Every finding on record at Mona Hospice, Inc

Upon patient record review 1 of 14 records reviewed (Patient #3) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient #3: The record indicated a spiritual comprehensive assessment was due in 5 calendar days of the start of care date 02/28/24. There was no evidence of this component being completed. The records was marked as "declined".

Upon patient record review, 2 of 14 Records Reviewed (Patient #7, #10) 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 #7: The record indicated Azelastine Hydrochloride Ophthalmic Solution 0.05% one drop instill to affected eye twice daily. The record did not indicate which eye was affected. Corrected on site. Patient #10: The record indicated Calmoseptine Topical Ointment 0.44% twice daily as needed to affected areas. The record did not indicate where the ointment was to be applied specifically. Corrected on site.

Upon patient record review, 3 of 14 records reviewed (Patient #5, #6, #8) 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 #5: The record indicated this patient was prescribed insulin and had a related condition that required monitoring and management. There was no evidence on the chart of a care plan for the insulin (diabetic management). Patient #6: The record indicated the SW discussed fall and safety on 3/15/24. There was no evidence on the chart of a fall and safety care plan to include goals and interventions based on the problem identified. Patient #8: The record indicated a fall risk assessment with a score of 17 (high risk). There was no evidence on the chart of a fall and safety care plan to include goals and interventions based on the problem identified. In addition, the patient had an MD order for continuous care. There was no evidence on the chart of symptom management problem with goals and interventions based on the problem identified.

Upon patient record review, 2 of 14 records reviewed (Patient # 7, #10) 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 #7: The record indicated the MD order written for Azelastine Hydrochloride Ophthalmic Solution 0.05% one drop instill to affected eye twice daily. The MD Order did not indicate which eye was affected. Corrected on site. Patient #10: The record indicated the MD order was written for Calmoseptine Topical Ointment 0.44% twice daily as needed to affected areas. The order did not indicate where the ointment was to be applied specifically. Corrected on site.

Upon patient record review, 3 of 14 records reviewed (Patient #5,#10,#12) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient #5: The record indicated the patient record should have had a revised plan of care from the patients updated comprehensive assessment to include progress towards outcome/goals from the plan of care. There record had no evidence of the plan care updates since 4/2/24. Patient #10: The record indicated the RN made a visit on 7/15/23 and documented under the imminent dying section that the patient had increased episodes of anxiety and increased shortness of breath per the caregiver. There was no evidence of an update to the plan of care related to these symptoms Patient #12: The record indicated the LVN nurse documented on 4/1/24 that the patient was having episodes of anxiousness and confusion. The RN visit on 3/20/24 the RN documented under the imminent death section of the assessment the patient was having increased respiratory distress. There was no evidence the POC was updated to manage patient and the family needs during the final 2 days of life.

Upon client record review, 1 of 14 records reviewed (Patient #4) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #4: The record indicated on the start of care 03/01/24 by the social worker she would follow up monthly and there was an order for monthly visits. There was no evidence of a social worker follow up until the home visit with the surveyor.

Upon observation, there was no evidence the hospice documented the cost savings achieved through the use of volunteers. Documentation must include the following: • The identification of each position that is occupied by a volunteer • The work time spent by volunteers occupying those positions • Estimates of the dollar costs that the hospice would have incurred if paid employees occupied the positions identified in paragraph (d)(1) of CFR 418.78 for the amount of time specified in paragraph (d)(2) of CFR 418.78 The Volunteer Coordinator was not able to verbalize the cost savings total. There was no evidence in the notebook binder of these cost savings calculations.

Upon observation, there was no evidence the annual report documents the use of volunteers providing day to day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract personnel. The Volunteer Coordinator was not able to verbalize the number of hours worked by the staff to ensure the 5% was being met by the volunteers. There was no evidence of a minimum of 5% in volunteer hours were met.

Upon personnel record review, 1 of 14 records reviewed (Personnel # 2) did not have evidence the alternate administrator's personnel record verifies that: • The employee has appropriate education and experience requirements • There is a signed job description for this role • The employee has been orientated to this role Personnel File #2: The personnel file for the Alternate Administrator did not have a job description. This was corrected on site. In addition, there was no evidence of the Alternate Administrator having been oriented to this role.

Upon personnel record review, 1 of 16 (Personnel #4) did not have evidence that the hospice employees have received orientation on their specific job requirements. Personnel File #4: The personnel file for the Alternate DPOS did not have an orientation checklist for this role.

Upon patient client record review, 10 of 14 records reviewed (Patient #1, #2 #3, #4, #5, #6, #7, #8, #9, #10) 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 #1: There was no evidence on the Medicare election that it specifically stated palliative rather than curative nature of treatment. Patient #2; There was no evidence on the Medicare election that it specifically stated palliative rather than curative nature of treatment. Patient #3: The record indicated a person with the initials J.P signed the legals. The record had no evidence of who this person was to the patient, the relationship was not identified. In addition, the nurse signature was not legible. There was no evidence on the Medicare election that it specifically stated palliative rather than curative nature of treatment. Patient #4: The record indicated the nurse signed as a witness on the legal forms. The signature is not legible. There was no evidence on the Medicare election that it specifically stated palliative rather than curative nature of treatment. Patient #5: The record indicated a person signing with the initials SM or JM (the initials are not clearly legible) signed the legals. The record had no evidence of who this person was to the patient, the relationship was not identified. In addition, the nurse signature was not legible. There was no evidence on the Medicare election that it specifically stated palliative rather than curative nature of treatment. Patient #6: There was no evidence on the Medicare election that it specifically stated palliative rather than curative nature of treatment. Patient #7: The record indicated the patient initialed the Notice of Election. There was no evidence of a full signature giving consent to elect the hospice benefit. There was no evidence on the Medicare election that it specifically stated palliative rather than curative nature of treatment. Patient #8: The record indicated a legal representative signed, the signature is not legible and the persons relation to the patient is not listed. Patient #9: There was no evidence on the Medicare election that it specifically stated palliative rather than curative nature of treatment. Patient #10: There was no evidence on the Medicare election that it specifically stated palliative rather than curative nature of treatment.

Upon patient client record review, 3 of 14 records reviewed (Patient #3, #5, #8) 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: The record indicated the staff signature is not legible on the legal documents. There was no evidence of a signature log. Patient #5: The record indicated the staff signature is not legible on the legal documents. There was no evidence of a signature log. Patient #8: The record indicated the staff signature is not legible on the legal documents. There was no evidence of a signature log.