Every finding on record at Melody Care Hospice

Upon observation, there was no evidence the Emergency Plan communication plan includes contact information for federal, state, tribal, regional, or local emergency preparedness staff. Upon review of the Emergency Communication Plan, the required regional and state the primary and alternate contact information for emergency preparedness staff was not present.

Upon personnel record review, 1 of 12 (Personnel # 6) did not have evidence that all Speech Therapy Services are provided by a qualified licensed Speech-Language Pathologist (SLP) or Audiologist in accordance with the state's Speech-Language Pathology Practice Act and the hospice's policies and procedures and/or job descriptions. Personnel # 6 - Upon personnel record review did not have evidence of a valid Speech Therapy License in the ST's personnel file.

Upon personnel record review, 1 of 12 (Personnel # 6) did not have evidence the hospice obtained a criminal background check on all contracted individuals who have direct patient care and access to patient records. Personnel # 6: Upon review of the personnel record were not contained in personnel file.

Upon patient record review, 3 of 5 records (Patients #1,#3,#5) 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: The plan of care included ordered frequencies for nursing once weekly and as needed for symptom management, social work monthly and as needed for psychosocial needs, and spiritual care monthly and as needed for spiritual needs. There was no evidence of a defined quantity for allowable PRN visits. Corrected on site. Patient 3: The plan of care included ordered frequencies for nursing once weekly and as needed for symptom management, social work monthly and as needed for psychosocial needs, and spiritual care monthly and as needed for spiritual needs. There was no evidence of a defined quantity for allowable PRN visits. Corrected on site. Patient 5: The plan of care included ordered frequencies for nursing once weekly and as needed for symptom management, social work monthly and as needed for psychosocial needs, and spiritual care monthly and as needed for spiritual needs. There was no evidence of a defined quantity for allowable PRN visits.

Upon patient record review, 1 of 5 records (Patients #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 3: The medical record contained nursing documentation upon admission identifying patient use of a wheelchair, hospital bed, bed rails, over the bed table and mattress overlay. There was no evidence of the chair, bed, rails, table, and mattress included for DME on the plan of care.

Upon patient client record review, 1 of 5 records (Patient #2) 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. Patient 2: The medical record contained contradicting documentation of aide frequencies. The initial physician order for frequency stated aide services ordered for once weekly. The initial plan of care and nursing comprehensive assessment both stated aide services were declined.