Every finding on record at Oldham Hospice Services LLC

Upon patient record review, 1 of 14 (Patient #4) 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 #4: During the home visit it was noted Donepezil on the hospice medication list, was not available in the home.

Upon patient record review, 1 of 14 (Patient #3) did not have evidence that each patient record contains Physician certification and recertification of terminal illness. Patient #3: The NP signed the initial certification of terminal illness instead of the physician.

Upon observation, there was no evidence the Emergency Plan communication plan must includes a primary and alternate means for communicating with hospice's employees and Federal, state, tribal, regional, and local emergency management agencies. Corrected on site.

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

Upon patient record review 2 of 11 (Patient #4,#6) 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 #4: SOC date 8/23/2024, psychosocial assessment occurred 8/29/2024, which is day 6. Patient #6: SOC date 7/19/2024, psychosocial assessment occurred 7/25/2024, which is day 6.

Upon patient record review 7 of 11 (Patient #2,#3,#4,#7,#8,#9,#11) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient #2: No evidence of spiritual assessment. Patient #3: No evidence of spiritual assessment. Patient #4: No evidence of spiritual or psychosocial assessment. Patient #7: No evidence of spiritual assessment. Patient #8: No evidence of spiritual or psychosocial assessment. Patient #9: No evidence of psychosocial assessment. Patient #11: No evidence of psychosocial assessment.

Upon patient record review, 5 of 11 (Patient #1,#4,#6,#7,#10) 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: Medication profile dated 6/19/2024 included O2 6-10 L via simple mask continuous, no evidence of parameters for dosing. Nitroglycerine 0.4mg SL 1 Q 5 minutes PRN Chest pain, no evidence of parameters/limits to dosing. Corrected on site. Patient #4: Medication profile dated 8/23/2024 included O2 2L via NC PRN, no evidence of and indication for O2. Corrected on site. Patient #6: O2 on DME list and noted in SN SOC nursing notes. On narrative 9/5/2024 documented "on oxygen". No evidence on medication profile for O2. Patient #7: Medication profile dated 8/21/2024 included O2 6-10L via simple mask, 4-6 L continuous for SOB. No evidence of a clear order or parameters for dosing. Patient #10: Medication profile dated 8/2/2024 included Nitroglycerine 0.4mg SL 1 Q 5 minutes PRN as needed, no evidence of parameters/limits or indication to dosing.

Upon patient record review, 1 of 11 (Patient #4) 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 #4: No evidence of a bereavement assessment.

Upon patient record review, 8 of 11 (Patient #1,#2,#3,#4,#5,#6,#9,#11) 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: Identified as diabetic with frequent BS checks by caregivers, no evidence on POC for DM. Pt found on SOC to have no funeral home planning or DNR, then on SW assessment "arrangements made" No evidence of arrangements and no evidence on POC for funeral planning/DNR. Corrected on site. Patient #2: Patient on Xarelto blood thinner, no evidence on POC of at risk for bleeding. Corrected on site. Patient #3: Patient on Eloquis blood thinner, no evidence on POC of at risk for bleeding. Corrected on site. Patient #4: Patient scores 14 (moderate risk) on Norton scale for risk of skin breakdown, no evidence on POC for problems/goals/interventions for integumentary. Corrected on site. Patient #5: Admitted with brain mass frontal lobe and no funeral home arrangements, no evidence on POC of problem/goals/interventions for neuro or funeral home planning. Corrected on site. Patient #6: Patient on Apixaban blood thinner, no evidence on POC of at risk for bleeding. Patient #9: SN identified as high fall risk on SOC, no evidence on POC for problem/goals/interventions for safety/falls. Patient #11: SN on SOC identified pain level at "8" on scale 1-10 "severe", no evidence on POC for problem/goals/interventions pain.

Upon patient record review, 5 of 11 (Patient #1,#4,#6,#7,#10) 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 dated 6/19/2024 included O2 6-10 L via simple mask continuous, no evidence of parameters for dosing. Nitroglycerin 0.4mg SL 1 Q 5 minutes PRN Chest pain, no evidence of parameters/limits to dosing. Corrected on site. Patient #4: Order dated 8/23/2024 included O2 2L via NC PRN, no evidence of an indication for O2. Corrected on site. Patient #6: O2 on DME list and noted in SN SOC nursing notes. On narrative 9/5/2024 documented "on oxygen". No evidence of an order for O2. Patient #7: Order dated 8/21/2024 included O2 6-10L via simple mask, 4-6 L continuous for SOB. No evidence of a clear order or parameters for dosing. Patient #10: Order dated 8/2/2024 included Nitroglycerin 0.4mg SL 1 Q 5 minutes PRN as needed, no evidence of parameters/limits or indication to dosing.

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. Patients #1,#2: RN entered clean bag several times during patient care without cleansing hands.

Upon patient record review, 1 of 11 (Patient #9) 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 #9: Pt on oxygen, no evidence on aide POC/assignment of patient on oxygen precautions.

Upon observation, there was no evidence the hospice is directed by a Board of Directors/governing body which assumes full legal authority and responsibility for the operation of the hospice. No evidence in meeting minutes provided of an appointed Administrator. He is listed as a member of the committee but not formally appointed in any minutes.

Upon personnel record review, 1 of 9 (Personnel #6) 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 #6: No evidence of a skills assessment initially during orientation.

Upon patient client record review, 1 of 11 (Patient #5) 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 #5: On consents/EOB area for attending is blank.

Upon client record review, 11 of 11 (Patient #1,#2,#3,#4,#5,#6,#7,#8,#9,#10,#11) did not have evidence that the written policies and procedures for managing controlled drugs was provided and discussed. Patients #1,#2,#3,#4,#5,#6,#7,#8,#9,#10,#11: No evidence that written policies and procedures for managing controlled drugs was provided and discussed.

Upon observation, there was no evidence of a contract for short term inpatient care for pain control and symptom management with a Medicare certified hospice, if applicable. Contract was obtained on 9/11/2024. Corrected on site.