Every finding on record at Ogada Hospice Care Inc

Upon patient record review, 6 of 15 (Patient #8,9,10,11,12,13) 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 #8-There is no evidence that Oxygen 2 LPM via NC prn shortness of breath on the medication profile dated 10/22/24. #9-The medication profile dated 09/21/23 includes Lidocaine 5% ER film transdermal daily. There is no location included in the order. #10-There is no evidence that Oxygen 2 LPM via NC prn shortness of breath on the medication profile dated 08/01/24. #11-There is no evidence that Oxygen 2 LPM via NC prn shortness of breath on the medication profile dated 07/18/24. #12-There is no evidence that Oxygen 2 LPM via NC prn shortness of breath on the medication profile dated 07/13/23. #13-There is no evidence that Oxygen 2 LPM via NC prn shortness of breath on the medication profile dated 06/11/23.

Upon patient record review, 2 of 15 (Patient #12,13) 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. #12-There is no evidence that an initial bereavement assessment was completed as part of the comprehensive assessment. #13-There is no evidence that an initial bereavement assessment was completed as part of the comprehensive assessment.

Upon patient record review, 3 of 15 (Patient #8,9,13) 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. #8- The plan of care dated 10/22/24 lists Oxygen 2 LPM via NC prn shortness of breath on the medication profile. The order on the care plan states oxygen may be titrated to 3-5 LPM for moderate to severe shortness of breath or 6-10 LPM via non-rebreather mask. There are no instructions for how to titrate. #9-The plan of care dated 09/21/23 includes Lidocaine 5% ER film transdermal daily. There is no location included in the order. #13-The plan of care dated 06/11/23 lists an O2 humidifier prn shortness of breath. The oxygen equipment is listed, but not the oxygen as a medication.

Upon patient record review, 5 of 15 (Patient #9,10,11,13,14) 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 #9-There is no evidence that any bereavement services were offered to the bereaved after the bereavement assessment was completed on 10/23/23. #10-There is no evidence that any bereavement services were offered to the bereaved after the bereavement assessment was completed on 08/06/24. #11-There is no evidence that any bereavement services were offered to the bereaved after the patient's death on 08/02/24. There was no evidence of a bereavement plan of care or a post death bereavement assessment. #13-There is no evidence of a bereavement plan of care after the patient's death on 06/13/23. #14-There is no evidence of a bereavement plan of care after the patient's death on 05/27/24.

Upon patient record review, 4 of 5 (Patient #1, #2, #3, #5) 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, 5: There was no evidence of progress towards goals on the plan of care documented in IDG by the RN. The nursing assessments during the prior 14 days reflected the patient had changes in the assessment.

Upon client record review, 1 of 5 (Patient #2) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #2: spiritual care ordered 1 time per month and 1prn on the plan of care. No evidence of visits made by spiritual care.

Upon patient record review 1 of 2 applicable (Patient #4) 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 #4:The aide documented the completion of making the bed, the aide care plan did not include the task to make the bed. The aide documented ambulation with cane but the aide POC included ambulation with walker.

Upon personnel record review, 1 of 11 (Personnel #1) 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 #1: The initial competency on record was incomplete. The competency assessment did not include validation of skills such as vital signs, respiratory assessment, and cardiovascular assessment prior to performing care independently.

Upon patient client 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: The record indicated an order for a mechanical soft diet the nursing assessment on 5/3/22 documented patient was on a puree diet there was a discrepancy in the documentation confirmed by the RN. The nursing assessment on 4-26-22 contained Tylenol 500 mg PO every 4-6 hours 1 tablet, there was a discrepancy in the documentation confirmed by the RN the physicians order and medication profile list 500 mg PO every 4-6 hours 2 tablets. Problems, interventions, and goals for volunteer and spiritual are documented on the updates to the plan of care when services have been declined and no frequency ordered by the IDG.