Every finding on record at New Haven Hospice Care, Inc

Upon patient record review, 2 of 5 (Patient #1 & 3) 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: Multiple medications for pain (Tylenol, Morphine Sulfate concentrate, and Norco) listed on medication record without clear directions on which medication to use for specific pain level. No evidence of pain rating or severity that would indicate medication use, stating only "pain". Patient 3: Multiple medications for pain (Tylenol and Norco) listed on medication record without clear directions on which medication to use for specific pain level. No evidence of pain rating or severity that would indicate medication use, stating only "pain".

Upon patient record review, 2 of 5 (Patient #1 & 3) 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: Multiple medications for pain (Tylenol, Morphine Sulfate concentrate, and Norco) listed on medication record without clear directions on which medication to use for specific pain level. No evidence of pain rating or severity that would indicate medication use, stating only "pain". Patient 3: Multiple medications for pain (Tylenol and Norco) listed on medication record without clear directions on which medication to use for specific pain level. No evidence of pain rating or severity that would indicate medication use, stating only "pain".

Upon patient record review 1 of 14 (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, Patient admitted on 8/27/23, MSW initial visit 9/11/23.

Upon patient record review, 5 of 14 (Patient #3,5,6,9,13) 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 #3,5,6,9,13, oxygen 2l/NC as needed, noted on treatment sheet, no evidence of oxygen on medication profile sheet.

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

Upon patient record review, 1 of 14 (Patient #9) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient #9, On call note documented on 7/4/23 at 1600, patient is having a spell with chest pain, documented nurse to make visit. Visit was completed on 7/5/23 at 1000 when oxygen was ordered.

Upon patient record review, 1 of 14 (Patient #1) 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, The care plans did not have evidence of goals or interventions related to terminal illness and related conditions.

Upon patient record review, 11 of 14 (Patient #1,2,3,5,6,8,9,10,11,13,14) 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 #1, SN frequency 2x/week with 10 PRN. Patient #2, SN frequency 2x/week with 5 PRN. MSW frequency 1x/week with 5 PRN. Patient #3, SN frequency 2x/week with 10 PRN. Patient #5, SN frequency 2x/week with 10 PRN. Patient #6, SN frequency 2x/week with 10 PRN. Recertification frequency SN 2x/week and 5 PRN, MSW 1x/week and 5 PRN. Patient #8, SN frequency 2x/week with 5 PRN. MSW 1x/week and 5 PRN. Patient #9, SN frequency 4/6/23 1x/week, 4/9/23 2x/week, 6/28/23 10 PRN, 9/20/23 10 PRN, 11/29/23 10 PRN. MSW 8/18/23 1w4, 6/28/23 10 PRN, 9/28/23 3 PRN. SC 6/28/23 10 PRN, 8/12/23 1w2, 8/13/23 1w4. Patient #10, SN frequency 2x/week, 3 PRN, 11/13/23 10 PRN. Patient #11, SN frequency 2w1, 10 PRN. Patient #13, SN frequency 2x//week 15 PRN. Volunteer 16 PRN visits. Patient #14, SN frequency 2x/week 14 PRN.

Upon patient record review, 1 of 14 (Patient #14) 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 #14, SN notes states patient is using oxygen. Oxygen concentrator listed under DME. No evidence of oxygen order.

Upon patient record review, 1 of 14 (Patient #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 equipment and supply needs. Patient #10, No evidence of DME listed on POC, initial assessment note on 8/27/23 states patient uses wheelchair.

Upon client record review, 6 of 14 (Patient #1,2,3,7,9,14) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1, Volunteer 1x/week, no visits made. Patient #2, SN frequency 2x/week, 3 visits made the first week. Volunteer frequency 1x/week, no evidence of visits made. Patient #3, SC frequency 1xweek, missed first 2 weeks. Volunteer 1x/week, missed first week and 2 visits missed between 12/19/23 and 1/19/24. Patient #7, SN frequency 2x/week, missed 1 visit first week then seen 3x/week the next 2 weeks. Patient #9, SN frequency 4/6/23 1x/week, 4/9/23 2x/week, 4/16/23 1x/week, 6/28/23 2x/week, Visits completed on 4/6/23, 4/10/23, 4/13/23, 4/17/23, 4/26/23, 5/3/23, 5/8/23, 5/10/23. Patient #14, SN frequency 4/14/23 2x/week, 4/25/23 7x/week

Upon patient record review, 1 of 14 (Patient #1) 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, Aide care plan states shave face as needed, weekly.

Upon patient record review 2 of 14 (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 • 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, Aide care plan states shave face as needed, weekly. Visits completed 1/31/24, 2/2/24, 2/6/24 with shave face completed. Patient #2, Aide care plan does not state to provide back rub. Back rub provided 1/30/24, 2/2/24, 2/6/24.

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 annual report reviewed for volunteer savings, however no evidence of noted 1.39% which is less than the required 5% of the total patient care hours of all paid hospice employees and contract personnel.

Upon personnel record review, 1 of 12 (Personnel #1) did not have evidence that the administrator is a hospice employee and possesses the education and experience required by the governing body. Personnel #1, Job Description qualifications, A healthcare professional with a minimum of two years of health-related experience, knowledge and the ability to effectively administer the Hospice Service which shall include at least one year of supervisory/administrative experience.

Upon personnel record review, 3 of 12 (Personnel #4,5,9) 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 #4,5,9, Administrator completed evaluations and not the DPS.

Upon personnel record review, 6 of 12 (Personnel #10, 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.