Every finding on record at Oakwood Acquisitions, LLC

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 bedside commode and bedside table. These items were not included on the Plan of Care. Corrected on site.

Upon patient client record review, 2 of 14 (Patients #4,13) did not have evidence that each patient record contains: • Signed election statement in accordance with 418.24 Patients #4 and 13: The election statement form did not have start of care filled in space provided on the form. Corrected on site per Policy and procedures for missing information.

Upon patient client record review, 7 of 14 (Patients #2.3.4.6.8.10 and 11) 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. Patients #2.3.4.6.8.10 and 11: The patients informed consent form the hospice employee signed did not include MSW credential.

Condition of Participation: Initial and Comprehensive Assessment of the Patient.

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: SOC 3/17/2023, No SC assessment completed until 4/13/2023.

Upon patient record review, 4 of 14 (Patient #3, #4, #9, #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 #3: The medication profile dated 6/5/2023 included Miralax oral powder for reconstitution, admin 17GM orally Q 72 hrs. prn constipation. There was no evidence of a diluent. Aspercreame with 4% Lidocaine, apply one patch topical daily for pain. There was no evidence of an area in which to apply. Corrected on site. Patient #4: The medication profile dated 5/23/2023 included Miralax oral powder for reconstitution, admin 17GM orally Q 72 hrs. prn constipation. There was no evidence of a diluent. Corrected on site. Patient #9: The medication profile had two conflicting active O2 orders; 5/22/2023 O2 2LPM via NC PRN SOB, and 7/21/2023 O2 1-4 LPM via NC PRN SOB or O2 sat <90%. Corrected on site. Patient #11: The medication profile dated 7/6/2023 included Miralax oral powder for reconstitution, admin 17GM orally Q 72 hrs. prn constipation. There was no evidence of a diluent.

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

Upon patient record review, 1 of 14 (Patient #6) 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 #6: Order dated 7/14/2023 at SOC, Monitor seizure activity. There is no evidence on the POC of monitoring or seizures precautions. Corrected on site.

Upon patient record review, 4 of 14 (Patient #3, #4, #9, #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 #3: There is an order dated 6/5/2023 included Miralax oral powder for reconstitution, admin 17GM orally Q 72 hrs. prn constipation. There was no evidence of a diluent. Dated 6/5/2023 included Aspercreame with 4% Lidocaine, apply one patch topical daily for pain. There was no evidence of an area in which to apply. Corrected on site. Patient #4: There is an order dated 5/23/2023 included Miralax oral powder for reconstitution, admin 17GM orally Q 72 hrs. prn constipation. There was no evidence of a diluent. Corrected on site. Patient #9. The physician orders had two conflicting active O2 orders; 5/22/2023 O2 2LPM via NC PRN SOB, and 7/21/2023 O2 1-4 LPM via NC PRN SOB or O2 sat <90%. Corrected on site. Patient #11: There is an order dated 7/6/2023 included Miralax oral powder for reconstitution, admin 17GM orally Q 72 hrs. prn constipation. There was no evidence of a diluent.

Upon client record review, 11 of 14 (Patient #1, #2, #3, #4, #6, #9, #10, #11, #12, #13, #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: NP made visit on 6/29/2023, there was no order for this visit. Patient #2: NP made visits on 6/22/2023, 7/16/2023, 7/17/2023, and 7/28/2023, there were no orders for these visits. Patient #3: NP made visit on 6/8/2023, there was no order for this visit. Patient #4: NP made visits on 6/30/2023, 7/6/2023, and 7/21/2023, there were no orders for these visits. Patient #6: NP made visit on 6/19/2023, there was no order for this visit. Patient #9: NP made visit on 7/6/2023, there was no order for this visit. SN visit frequency dated 7/21/2023 included RN 2x week x 12, with 5 PRN visits (excessive). MSW 1x1 month with 5 PRN visits (excessive). Patient #10: NP made visits on 7/20/2023 and 7/27/2023, there were no orders for these visits. Patient #11: NP made visits on 7/5/2023 and 7/6/2023, there were no orders for these visits. Patient #12: NP made visit on 7/20/2023, there was no order for this visit. Patient #13: NP made visit on 4/29/2023, there was no order for this visit. Patient #14: NP made visit on 4/8/2023, there was no order for this visit.

Upon observation, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient 1: RN entered room with stethoscope draped over neck, used on patient without cleansing prior to use. Patient 2: RN removed stethoscope from clean area in nursing bag and draped it around her neck prior to use with pt. RN cleansed stethoscope after use, and draped over her neck, left pt. residence. Patient 3: RN enters pt. room with stethoscope draped over neck, does not clean prior to use on pt, after use draped over neck.

Condition of Participation: Hospice Aide and Homemaker Services. L607

Upon personnel record review, 1 of 14 (Personnel #7) 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.) ·Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff. ·Reading and recording temperature, pulse, and respiration ·Safe transfer techniques and ambulation. ·Normal range of motion and positioning ·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 ·(D) Nail and skin care ·(E) Oral hygiene ·(F) Toileting and elimination The other subject areas in this section may be evaluated through written examination, oral examination or after observation of a Hospice Aide with a patient. Personnel #7; There was no evidence that a competency assessment was performed by the aide with a patient or pseudo-pt.

Upon patient record review, 8 of 14 (Patient #2, #3, #4, #5, #6, #7, #8, #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 #2: SOC SN assessment identified fall risk, Fall risk exists on POC, there was no evidence of a fall risk on the aide POC. Corrected on site. Patient #3: SOC SN assessment identified fall risk, Fall risk exists on POC, there was no evidence of a fall risk on the aide POC. Corrected on site. Patient #4: SOC SN assessment identified fall risk, Fall risk exists on POC, there was no evidence of a fall risk on the aide POC. Pt on Eloquis, no evidence of bleeding precautions on the aide POC. Corrected on site. Patient #5: SOC SN assessment identified fall risk, Fall risk exists on POC, there was no evidence of a fall risk on the aide POC. Corrected on site. Patient #6: SOC SN assessment identified fall risk, Fall risk exists on POC, there was no evidence of a fall risk on the aide POC. History of intracranial bleed from fall, no seizure precautions on aide POC. Corrected on site. Patient #7: SOC SN assessment identified fall risk, Fall risk exists on POC, there was no evidence of a fall risk on the aide POC. Corrected on site. Patient #8: SOC SN assessment identified fall risk, Fall risk exists on POC, there was no evidence of a fall risk on the aide POC. Corrected on site. Patient #11: SOC SN assessment identified fall risk, Fall risk exists on POC, there was no evidence of a fall risk on the aide POC.

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: Pt SOC 6/15/2023, HHA visits ordered 1x week. No evidence of aide visits or missed visit week of 6/25/2023.

Upon patient record review 1 of 14 (Patient #2) 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 #2: There was no evidence of on site visits every 14 days to assess quality of care and services provided, none evident since 6/21/2023, todays date 8/8/23.

Upon personnel record review, 1 of 13 (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.

Upon patient record review, 1 of 14 (Patient #3) did not have evidence that the hospice provided the following information to the SNF: • Physician certification and recertification of the terminal illness specific to each patient • Names and contact information for hospice personnel involved in hospice care of each patient Patient #3: There was no evidence of physician certification or list of names and contact information for hospice personnel.