Every finding on record at Omni Care Hospice

Upon observation, there was no evidence of a written contract/agreement, with other Facilities/Agencies/Hospices, to receive Omni Hospice's patients in the event that Omni Hospice cannot provide care to their patients during an emergency.

Upon patient record review, 1 of 11 (Patient #2) did not have evidence of a bereavement risk assessment completed as part of the comprehensive assessment which must be completed within 5 days of election of the hospice benefit. The SOC was 07/20/2021. The Bereavement Risk Assessment was conducted on 07/27/2021.

Upon patient record review, 3 of 11 (Patients #1, 2, 5) did not contain evidence that the Plan of Care included all services necessary for the palliation and management of the terminal illness and related conditions, specifically: A detailed statement of both the scope and frequency of the services necessary to meet the specific patient and family needs: Patient #1: The most current IDG POC order, dated 03/08/22 assigned the SW visit frequency as, "2 p.r.n. for Psychosocial care", without a baseline visit frequency. Patient #2: The most current IDG POC order, dated 03/08/22 assigned the SW visit frequency as, "2 p.r.n. for Psychosocial care", without a baseline visit frequency. Patient #5: The most current IDG POC order, dated 03/08/22 assigned the Chaplain visit frequency as, "2 p.r.n. visits", without a baseline visit frequency.

Upon patient record review, 1 of 11 (Patient #1) did not contain evidence that the Plan of Care included all services necessary for the palliation and management of the terminal illness and related conditions, specifically orders for medications and treatments. An order was obtained on 01/03/2022 for, "SN to insert a Foley Catheter 16 F, 10-15 cc balloon. Change Q month and p.r.n.", without an indication for such p.r.n. change.

Upon patient record review, 1 of 11 (Patient #5) did not contain evidence that the IDG had ensured that care and services were provided in accordance with the Plan of Care. Two separate Physician orders were obtained on 12/15/21, including the wound procedure details, for twice a week wound care, to the coccyx pressure area, facial wound, and the back skin tear. The week of December 12-16, 2021, the back skin tear wound care was provided once this week, no evidence that wound care was provided a second time this week. The week of December 19-25, 2021, facial wound care provided once this week, there was no evidence of the facial wound care having been provided a second time.

Upon observation, there was not evidence that the Hospice had provided each newly admitted patient/caregiver with education related to Infection Control/Prevention, as appropriate to the care/services provided.

Upon personnel record review, 1 of 1 applicable (Personnel #9) did not contain evidence that an Aide Skills Competency Assessment had been conducted, at the time of hire, as per CMS guidance. The Competency Evaluation must address each of the subjects listed in 42 CFR418.76 (b)(3). Subject areas specified under 42 CFR 418.76(b)(3)(i), (iii), (ix), (x), and (xi) must be evaluated by observing an Aide's performance of the task with patient or pseudo-patient. The remaining subject areas may be evaluated through written examination, oral examination, or after observation of a Hospice Aide with a patient or with a pseudo-patient as part of a simulation. The RN made 3 separate home visits with this Aide on 07/31/2021, prior to her providing care/services independently. The tool utilized by the Agency to document such Aide Skills competence, had been completed by the RN through her writing "Question and Answer" as the method of evaluation for all of the tasks performed.

Upon patient record review, 1 of 1 applicable (Patient #8) did not contain evidence that the Discharge Summary included all CMS-required content, as follows: • A summary of the patient's stay, including treatments, symptoms and pain management • The patient's current plan of care • The patient's latest physician orders

Upon patient record review, 1 of 11 (Patient #3) did not contain evidence that the Interdisciplinary Group, as part of the review of the Plan of Care, had determined the ability of the patient and/or family to safely self-administer drugs and biologicals to the patient in his/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.