Every finding on record at Nu Care Hospice Inc

Upon patient record review, 1 of 5 (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: 12/24/24 order for bleeding precautions for an Aspirin prescription, but no related problems, goals, interventions listed. The activity problems, goals and interventions are inconsistent on the initial plan of care as the IDG Plan of Care includes musculoskeletal/safety includes interventions for use of DME/exercise with IDG notes referencing use of walker but there is a 12/24/24 activity order for non-ambulatory, bed to chair transfers. The Comprehensive assessment includes walker with moderate assist and KPS and PPS 50/50. The SN visit note on 12/31/24 mobility assessment of ambulatory status states stands with little support and walker with moderate assist, endurance of 10 steps before resting.

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 equipment and supply needs. Patient #1: 12/24/24 Initial Comprehensive Nursing assessment says walker moderate assist. The IDG notes reference use of walker. The initial hospice order is uploaded and includes DME for walker. The walker is not included on the POC.

Upon patient record review, 1 of 5 (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: Initial and ongoing visit frequencies RN every 14 days for comprehensive assessment of patient's condition and 1 prn/week for changes in condition. LVN 1 visit every 2 weeks and 1 prn for changes in condition. Both RN and LVN visited 1/2/25. LVN had visited prior week 12/26/24. No evidence either visit was PRN

Upon patient record review, 1 of 5 (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: Admission consent proposed disciplines and frequencies form includes hospice aide frequency of 1 visit/week, but there is documentation that the patient declined in the narrative.

Upon patient record review, 1 of 5 (Patient #1) did not have evidence that the hospice informed and provided written information to the patient concerning its policies on advance directives, including a description of applicable state law. Patient 1: There was no evidence the patient's responsible party received policies on advance directives.

Upon patient record review, 1 of 5 (Patient #1) did not have evidence that the hospice obtained the patient's or representative's signature confirming that they received a copy of the Patient's Rights and Responsibilities. Patient 1: There was no evidence the patient's responsible party received a copy of the Patient's Rights and Responsibilities.

Upon patient record review, 1 of 5 (Patient #1) did not have evidence that if a state court has not adjudged a patient incompetent, any legal representative designated by the patient in accordance with state law may exercise the patient's rights to the extent allowed by state law. Patient 1: The medical record contained nursing documentation upon admission assessing the patient as confused, disoriented, and a FAST score of 7E. The certification of terminal illness identified the patient's primary hospice diagnosis as Alzheimer's Disease. The election and consent forms were all signed by the patient.

Upon patient record review, 1 of 5 (Patient #1) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient 1: There was no evidence the patient's responsible party chose an attending physician.

Upon patient record review, 1 of 5 (Patient #1) did not have evidence of the appropriate documentation for release of confidential information. Patient 1: There was no evidence the patient's responsible party signed a release of confidential information.

Upon patient record review, 1 of 5 (Patient #1) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications. Patient 1: The medical record contained nursing documentation upon admission identifying patient use of oxygen. There was no evidence of oxygen included on the medication profile. The profile also contained lidocaine topical cream with no area defined for administration.

Upon patient record review, 3 of 5 (Patients #2,#3,#4) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual's attending physician, if any) • Changes that have taken place since the initial assessment • Information on the patient's progress toward desired outcomes • Reassessment of the patient's response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days Patient 2: There was no evidence of an RN comprehensive assessment since admission 10/30/24. Patient 3: There was no evidence of an RN comprehensive assessment since 10/22/24. An RN visit note entered for 11/9/24 contained no assessment or narrative and was not signed by the RN. Patient 4: There was no evidence of an RN comprehensive assessment since 10/8/24. An RN visit note entered for 11/8/24 contained no assessment or narrative and was not signed by the RN.

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

Upon patient record review, 3 of 5 (Patient #2,3,4) 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 2: There was no evidence of an RN comprehensive assessment since admission 10/30/24. Patient 3: There was no evidence of an RN comprehensive assessment since 10/22/24. An RN visit note entered for 11/9/24 contained no assessment or narrative and was not signed by the RN. Patient 4: There was no evidence of an RN comprehensive assessment since 10/8/24. An RN visit note entered for 11/8/24 contained no assessment or narrative and was not signed by the RN.

Upon patient record review, 2 of 5 (Patients #1,#2) 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 medical record contained nursing documentation upon admission identifying patient hospice diagnosis of Alzheimer's disease, and issues of high risk for skin impairment, high risk of falls, and dysphagia. There was no evidence of problems, goals, and interventions related to neurological dysfunction, risk for skin impairment, fall safety, and dysphagia. Patient 2: The medical record contained nursing documentation upon admission identifying patient issues with dysphagia, high risk for skin impairment, and seizures. There was no evidence of problems, goals, and interventions related to dysphagia, risk for skin impairment, and neurological dysfunction.

Upon patient record review, 4 of 5 (Patients #1,#2,#3,#4) 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. Patients 1,2,3,4: There was no evidence of orders for visit frequencies. The care plans created by the RN contained an outline of intended frequencies, however the care plans were not acknowledged or signed by the medical director and IDG members.

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 medical record contained nursing documentation identifying patient use of oxygen. There was no evidence of an order for oxygen dose, frequency, and delivery method. The record also contained an order for lidocaine topical cream with no area defined for administration.

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 equipment and supply needs. Patient 1: The medical record contained nursing documentation upon admission identifying patient use of an air mattress, hospital bed, walker, shower chair, commode, and oxygen equipment. There was no evidence of orders for the DME included in the plan of care.

Upon patient record review, 4 of 5 (Patients #1,#2,#3,#4) 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. Patients 1,2,3,4: There was no evidence of plan of care revisions in collaboration with the attending physician.

Upon patient record review, 4 of 5 (Patients #1,#2,#3,#4) 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. Patients 1,2,3,4: There was no evidence of comprehensive assessments to note patient progress towards outcome/goals.

Upon observation, there was no evidence the hospice is in compliance with accepted professional standards and principles for all core services which includes nursing services. Patient 2: Upon medical record review, there was no evidence of RN or LVN visits completed since admission. The record contained LVN forms in the chart 11/7/24 and 11/14/24 that did not contain any information on what was completed during the visit and the clinician did not sign the visits to acknowledge completion. Corrected on site with late data entry of visit by LVN and additional RN visit entered for 11/13/24 by administrator/RN. Patient 3: Upon medical record review there was no evidence of RN or LVN visits completed since admission. The record contained LVN forms in the chart 10/29/24, 11/5/24, and 11/12/24, and an RN supervision form 11/9/24 that did not contain any information on what was completed during the visit and the clinician did not sign the visits to acknowledge completion. Corrected on site with late data entry of visit by LVN and additional RN visit entered for 11/5/24 by administrator/RN. Patient 4: Upon medical record review there was no evidence of RN or LVN visits completed since admission. The record contained LVN forms in the chart 10/18/24, 10/25/24, and 11/1/24, and an RN forms 10/8/24 and 11/8/24 that did not contain any information on what was completed during the visit and the clinician did not sign the visits to acknowledge completion. Corrected on site with late data entry of visit by LVN and administrator/RN.

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 plan of care identified an aide frequency for three times weekly to start 10/24/24. There was no evidence of an aide visit completed until 10/28/24 and evidence of one visit each during the weeks of 11/3/24 and 11/14/24.

Upon patient record review, 1 of 5 (Patient #1) 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: The medical record contained nursing documentation upon admission assessing the patient as confused, disoriented, and a FAST score of 7E. The certification of terminal illness identified the patient's primary hospice diagnosis as Alzheimer's Disease. The election was signed by the patient and was a Medi-Cal election form that did not explain hospice services, explain the right to receive the Notification of Hospice Non-Covered Items, or the choice of an attending physician. There was no evidence the patient's responsible party received a notice of patient rights.

Upon patient record review, 2 of 5 (Patients #1,#3) 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: The medical record contained two revocation forms signed the day of admission 10/16/24 with effective dates of revocation 10/16/24 and 10/22/24. Patient 3: The initial certification of terminal illness contained a narrative identified as face to face narrative, identifying an assessment completed by a non-hospice physician. The patient admitted hospice in their first benefit and did not require a face to face visit.

Upon patient record review, 1 of 5 (Patient #1) did not have evidence that the written policies and procedures for managing controlled drugs was provided and discussed. Patient 1: There was no evidence the patient's responsible party received policies and procedures for managing controlled drugs.

Upon patient record review, 2 of 14 (Patients #1, 2) 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: During medication reconciliation at home visit, the following medications were at patients home but not included on hospice medication profile-Atorvastatin 80 mg, Allopurinol 100mg and Keppra 750 Mg. Patient #2: During medication reconciliation at home visit, the following medications were at patients home but not included on hospice medication profile- Melatonin 5mg and Fungi Spray (OTC).

Upon patient record review, 10 of 14 (Patients #1,4,5,6,7,8,9,11,12,14) 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 #1: The patient Start of Care was 10/1/24. There is no bereavement risk assessment completed to date. Patient #4: The patient Start of Care was 9/20/24. There is no bereavement risk assessment completed to date. Patient #5: The patient Start of Care was 7/18/24. There is no bereavement risk assessment completed to date. Patient #6: The patient Start of Care was 6/13/24. There is no bereavement risk assessment completed to date. Patient#7: The patient Start of Care was 5/20/24. There is no bereavement risk assessment completed to date. Patient #8: The patient Start of Care was 5/15/24. There is no bereavement risk assessment completed to date. Patient #9:The patient Start of Care was 5/5/24. There is no bereavement risk assessment completed to date. Patient #11: The patient Start of Care was 5/29/24. There is no bereavement risk assessment completed to date. Patient #12: The patient Start of Care was 4/20/24. There is no bereavement risk assessment completed to date. Patient #14: The patient Start of Care was 4/23/24. There is no bereavement risk assessment completed to date.

Upon patient record review, 2 of 14 (Patients #1,2) 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: During medication reconciliation at home visit, the following medications were at patients home but not included on hospice plan of care-Atorvastatin 80 mg, Allopurinol 100mg and Keppra 750 Mg. Patient #2: During medication reconciliation at home visit, the following medications were at patients home but not included on hospice plan of care-Melatonin 5mg and Fungi Spray (OTC).

Upon patient record review, 1 of 14 (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 equipment and supply needs. Patient 1: This patient had a bed trapeze and bedside table. These were not included on the Plan of Care.

Upon observation, there was no evidence the hospice is in compliance with accepted professional standards and principles for all core services which includes wound care services. Patient #13 had one visit with wound care company. The payment type listed was "self pay" by the patient. There was no evidence in patient record that the wound care needs were not related to terminal prognosis/condition.

Upon patient record review, 1 of 14 (Patient #14) did not have evidence the hospice offers bereavement counseling that includes: • Making bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. Bereavement counseling also extends to residents of a SNF/NF or ICF/IID when appropriate and identified in the bereavement plan of care • Ensuring that bereavement services reflect the needs of the bereaved • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery Patient #14: There is no evidence of Bereavement Plan of Care in patient file. Agency has been sending cards and letters.

Upon patient record review 1 of 14 (Patient #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 (POC) Patient #10: The POC listed Aide visit frequency 1 X per week. There were no visits performed by the Aide in the first benefit week.

Upon personnel record review, 1 of 12 (Personnel #12) 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 #12: Did not have initial skills competency in their employee file.

Upon patient record review, 9 of 14 (Patients # 4,5,7,8,9,10,11,13,14) did not have evidence that the medical director or physician designee provides written certification that it is anticipated that the patient's life expectancy is 6 months or less if the illness runs its normal course. The physician must consider the following when making this determination: • The primary terminal condition • Related diagnosis • Current subjective and objective medical findings • Current medication and treatment orders • Information about the medical management of any of the patient's conditions unrelated to the terminal illness Patients # 4,5,7,8,9,10,11,13,14: The CTI indicated primary diagnosis only and did not include secondary or co-morbidity diagnoses on form or in physician narrative.

Upon patient client record review, 14 of 14 (Patients #1,2,3,4,5,6,7,8,9,10,11,12,13,14) did not have evidence that each patient record contains: • Signed election statement in accordance with 418.24 Patients #1,2,3,4,5,6,7,8,9,10,11,12,13,14The Hospice Medicare Election statement does not provide BFCC-QIO contact information or Notice of Non Covered Items addendum information. Patient #1: The medical record (CTI) indicated attending physician of choice in abbreviated format with initials (DVS), not the medical director's full name.

Upon client record review, 2 of 14 (Patients #12, 13) did not have evidence that the discharge summary includes all required information. Patients #12, 13: Did not have evidence that current plan of care was included in discharge summary.