Every finding on record at Mercy Villa Hospice, Inc

Upon patient record review, 1 of 14 (Patient #4) did not have evidence that the patient chooses a health care provider, including an attending physician Patient #4 - Upon record review, noted on page 1 of 2 of the Election of Benefit form, there is an area for which the patient/representative should chose and document their choice of attending practitioner. The document showed that this area was left blank and the patient neither chose or declined choosing an attending physician. The record showed that the Medical Director provided the certification of terminality as well as signed that attending certification.

Upon patient record review, 6 of 14 (Patient #1,2,5,7,8,9) 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 #1,5,7,8,9 medication lists all contained Tylenol to be given as needed for pain or fever. There was no evidence that the POC order contained a 4000mg maximum daily dose. Patient#2 - Upon review of the medication profile, it was noted that patient had multiple medications ordered prn for constipation. There was no evidence of the progression of therapy and when and how to use which medication. Patient#8 - Upon review of the medication profile, it was noted that patient had two different as needed medications ordered for constipation. There was no evidence of the progression of therapy and when and how to use which medication.

Upon patient record review, 4 of 14 (Patient #2,#4,#8,#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 - The medical record showed that the patient had a nebulizer listed on DME list along with an order for a DuoNeb to be given every six hours as needed for shortness of breath. There was no evidence in the plan of care outlining the use of a nebulizer as an intervention for shortness of breath. Patient#4 - The patient medication list contained an albuterol inhaler to be used as needed for shortness of breath. The plan of care did not include this as an intervention for respiratory distress. Patient #8 - The patient medication list contained both senna and enulose both as needed medications to be used for constipation. The constipation problem did not outline the use of these medications as interventions. Patient #10 - The patient medication list contained a pain regimen of Fentanyl with morphine as needed for breakthrough pain. The pain problem on the plan of care did not show evidence that these medications were being used as interventions.

Upon patient record review, 4 of 14 (Patient #4,#5,#12,#13) 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#4 - The IDG documentation from 02/07/25, showed an order for spiritual care to be provided as needed. There was no evidence of a scope or frequency for visits. Patient #5 - The IDG documentation from 02/04/25, showed an order for spiritual care to be provided as needed. There was no evidence of a scope or frequency for visits. Patient #12 - The IDG documentation from 03/09/25 to 03/21/25, showed an order for spiritual care to be provided as needed. There was no evidence of a scope or frequency for visits. Patient #13 - The IDG documentation from 02/14/25 to 04/30/25, showed an order for spiritual care to be provided as needed. There was no evidence of a scope or frequency for visits.

Upon patient record review, 5 of 14 (Patient #1,5,7,8,9) 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 #1,5,7,8,9 medication lists all contained Tylenol to be given as needed for pain or fever. There was no evidence that the POC order contained a 4000mg maximum daily dose.

Upon observation, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient#1 Upon entering the home during a patient visit with the chaplain, it was noted that the chaplain entered the home, and placed his bag directly on the patients bedside table. There was no evidence of barrier used between the bag and the table as directed in the agency policy. There was also no evidence of hand washing or sanitizing prior to touching the patient.

Upon patient record review 1 of 14 (Patient #6) 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 #6 - On admission, the initial plan of care dated 12/22/24, contained an order for aide visits to occur twice per week. The aide care plan outlined necessary care to be conducted. There was no evidence in the medical record of aide visits between 04/14/25 and 06/03/25. On 06/03/25 there was an aide visit, but no other visits noted since then. There was no evidence of an order to discontinue those visits.

Upon patient record review, 1 of 14 (Patient #4) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient #4 - Upon record review, noted on page 1 of 2 of the Election of Benefit form, the document showed that this area was left blank and the patient neither chose or declined choosing an attending physician. The record showed that the Medical Director provided the certification of terminality as well as signed that attending certification.

Observed in Record Review. In 2 of 5 patient records reviewed, the assessment did not include spiritual assessment. The agency policy, Initial Assessment/Comprehensive Assessment states the assessment will include Pt/Family spiritual orientation, including their desire for the involvement of a religious group. In HV/RR #2 and HV/RR #3, the surveyor noted the patient declined the chaplain and the nursing assessment only had signs of spiritual distress in the comprehensive assessment and did not include their orientation or desired involvement of a religious group. This was reviewed with the case manager.

Observed in Record Review. In 1 of 2 records reviewed with Aide services, the CHHA did not provide care according to the patient's plan of care. Upon review of the record for HV/RR #3, the aide performed care that was not ordered on the Aide Care plan on multiple visits.. The new aide delegation sheet for the second benefit period had the assist with dressing not ordered but the CHHA performed them on every visit after that Aide Delegation was created. This was reviewed and validated with the Case Manager.