatigue and the MOST form ";slipped my mind." 2. Patient #12 was admitted on 8/25/23 with a diagnosis of senile degeneration of the brain. The Plan of Care (POC) for 8/25/23-11/22/23 included orders for skilled nursing weekly for 13 weeks and medical social work (MSW) monthly. The initial assessment noted on 8/25/23 stated, ";Son wants patient to be a DNR and MOST form completed for comfort measures only." There was no evidence that a DNR was completed until 9/19/23. An interview with RN #6 on 9/20/23 at 9:19 a.m. confirmed advanced directives were implemented 9/19/23. 3. Patient #12 was admitted on 8/25/23 with a diagnosis of senile degeneration of the brain. The Plan of Care (POC) for 8/25/23-11/22/23 included orders for skilled nursing weekly for 13 weeks. On 8/27/23, the nurse visit note stated, ";Son asked about physical therapy for his Dad. Son has concerns over patients shuffling gait and difficulty getting up. SN explained disease progression to son and said we can get a few visits of physical therapy." There was no evidence of any further discussion related to therapy. An interview with RN #6 was conducted on 9/20/23 at 9:21 a.m. revealed the RN was not aware of the caregivers request for physical therapy.

Based on policy and procedure, clinical record review and staff interview the agency failed to show evidence of an order for a medication for constipation for 1 of 3 patients with chronic obstructive pulmonary disease [#10]; and evidence of an order for removing a foley catheter (bladder tube) for 1 of 1 patients with a catheter [#17]. Findings included: --- 2. Patient # 17 had a Start of Care date of 5/4/23 and a terminal diagnosis of cerebral infarction [stroke]. Review of the Plan of Care [POC] for the certification period 5/4/23 to 8/1/23 included orders for SN [skilled nursing] 2 times a week for 13 weeks and ";Change foley catheter 16 fr/10 cc every month on the 25th of each month." Review of the clinical record revealed the following documentation by RN # 13, ";Foley catheter pulled per NP [nurse practitioner] and spouses wishes..." Further review of the clinical record revealed no physicians order to discontinue the catheter. RN # 13 was not available for interview. An interview was conducted with the agency administrator on 9/19/23 at approximately 3 pm. During the interview the administrator confirmed there was no documented order to discontinue the catheter. A policy, ";Medication Orders" revised 12/2022 was provided by agency administrator on 09/19/23 at 2:25 p.m. stated, ";...verbal and written medication orders are documented in the clinical record..." 1. Patient #10 had a Start of Care of 05/07/21 with diagnoses of copd (chronic obstructive pulmonary disease), hypothyroidism (low thyroid), gerd (gastro esophageal reflux disease), and dependence of oxygen. The Plan of Care for certification period of 08/07/23 to 11/04/23 included orders for skilled nursing 1 times a week for 13 weeks. Review of the skilled nurse visit for 08/17/23 had documentation of this registered nurse ordered miralax (medication for constipation). Review of the clinical record revealed no order was in the record for miralax, nor was it on the standing orders. Interview with Employee #8 on 9/19/23 at 12:16 p.m. revealed, ";I just added the miralax to the medication profile today, I missed it" I used the standing orders". Interview with the clinical manager at 12:45 p.m. on 09/19/23 revealed, ";miralax is not on the standing orders".