Every finding on record at Mlife Hospice, Inc.

Observed in Record Review. In 1 of 10 patient records reviewed, During HV#3 record reivew it was noted lack of an initial bereavement assessment without documentation of the reason for the delay. This was discussed with the organization leadership.

Observed in Record Review. In 1 of 10 patient records reviewed, During RR#4 it was noted the IDG meeting after the initial IDG was documented 16 days later. This was discussed with the organization leadership.

Observed in Record Review. In 5 of 10 patient records reviewed, During RR#2 it was noted a patient goal of BM every 3 days without interventions added to accomplish the goal. During HV#2 and HV#3 record reivew it was noted lack of interventions added to the POC to instruct on safety and use of oxygen equipment ordered. During RR#3 it was noted the chaplain visited the patient the beginning of August 2024 with a frequency established, however the POC was not updated with interventions for the spiritual issues identified. During RR#4 it was noted at the IDG meeting the beginning of September 2024 the patient had experienced vomiting with a medication ordered by the physician, however, GI interventions were not added to the POC. This was discussed with the organization leadership. Observed in Record Review. In 2 of 10 patient records reviewed, During HV#2 and RR#3 it was noted an order for Plavix 75 mg daily PO. The POCs lacked interventions related to education to the patient/family on S/S bleeding and bleeding precautions. This was discussed with the organization leadership

Observed in Record Review. In 1 of 10 patient records reviewed, During HV#1 record review it was noted an intervention Monitor/assess effectiveness of current and new medication/treatment. Patient on Lantus 42 Units at bedtime and Humulin R (per sliding Scale) before meals and at bedtime with a goal Patient will have no hospitalization d/t adverse reaction from Insulin in the next 14 days. The visit notes by the SNs lack documentation of the assessment of the patient's diabetic status related to the stated interventions in the POC. This was discussed with the organization leadership.

Observed in Patient Home. In 2 of 3 home visits conducted, During HV#2 and #3 it was noted the SN did not adhere to the wet disinfectant contact time of 4 minutes for the product used to disinfect the BP cuff, stethoscope, and pulse oximeter. This was discussed with the organization leadership. Observed in Patient Home. In 1 of 3 home visits conducted, During HV#2 it was noted the SN used the patient's bar soap to wash her hands. She then used toilet paper to dry her hands. In addition, the SN after examining and touching the patient's feet did not remove her gloves and disinfect her hands before touching the patient's upper body and hands. This was discussed with the organization leadership. Observed in Patient Home. In 1 of 3 home visits conducted, During HV#1 it was noted the hospice aide took the patient's clean gown and towel and placed them on another patient's beside stand from another room without disinfection of the surface. The hospice case manager present during the visit requested a clean gown and towel. This was discussed with the organization leadership.

Observed in HR File Review. In 1 of 10 HR files reviewed, During HR#4 file review it was noted the required aide competencies were completed and documented with a verbal evaluation method, however, the documentation failed to confirm the competencies required to be completed with an actual patient or a qualified pseudo patient. This was discussed with the organization leadership.

Observed in Record Review. In 6 of 7 patient records reviewed, who were receiving hospice aide services, During HV#1 record review, HV#3 record review, RR#2, RR#4, RR#5, and RR#7 it was noted the aide assignment POC included a titration order for O2 2-5L/min via nasal cannula PRN SOB, which was not within their duties per job description and organization policy. This was discussed with the organization leadership.

Observed in Record Review. In 1 of 10 patient records reviewed, During RR#4 it was noted interventions on the POC to instruct and assess colostomy and G-tube care without documentation by the RNs that the patient had a G-tube or a colostomy. This was discussed with the organization leadership.

Observed in Document Review. During review of the contract for transportation serivces and therapy serivces it was noted lack of a stipulation that the outside agency will complete criminal background checks on contracted employees who provide direct patient care or have access to patient records. The transportation contract lacked the stipulation of the manner in which the contracted services will be coordinated, supervised, and evaluated by the hospice. This was discussed with the organization leadership.