Every finding on record at Melrose Comfort Hospice, Inc

Upon patient record review, 2 of 14 (Patients #4, 5) 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. Patients #4 and #5: There was no evidence of an initial bereavement assessment having been completed in the record.

Upon patient record review, 7 of 14 (Patients #2, 3, 6, 7, 8, 9, 10) 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 #2: Patient is taking clopidogrel. There are no interventions or goals on the plan of care for use of anticoagulants or bleeding precautions. Patient #3: Patient is taking Eliquis. There are no interventions or goals on the plan of care for use of anticoagulants or bleeding precautions. Patient is taking Keppra with history of traumatic subdural hematoma. There are no interventions or goals related to seizure on the plan of care. Patient #6: Patient is taking Eliquis and Aspirin. There are no interventions or goals on the plan of care for use of anticoagulants or bleeding precautions. Patient #7: Patient is taking MiraLax daily to prevent constipation. There are no interventions or goals related to constipation on the plan of care. Patient #8: Patient is taking Eliquis. There are no interventions or goals on the plan of care for use of anticoagulants or bleeding precautions. Patient #9: Patient is taking Eliquis. There are no interventions or goals on the plan of care for use of anticoagulants or bleeding precautions. Patient #10: Patient has been given Tylenol for mild pain there is not interventions or goals on the plan of care for pain. Patient was given trazadone for insomnia, there is no interventions or goals for sleep on the plan of care.

Upon patient record review, 2 of 14 (Patients #4, 7) 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: Patient has wound order that reads, "Left Buttocks, cleanse with NS, pat dry. Apply Medi honey, cover with island dressing daily x 30 days." The order does not state what kind of wound it is. The order does not state who will change the dressing, nor does it delineate when the Hospice nurse will change the dressing and when the caregiver will change the dressing. Patient #7: The patient has two wound orders for two wounds. The first reads, "Left buttock stage 3 wound. Cleanse with wound cleanser, pat dry. Apply Medi Honey to wound bed, Zinc 40%, apply foam dressing three times weekly and prn soiled." The order does not state who will change the dressing, nor does it delineate when the Hospice nurse will change the dressing and when the caregiver will change the dressing. The second order is for the Right buttock, and reads, "Right buttock stage 2 cleanse with wound cleanser and pat dry. Apply Medi Honey to wound bed and cover with dry dressing." The order does not state who will change the dressing, nor does it delineate when the Hospice nurse will change the dressing and when the caregiver will change the dressing. This order also does not state how often to perform dressing change.

Upon personnel record review, 8 of 13 (Personnel #1, 3, 4, 9, 10, 11, 12, 13) does not show evidence of criminal background checks being obtained in accordance with state requirements. In the absence of state requirements, criminal background checks are obtained within three months of the date of employment for all states that the individual has lived or worked in the past 3 years. Personnel # 1, 3, 4, 9, 10, 11, 12, 13: Although these employees show evidence of National sex offender reports, OIG reports, and National background checks, there is no evidence of a state background check being obtained.

Upon patient record review, 3 of 11 (Patient #1, #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 #1, #6, and #8 Oxygen use mentioned in chart but did not contain evidence of oxygen in the medication profile.

Upon patient record review, 1 of 11 (Patient #6) 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 #6 Oxygen use mentioned in chart but did not contain oxygen concentrator nor e tank in durable medical equipment order.

Upon personnel record review, 3 of 14 (Personnel #11, #12, #13) did not have evidence the hospice employees and contract employees have received orientation on the hospice philosophy.

Upon patient record review, 1 of 11 (Patient #5) 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 #5 Certification of Terminal Illness of 9/21/22 included a verbal order with a future date of 1/21/23.

Upon patient client record review, 1 of 11 (Patient #3) 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 #3 Election of benefit listed two names under elected person, the patient and the caregiver.

Upon client record review, 2 of 11 (Patient #10, #11) did not have evidence that the discharge summary includes all required information. Patient #10, #11 did not contain evidence that discharge summaries included summary of the patient's stay, patient's current plan of care, the latest physician orders nor any other documentation that will assist in post-discharge continuously of care.