Every finding on record at Oak Hospice and Palliative Care, Inc.

Upon patient record review, 1 of 14 (Patient #3) 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 #3: Patient has needs for anxiety and support of daughter with care of the patient. There were no interventions or goals listed for psychosocial or spiritual care.

Upon patient record review, 4 of 14 (Patients #2, 3, 4, 8) 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 #2: The initial assessment stated patient was to have DME ordered including a walker, shower chair, commode, and manual blood pressure cuff. The walker was not included on the plan of care for DME. Patient #3: The initial nursing assessment and plan of care listed DME that included a hospital bed, side rails, over bed table, Nebulizer, Oxygen, and E tanks. Upon home visit, the patient does not have oxygen or e tanks. The patient does have full side rails with padding and a low air loss mattress which is not included on the plan of care. Supplies also not included on the plan of care were foley supplies. Patient #4: The initial assessment stated patient was to have DME that included a cane, a walker, a nebulizer, and an oxygen concentrator with back ups. There is no DME listed on the plan of care. Patient #8: The patient has a walker which is not included in the DME on the Plan of care.

Upon patient record review, 1 of 14 (Patient #3) 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 #3: On 01/27/25, there was a call that is documented in the communication notes stating daughter called and patient had signs and symptoms of a UTI and Bactrim was ordered. The infection was not added to the plan of care.

Upon patient record review, 2 of 14 (Patients #2, 3) 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 #2: The aide plan of care is blank and therefore has no tasks ordered by the nurse. Patient #3: The aide plan of care states to apply lotion each visit. It does not specify where the lotion is to be applied. The aide plan of care has oxygen checked on the plan of care, however, the patient does not have oxygen in the home.

Upon patient record review 1 of 14 (Patient #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 #2: There is an aide plan of care in the record which is blank. However, the aide has been seeing the patient without a plan of care and documenting on each visit, "assisted with bathing and dressing".

Upon patient record review, 2 of 14 (Patients #2, 9) did not have evidence in the patient record that the interdisciplinary group, as part of the review of the plan of care, determines the ability of the patient and/or family to safely self-administer drugs and biologicals to the patient in his or her home. If the patient and/or family are not capable of safely administering drugs and biologicals in the home, the hospice must address this issue in the patient's plan of care. Patient #2: The RN assessed the caregiver for the ability to safely administer medications, however, left the patient assessment for the ability to administer medications blank. Patient #9: The RN assessed the caregiver for the ability to safely administer medications, however, left the patient assessment for the ability to administer medications blank.