Every finding on record at Noble Care Services LLC

Upon patient record review, 1 of 19 (Patient #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 3# During home visit found to be taking Potassium 20mEq two tablets daily. Hospice medication profile stated taking one tablet daily. This was Corrected on Site.

Upon patient record review, 1 of 19 (Patient #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 3# During home visit found to be taking Potassium 20mEq two tablets daily. Hospice plan of care stated taking one tablet daily. This was Corrected on Site.

Upon personnel record review, 1 of 17 (Personnel # 5) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) ·Appropriate and safe techniques in personal hygiene and grooming that include-- ·(A) Bed bath ·(B) Sponge, tub, and shower bath ·(C) Shampoo, sink, tub, and bed Personnel #5 competency included Bath and Shampoo, however; did not include each individual technique.

Upon patient record review 2 of 13 (Patient #3,#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 3: Admitted on 10/13/2022, no psychosocial assessment completed within the first 5 days. Completed on 10/19/22. Patient 10: Admitted on 08/31/22, no psychosocial assessment completed within the first 5 days. Completed on 09/07/22.

Upon patient record review, 4 of 13 (Patient #1,#3,#5,#7) 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: 10/6/22 Bisacodyl 10mg 1 supp rectally one time a day as needed for constipation. 10/6/22 Milk of Magnesium 30 ml via PEG tube daily as needed for constipation. No instructions on which medication is to given first for constipation listed on med profile. 10/6/22 Glycolax 17gm/scoop, give 17 grams mixed in liquid 1 time a day per PEG for bowel care. No evidence of diluent or amount of diluent listed on med profile. All 3 corrected on site. Patient 3: Order written on 10/13/22 for Docusate sodium 100mg one time a day as needed for constipation. Order written on 11/11/22 for Milk of Magnesium 30 ml orally daily as needed for constipation. No evidence on med profile of instructions on which medication to given first for constipation. On 2LNC of oxygen, continuously, at time of admit. No evidence on med profile for oxygen. All corrected on site. Patient 5: Ensure 1ml by mouth 4 times a day and once as requested. Incorrect on med profile. Tums 2 chewable tabs orally 2 times a day for 7 days then PRN. No clear instructions for when to give the Tums PRN. All corrected on site. Patient 7: On 3LNC of oxygen, continuously, at time of admit. DME order states "oxygen 2-5LPM as needed to keep O2 sat >90%", Oxygen not on med profile. Miralax 1pack orally one time a day. No evidence of instructions on how to dilute. All corrected on site.

Upon patient record review, 3 of 13 (Patient #2,#3,#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 2: Admitting dx of Parkinson's Disease. Listed in multiple places in the chart that patient had uncontrolled body tremors. No evidence of neuro goals and interventions listed on the POC. Corrected on site. Patient 3: On oxygen 2LNC at the time of admit. No evidence of oxygen precautions/goals and interventions listed on the POC. Corrected on site. Patient 8: Admitted with subdural hemorrhage with secondary of unspecified convulsions. Personal history of seizures and on Keppra daily for seizures. No evidence of neuro goals and interventions listed on POC. Corrected on site.

Upon patient record review, 3 of 13 (Patient #1,#3,#7) 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: Order written on 10/6/22 has Bisacodyl 10mg 1 supp rectally one time a day as needed for constipation. Order written on 10/6/22 Milk of Magnesium 30 ml via PEG tube daily as needed for constipation. No evidence of instructions on which medication to given first for constipation listed on order. 10/6 Glycolax 17gm/scoop, give 17 grams mixed in liquid 1 time a day per PEG for bowel care. No evidence of diluent or amount of diluent listed on order. Corrected on site. Patient 3: Order written on 10/13/22 for Docusate sodium 100mg one time a day as needed for constipation. Order written on 11/11/22 for Milk of Magnesium 30 ml orally daily as needed for constipation. No evidence on order for which medication to given first for constipation. On 2LNC of oxygen, continuously at time of admit, no evidence of order on the chart. Corrected on site. Patient 7: On 3LNC of oxygen, continuously, at time of admit. DME order on paper states "oxygen 2-5LPM as needed to keep O2 sat >90%", no evidence of MD order for oxygen in the EMR. Miralax 1pack orally one time a day. No evidence of instructions on how to dilute on order. Corrected on site.

Upon client record review, 1 of 13 (Patient #10) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 10: Has missed RN visit on 09/05/2022 for "Holiday scheduling" with no evidence that CG/patient refused or an order to decrease the visit frequency for this week.

Upon patient record review, 10 of 13 (Patient #1,#2,#3,#4,#5,#6,#8,#9,#10,#11) 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,#2,#3,#4,#5,#6,#8,#10,#11: The Aide plan of care called for the Aide to take temperature M, T, W, Th, F. There were no parameters listed for when to notify the nurse of abnormal temp. Patient #2: The Aide care plan calls for the Aide to get patient dressed per patient choice. The Aide care plan calls for the Aide to get patient up to the bathroom per patient choice. Patient #6, #8: The Aide care plan calls for the Aide to get patient dressed as needed on M,T,W,Th,F. The Aide care plan calls for the Aide to get patient up to the chair as tolerated on M,T,W,Th,F. Patient #9: The Aide plan of care called for the Aide to take temperature M,W,F. There were no parameters/range listed for when to notify the nurse of abnormal temp. The aide care plan calls for the Aide to get patient dressed as needed on M,W,F. The Aide care plan calls for the Aide to get patient up to the bathroom as needed on M,W,F. Patient #10: The Aide care plan calls for the Aide to get patient dressed as needed on M,T,W,Th,F. The Aide care plan calls for the Aide to give patient a complete bed bath on M,W,F and a shower on M,Th. Patient #11: The Aide care plan calls for the Aide to get patient dressed as needed on M,T,W,Th,F. The Aide care plan calls for the aid to get patient up to the bathroom as needed on M,T,W,Th,F. The Aide care plan calls for the Aide to give the patient a shower or a full bath on M,W,F.

Upon patient record review 9 of 13 (Patient #1,#2,#3,#4,#5,#6,#8,#9,#10) 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 Patient 1,2,3,4,5,6,8: Has missed Aide visit on 11/24/2022 for "Holiday scheduling" with no evidence that CG/patient refused the visit or an order to decrease visit frequency for this week. Patient 9: Patient admitted on 11/2/22, no Aide listed on initial POC. Order written on 11/08/22 to start Aide x2 with an effective date of 11/07/22. Aide visit documented for 11/04/22. No evidence of an order written for the aide to start on 11/04/2022. Missed Aide visit on 11/25/2022. No documentation as to why the visit was missed. Patient 10: Has missed Aide visit on 09/05/2022 for "Holiday scheduling", missed Aide visit on 10/06/22 "Due to staffing", missed Aide visit on 10/31/22 "Due to scheduling", and missed Aide visit on 11/24/22 for "Holiday scheduling". No evidence that CG/patient refused the visit or an order to decrease visit frequency for these visits (weeks).

Upon contract review, 1 of 5 contracts (Alt MD) did not have evidence of a contract to fulfill the role of alternate medical director. There was not evidence that the contract specifically identified an alternate medical director. Contracts for both positions indicated Medical Director. Corrected on site.

Upon patient client record review, 1 of 13 (Patient #5) 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 5: On Notice of non-coverage form, losartan 100mg daily and fluoxetine 10mg daily, improperly crossed off medication list. Just a line through both medications, no initials following.