Every finding on record at Nayar Hospice Bedford LLC

Upon patient record review, 1 of 5 (Patient #1) 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: The POC 10/25/24 contains an order for dressing to be done for a skin tear PRN or twice weekly by facility staff or hospice nurse." There is no frequency to the PRN. Corrected on site.

Upon patient record review, 1 of 5 (Patient #4) 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 4: The SN documented on 10/14/24 that the patient is requiring use of a "Stand to lift device". There is no evidence of an order for this DME item. Corrected on site.

Upon patient record review 1 of 5 (Patient #1) 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 1: The medical record contains missed visits by the aide with the documented reason as "No coverage" on 10/17/24,10/22/24, 10/31/24. The agency aide amended their documentation to state the patient's caregiver refused care for the visit due to the aide they wanted is off for medical reasons.

Upon patient record review 1 of 19 (Patient #10) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient 10: Initial spiritual assessment documented on 09/10/2024. Initial comprehensive assessment documented on 09/03/2024. There is no evidence of spiritual assessment within the first five days of hospice admission.

Upon patient record review 1 of 19 (Patient #15) 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 15: There is no evidence of initial spiritual assessment in the patient’s medical record.

Upon patient record review, 4 of 19 (Patient #1,2,3,11) 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: Patient has physician’s order for oxygen in plan of care. There is no evidence of oxygen in patient’s medication list. COS Patient 2: Patient has oxygen in medication list. There is no evidence of administration route. COS Patient 3: Patient has physician’s order for oxygen in plan of care. There is no evidence of oxygen in patient’s medication list. COS Patient has active order for ceftin on medication list. Instructions read: ceftin 300mg capsules. Take 2 capsules by mouth at bedtime for 10 days for UTI/pneumonia. Start date 04/14/2024 with no end date. Patient11: Patient has order for oxygen in the medication list. Instructions read: administer 5LPM daily. There is no evidence of route, how long oxygen to be worn, or other instructions in this medication order. Patient has order for pyridium 200mg in the medication list. Instructions read: 1 tab by mouth 3 times daily for 3 days. Order written 09/07/2024. There is no evidence of end date for this order, as order is still active.

Upon patient record review, 1 of 19 (Patient #2) 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. Patient 2: There is no evidence of initial bereavement assessment being completed.

Condition of Participation: Interdisciplinary Group, Care Planning, and Coordination of Services. L536

Upon patient record review, 6 of 19 (Patient #1,5,6,8,11,14) 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 1: Patient has aspiration precautions noted in the plan of care. There is no intervention for aspiration precautions noted in the patient’s nutrition care plan. Patient 5: Patient has aspiration precautions noted in the plan of care. There is no intervention for aspiration precautions noted in the patient’s nutrition care plan. Patient has oxygen precautions noted in the plan of care. There is no intervention for oxygen noted in the patient’s respiratory care plan. Patient 6: Patient has aspiration precautions noted in the plan of care. There is no intervention for aspiration precautions noted in the patient’s nutrition care plan. Patient has oxygen precautions noted in the plan of care. There is no intervention for oxygen noted in the patient’s respiratory care plan. Patient has aspirin 81mg 1 tab po daily/blood thinner noted in the plan of care. There is no evidence of bleeding precautions in the plan of care. Further, there is no evidence of bleeding precautions as an intervention in the patient’s care plan. Patient 8: Patient has Eliquis 5mg PO twice daily/anticoagulation noted in the plan of care. There is no evidence of bleeding precautions in the plan of care. Further, there is no evidence of bleeding precautions as an intervention in the patient’s care plan. Patient 11,14: Patient has oxygen precautions noted in the plan of care. There is no intervention for oxygen noted in the patient’s respiratory care plan.

Upon patient record review, 4 of 19 (Patient #1,2,3,11) 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: Patient has physician’s order for oxygen in plan of care. There is no evidence of medication order for oxygen in the patient’s plan of care. COS Patient 2: Patient has oxygen in plan of care. There is no evidence of administration route for oxygen order. (COS) Patient 3: Patient has physician’s order for oxygen in plan of care. There is no evidence of medication order for oxygen in patient’s plan of care. (COS) Patient has active order for ceftin on plan of care. Instructions read: ceftin 300mg capsules. Take 2 capsules by mouth at bedtime for 10 days for UTI/pneumonia. Start date 04/14/2024 with no evidence of end date. Patient 11: Patient has order for oxygen in the plan of care. Instructions read: administer 5LPM daily. There is no evidence of route, how long oxygen to be worn, or other instructions in this medication order. Patient has order for pyridium 200mg in the plan of care. Instructions read: 1 tab by mouth 3 times daily for 3 days. Order written 09/07/2024. There is no evidence of end date for this order, as order is still active.

Upon patient record review, 4 of 19 (Patient #7,11,12,13) 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 7,12,13: Patient has wheelchair noted as required in activities permitted section of plan of care. Wheelchair is not listed in DME section of plan of care. Patient11: Patient has wheelchair and walker noted as required in activities permitted section of plan of care. Wheelchair and walker are not listed in DME section of plan of care.

Upon client record review, 4 of 19 (Patient #1,4,7,13) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 1: Physician’s order for SN visit frequency written on 08/25/2024 is twice weekly. There is also an order noted for 3PRN SN visits. During the week of 09/08/2024, there is evidence of 3 SN visits dated 09/08/2024, 09/10/2024, and 09/13/2024. There is no evidence of documentation that any of these visits were PRN visits. Patient 4: Physician’s order for SN visit frequency written 11/28/2023 is weekly and 3 PRN. There is no evidence of SN visit made between 07/23/2024 and 08/07/2024. Further, there is no evidence of documentation of a missed visit during this period. Patient 7: Physician’s order for MSW visit frequency written 06/22/2024 is monthly and 5 PRN. There is evidence of MSW visits on 08/05/2024 and 08/23/2024. There is no evidence of documentation that either of these visits was a PRN visit. Patient 13: Physician’s order for SN visit frequency written on 07/19/2024 is weekly and 5 PRN. There is no evidence of SN visit between 08/12/2024 and 08/27/2024. Further, there is no evidence of documentation of a missed visit during this period.

Upon observation, there was no evidence the hospice investigates all adverse events, incidents, accidents, variances or unusual occurrences that involve patient care and develops a plan of correction to prevent the same or similar event from occurring again. Patient 3: During aide visit on 09/16/2024, it is documented that patient, “was sliding from chair.” Aide documented that they and the paid caregiver assisted patient to floor and then off of the floor. Hospice policy AD.A20 states in the Procedure section: (2) Any employee who is involved in, witnesses or discovers any event that is no consistent with routine operations and/or has resulted in, or has the potential to result in, injury or harm, is required to complete a written incident/adverse report. There is no evidence of an adverse event report submitted for this adverse event and the adverse event was not reported to the case manager.

Condition of Participation: Hospice Aide and Homemaker Services. L607

Upon patient record review, 12 of 19 (Patient #1,3,4,5,7,8,9,10,11,12,13,14) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient 1: Patient has walker listed on POC as DME need. Walker is not listed on aide care plan. Aide task shave is listed as PRN on the aide care plan. Patient 3: COS Aide task assist with meals is listed as PRN on the aide care plan. Patient 4: COS Aide tasks listed as PRN on the aide care plan: bed bath and assist with feeding. Patient 5: Aide tasks listed as PRN on the aide care plan: assist with feeding; chair/bed bath; assist with ambulation; transfer assist. Patient 7,8,9: Aide tasks listed as PRN on the aide care plan: all vital signs; oxygen saturation; weight; intake, output, pain. Patient 10: Aide tasks listed as PRN on the aide care plan: all vital signs; oxygen saturation; weight; intake, output. Patient 11: Aide tasks listed as PRN on the aide care plan: assist with feeding; change bed linen; equipment care. Patient 12, 13: Aide tasks listed as PRN on the aide care plan: all vital signs; oxygen saturation; weight; intake, output, pain, shampoo. Patient 14: Aide tasks listed as PRN on the aide care plan: shave face; assist with feeding; change linen (task frequency noted to say weekly and PRN); notify case manager for changes/decline.

Upon patient record review 7 of 19 (Patient #1,3,4,5,7,9,12) 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 1: No evidence of task “pain” completed on following dates: 07/25/24, 07/30/24, 08/01/24, 08/15/24, 08/19/24, 08/21/24, 08/26/24, 09/03/24, 09/12/24. Pain task documented as completed without evidence of data collection on these dates: 8/08/24, 8/13/24, 9/05/24, 9/09/24. Task-weight: On 8/13/24, weight is documented as completed with result documented as no. On 08/21/24, weight documented as completed with no evidence of data collection. On 9/13/24, aide care plan updated to include weight twice weekly. On 09/16/2024, it is documented that weight task is completed. There is no evidence of data collection this date. On 08/26/2024, aide documented “too much pain” to get out of bed for lunch. There is no evidence of pain rating or data collection for pain on this date. On 09/09/2024, there is evidence that the following tasks were not completed. Further, there is no evidence of documentation of why these tasks were not completed. Charting simply stated, “very irritated and confused.” Tasks: nutrition/diet; environmental; safety; activity. Patient 3: Pain task is assigned to aide twice weekly per aide care plan. On the following dates, there is no evidence that this task was performed. 08/27/2024, 09/06/2024, 09/12/2024, 09/16/2024. There is evidence that patient refused aide care on the following dates: 8/19/24, 8/21/24, 9/04/24, 9/09/24. There is no evidence that the case manager was notified of these refusals. Patient 4: Weight task is assigned to aide monthly. There is no evidence of weight obtained during month of Aug. 2024. Pain task is assigned to aide twice weekly. There is no evidence of this task being completed on the following date: 09/16/2024. On the following date, there is documentation that the pain task was completed, but no data collected: 9/11/24. Weight task is assigned to aide monthly. On the following dates, there is documentation that the weight task was completed, but no data collected: 09/11/2024, 09/16/2024. Patient 5: Pain task is assigned to aide twice weekly. There is no evidence of this task being completed on the following dates: 9/06/24, 9/18/24. On the following dates, there is documentation that the pain task was completed, but no data collected: 9/04/24,09/11/24, 9/13/24. Blood pressure task is assigned to aide twice weekly. On the following dates, there is documentation that the blood pressure task was completed, but no data collected: 9/04/24, 9/11/24. Vital signs task is assigned to aide twice weekly. On the following dates, there is documentation that the vital signs (with the exception of temp.) task was completed, but no data collected: 9/13/24. Patient 7: The following tasks are assigned to aide weekly: all vital signs; oxygen saturation; weight, intake, output, pain. There is evidence of completion of these tasks without data on the following dates: 08/28/2024, 09/18/2024. On 09/03/2024 and 09/11/2024, there is evidence of completion of these tasks without data-except the pain task. There is a pain rating on these two dates. Patient 9: The following tasks are assigned to aide weekly: all vital signs; oxygen saturation; weight, intake, output, pain. There is evidence of completion of the following tasks without data: all vital signs; oxygen saturation; weight, intake, output; on these dates: 9/04/24, 9/06/24, 9/13/24, 9/17/24. There is evidence of completion of the following tasks without data: all vital signs; oxygen saturation; pain, weight, intake, output; on these dates: 9/10/24, 9/20/24. Patient 12: The following tasks are assigned to aide weekly: all vital signs; oxygen saturation; weight, intake, output, pain. There is evidence of completion of the following tasks without data: all vital signs; oxygen saturation; weight, intake, output; on these dates: 8/28/24, 9/05/24, 9/09/24, 9/18/24. There is evidence of completion of the following tasks without data: all vital signs; oxygen saturation; pain, weight, intake, output; on these dates: 9/03/24, 9/11/24, 9/16/24.

Upon patient record review 1 of 19 (Patient #3) did not have evidence in the patient record that the hospice aides report: • Changes in the patient's medical, nursing, rehabilitative, and social needs to a registered nurse, as the changes relate to the plan of care and quality assessment and improvement activities • Hospice aides must also complete appropriate records in compliance with the hospice's policies and procedures. Patient 3: During aide visit on 09/16/2024, it is documented that patient, “was sliding from chair.” Aide documented that they and the paid caregiver assisted patient to floor and then off of the floor. Hospice policy AD.A20 states in the Procedure section: (2) Any employee who is involved in, witnesses or discovers any event that is no consistent with routine operations and/or has resulted in, or has the potential to result in, injury or harm, is required to complete a written incident/adverse report. There is no evidence that the 09/16/2024 adverse event was reported to the patient’s case manager.

Upon patient record review 12 of 19 (Patient #1,3,4,5,6,7,8,9,11,12,13,14) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs. Patient 1: There is no evidence of aide supervisory visit between 08/05/2024 and 08/22/2024. Patient 3: There is no evidence of aide supervisory visit between 07/31/2024 and 09/05/2024. There are two supervisory visits (08/15/2024 and 08/30/2024) without identifying information. Therefore, there is no way to tell who is being supervised during these visits. Patient 4: There is no evidence of aide supervisory visit between 08/15/2024 and 09/05/2024. Patient 5: There is no evidence of aide supervisory visit between 08/06/2024 and 08/29/2024. Patient 6: There is no evidence of aide supervisory visit between 08/06/2024 and 09/03/2024. There is a supervisory visit (08/23/2024) without identifying information. Therefore, there is no way to tell who is being supervised during this visit. Patient 7: There is no evidence of aide supervisory visit between 08/22/2024 and 09/17/2024. Patient 8: There is no evidence of aide supervisory visit between 08/26/2024 and 09/11/2024. Patient 9: There is no evidence of an aide supervisory visit since 08/19/2024. Patient 11: There is no evidence of aide supervisory visit between 07/31/2024 and 08/29/2024. There is no evidence of aide supervisory visit between 08/26/2024 and 08/29/2024. Patient 12: There is no evidence of aide supervisory visit between 08/21/2024 and 09/11/2024. Patient 13: There is no evidence of aide supervisory visit between 08/01/2024 and 09/12/2024. Patient 14: There is no evidence of aide supervisory visit between 08/14/2024 and 09/13/2024.

Upon patient record review, 5 of 6 (Patient #1, 2, 3, 4, 5) did not have evidence that the IDG in collaboration with the attending physician reviewed, revised and documents the individualized plan as frequently as the patient's condition requires but no less frequently then every 15 calendar days. Patient #1, 2, 3, 4, 5 IDG documented on 10/28/21 and 11/16/21 review of the comprehensive assessment which was more than 15 days. DON explained that they were starting a new rotation for every other Tuesday.

Upon patient record review, 2 of 6 (Patient #1, 2) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1 SN frequency was 2w13 starting 10/26/21. Only 1 visit was documented week of 10/26/21. Patient #2 SN frequency was 2xwk beginning week of 11/1/21. Only 1 visit documented week of 11/1, 11/8/21 and 11/23/21.

Upon patient record review, 1 of 6 (Patient #2) did not have evidence that Social work services are based on the patient's psychosocial assessment and the patient/family's needs and acceptance of these services. Patient #2 Initial Comprehensive Assessment dated 10/26/21, Pt/CG expressed desire for DNR. No follow up documentation in subsequent visits.

Upon patient record review 2 of 6 (Patient #1, 2) did not have evidence documentation in the patient record that a hospice aide provides services that are ordered by the interdisciplinary group and included in the plan of care Patient #1 The aide had orders for a frequency of 2 wk13 beginning week of 10/26. Only 1 visit was documented week of 10/26/21. Patient #2 The aide had a frequency of 2xwk beginning 11/1/21. Aide visit was documented on 10/27/21 with no evidence of an order. Week of 11/23/21 only one visit was documented. HA tasks assigned but not documented as performed on 11/01/21 and 11/03/21 included check pressure areas, hair care, pericare, foot care, clean/file nails, assist with dressing. Shampoo assigned 1xwk and was not documented on either of these visits that occurred in the same week.

Upon personnel record review, 1 of 12 (Personnel #8) did not have evidence that a skills competency assessment, specific to each discipline had been conducted for all personnel including volunteers initially during orientation. Personnel #8: The volunteer who is available to provide patient visits does not have a competency assessment on file. At this point, no patients have accepted patient volunteer visits.

Upon patient record review, 1 of 6 (Patient #1) 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 #1 RN Visit Note 11/12/21 was blank. Time in documented. Patient signature in place, but note was blank.

Upon personnel record review, 2 of 12 (Personnel #11. #12 ) did not have evidence that personnel credentialing activities are conducted to verify qualifications of all credentialed/licensed personnel in the positions they hold at the time of hire, at renewal or in accordance with specific state practice act requirements. Personnel #11, #12 personnel files for OT and ST were not available from contractor before end of survey, to verify background check. No OT/ST patient visits have been required/provided thus far.

Upon personnel record review, 1 of 1 applicable (Personnel #12) 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 #12 personnel file for ST was not available from contractor before end of survey, to verify background check. No ST patient visits have been required/provided thus far.

Upon personnel record review, 1 of 1 applicable (Personnel #11) did not have evidence all Occupational Therapy Services are provided by a qualified licensed Occupational Therapist (OT) in accordance with the state's Occupational Therapy Practice Act and the hospice's policies and procedures and/or job descriptions. Personnel #11 personnel file for OT was not available from contractor before end of survey, to verify credentials. No OT patient visits have been required/provided thus far.

Upon personnel record review, 2 of 4 applicable (Personnel #11, 12) 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 #11, #12 personnel files for OT and ST were not available from contractor before end of survey, to verify background check. No OT/ST patient visits have been required/provided thus far.