Every finding on record at One Legacy Hospice & Palliative Care, Inc.

Observed in Record Review. In 2 of 14 patient records reviewed, Also noted in RRNHV#4 the hospice did not obtain the signature from the legally authorized representative for the admission consent, election of benefit and advanced directive documentation was signed by the patient. The patient was admitted to hospice for Cerebral atherosclerosis and senile degeneration of the brain with a FASTof 7A. The social worker comprehensive assessment noted the facility administrator was the legal guardian. Reviewed and confirmed with the CEO. Observed in Record Review. The hospice did not seek out the authorized representative when obtaining it's written consent for hospice, the election of benefit and advanced directives. This was noted during record review for HV#3. The patient is on hospice for Post Cerebral Infarction and ES Alzheimer's Disease with a FAST at 7F. The organization policy for Informed Consent/Refusal of Treatment No. 1-002.1 was not followed. Reviewed with the CEO.

Observed in Record Review. The hospice did not provide a timely initial social worker comprehensive assessment within the required timeframe. The surveyor noted during record review NHV#6 the initial social worker assessment was over three weeks delayed without documentation to support. Reviewed with CEO.

Observed in Record Review. In 2 of 14 patient records reviewed, The surveyor noted two PRN medication orders for Acetaminophen one for 500 mg 1 tab PRN and another for 600 mg 1 tab PRN without specific indications for use. Reviewed with CEO. Observed in Patient Home. The organization did not have clear and accurate medication orders. This was noted during the medication review in one of three home visits (HV#3). The patient had active pain. Example two PRN orders for pain were active Acetaminophen 500 mg 1 tab 2 times per day PRN and Ibuprofen 600 mg 1 tab two times per day for pain and also noted to be given for increased temp per comfort level. The orders were not based on any specific indication. Reviewed with the CEO.

Observed in Leadership Session. The hospice has not provided core services directly by hospice employee's. The surveyor noted during leadership discussion that all core services are being provided by 1099 individual contractors. Reviewed and confirmed with the CEO. Draft

Observed in Record Review. The organization did not provide complete discharge information in 1of two discharged records reviewed. Upon live discharge for extended prognosis the surveyor noted in NHV#4 that the hospice did not provide the notice of non coverage as required. Reviewed and confirmed with the CEO.

Observed in Record Review. In 2 of 6 patient records reviewed, During RR#3 it was noted the patient revoked hospice to seek acute care. There is lack of a signed revocation form in the patient medical record. During RR#2 it was noted the choice of physician by name on the consent/EOB forms was blank.

Observed in Record Review. In 5 of 6 patient records reviewed, During HV#1 record review it was noted the RN documented in the middle of October 2022 that the PCG stated the patient was skipping doses of Donepezil and was more agitated. This information was not documented at the IDG meeting 3 days later. During RR#1 it was noted there was no update to the POC that the patient refused further chaplain visits after the middle of February 2022 per the Chaplain documentation. The spiritual portion of the POC is blank. During HV#2 record review it was noted lack of documentation update by the chaplain during the first IDG meeting in October 2022 that the patient refused further visits after the initial evaluation the end of September. During RR#3 it was noted the chaplain completed an initial phone visit and the patient refused further chaplain visits. There is lack of notification from the chaplain at the first IDG after the initial phone call that the patient refused further visits. During RR#3 it was noted the MSW documented at a visit the end of August 2022 that the patient seemed comfortable but depressed. She mentioned that they may have to move due to structural damage to the apartment and that it is hard for her to find and go to a new location. The IDG meeting 6 days later lacked an update from the MSW on the environmental and moving issue. During RR#4 it was noted the MSW documented during a visit the beginning of September 2022 PCG concerned about pt's condition. MSW suggested to contact OLH and report symptoms. The IDG meeting the next day lacked an update from the MSW on the PCG concerns about the pt's condition.

Observed in Record Review. In 1 of 6 patient records reviewed, During HV#2 record review it was noted the initial bereavement assessment form used to establish a bereavement risk score was blank. There is a notation at the bottom of the note by the MSW that stated daughter has lack of knowledge of bereavement services available.

Observed in Record Review. In 6 of 6 patient records reviewed, During HV#1 record review it was noted the goals established by the RN during the comprehensive assessment and on the POC were generic and not measurable. For example: Pt will maintain optimal mobility during care, caregiver will receive sufficient rest during patient's terminal illness, skin will be maintained at an optimal level, palliative care, address symptoms as they present themselves. During RR#2 it was noted the goals established by the RN during the comprehensive assessment and on the POC were generic and not measurable. For example: pt will have optimal mobility, pain at a comfortable level, optimum hygiene, agitation will be controlled although not assessed as a problem, pt. CG and family will achieve optimal grief reaction prior to pt's death. During RR#1 it was noted the goals established by the RN and on the POC were generic and not measurable. For example: pt will achieve optimal sleep/rest during care, pt will receive optimal level of pain and symptom relief on short term basis for GIP (pt. not on the GIP level of care). During HV#2 record review it was noted goals on the POC that were not measurable. For example: Terminal illness problem with goal: palliative care, address symptoms as they present themselves, neurological goal: intervene when symptoms present themselves. Psychosocial goal: pt will be comfortable. RR#3 it was noted that the goals were not measurable and generic with many goals that same as reviewed in other records. For example: terminal illness: goal: palliative care: address symptoms as they present, sensory status with goal: hearing and visual impairment, Neurological status with goal: address symptoms as they present. The goals remained the same since the initial POC established in February 2022 with the only change noted was each goal target date was advanced 14 days during each IDG meeting. During RR#4 it was noted the goals were generic and not measurable related to the patient's terminal prognosis and related conditions. For example: palliative care: address symptoms as they present, there will be no complications due to impaired sensation.

Observed in Record Review. In 3 of 6 patient records reviewed, During HV#1 record review it was noted the RN documented the presence of edema of lower extremities, right more than left without interventions and goals added to the POC the middle of August 2022. The end of August 2022 the RN documented the patient was started on Eliquis 5 mg, 1 tab twice a day without interventions and goals added to the POC for instruction on bleeding precautions. During HV#2 record review it was noted an order for Warfarin 2 mg daily without interventions and goals added to the POC for instruction on bleeding precautions. During RR#3 it was noted lack of instruction on oxygen use and safety in the POC. The patient was reported to be a smoker with an order for oxygen therapy at 2L/min PRN SOB.

Observed in Record Review. In 2 of 6 patient records reviewed, During RR#3 it was noted in the certification/recertification POC the MSW frequency of visits was 1x/month plus PRN for psychosocial issues. The order lacked the number of PRN visits ordered in 2 out of 3 certification periods. During RR#3 it was noted the Chaplain visits were refused by the patient after the initial phone call visit. The frequency of visits for the chaplain of 1x/certification remained on the POC through the first certification and 2 recertifications. During RR#4 it was noted the MSW frequency was 1x/certification and PRN for psychosocial issues. The order lacked the number of PRN visits to be provided.

Observed in Record Review. In 2 of 6 patient records reviewed, During HV#1 record review it was noted the RN documented in a clinical note that the patient stated she was going to try OTC Tylenol 500 mg for aches and pains and increased knee pain. Tylenol was not added to medication profile and the documentation also lacked notification to the physician. During review of RR#4 it was noted a supplemental physician medication order did not include the name of the medication. It was written as follows: give 37.5 mg in the AM for 7 days, monitor, increase the dose to 75mg a day if needed: split in 37.5 am and 37.5 pm.

Observed in Individual Tracer. In 1 of 2 home visits conducted, During HV#2 it was noted the aide did not follow the organization policy on equipment cleaning. Policy #4050 Equipment Cleaning stated vital sign equipment should be cleaned with a low level disinfectant after use and prior to placing the equipment back in the nursing bag for use on another patient. The aide disinfected the BP cuff and thermometer before use and placed the equipment back into the equipment carrying bag and then into her bag without disinfection.

Observed in Record Review. In 2 of 3 patient records reviewed, who received hospice aide services. During HV#2 record review and RR#4 it was noted the RN did not complete the assignment form for the hospice aide. The assignment form has a section for the RN to check as follows: level of activity, mental status, general condition, equipment the patient uses, problems identified and when to notify the nurse for conditions reportable. This portion of the form was blank.

Observed in Record Review. In 1 of 2 patient records reviewed, who had hospice aides services. During RR#2 it was noted the Hospice aide failed to notify the RN when vital signs were outside of ordered parameters. The end of September the aide documented the patient's pulse was 105. The instruction from the RN was to report a pulse reading over 100. The record lacked documentation that the RN was notified of the pulse rate over the parameter.