Every finding on record at Partners Hospice Quality Care LLC

Upon patient record review, 3 of 14 (Patient #3,#4,#7) 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: During home visit it was noted that Melatonin 10mg tablet was present. Caregiver states patient is currently taking 1 by mouth as needed at bedtime for sleep. There is no evidence of this medication on the Medication profile. Corrected on site. Patient#4: The record indicates patient ordered Voltaren 1% apply 2g to affected area twice a day PRN. There is no evidence of a specified area of application on medication profile. Corrected on site. Patient#7: The record indicates patient ordered hydrocortisone 1% topical to be applied 2-3 times a day prn. There is no evidence of a specified area of application on medication profile. Corrected on site.

Upon patient record review, 1 of 14 (Patient #3) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual's attending physician, if any) • Changes that have taken place since the initial assessment • Information on the patient's progress toward desired outcomes • Reassessment of the patient's response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days Patient#3: There is no evidence of RN visit between the dates of 8/25/24- 9/13/24. There was a missed visit on 09/08. RN visit on 9/13 was 19 days after RN visit on 8/25.

Upon patient record review, 1 of 14 (Patient #1) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient#1: Patient admitted with wound to sacrum on 12/18/23. Wound resolved 1/27/24. There were no measurements or RN assessment of wound documented from admit to 1/27. The wound reoccurred 10/21/24 to present. Wound was measured and assessment documented on 10/18 and 10/25. There is no evidence of measurements or assessment documented after 10/25.

Upon patient record review, 4 of 14 (Patient #1,#2,#3,#5) 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: The record indicates the patient was admitted with a terminal diagnosis of Alzheimer's disease. There is no evidence or problems, interventions or goals related to this diagnosis on the plan of care. Corrected on site Patient#2: The record indicates the patient is taking Basaglar 100 units/1ml 20 units before lunch to manage high blood sugar and metformin. There is no evidence of problems interventions or goals related to diabetes. The record indicates that the patient had a foley catheter placed on 11/11/24. There is no evidence of foley catheter care, interventions or goals on plan of care. Corrected on site. Patient#3: The record indicates the patient has issues with depression, incontinence, and high fall risk. There is no evidence of problems interventions or goals related to these issues on plan of care. Corrected on site. Patient#5: The record indicates the patient has issues with pain and constipation. There is no evidence of interventions or goals related to these issues on plan of care. Corrected on site.

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 medications and treatments. Patient#1: The record indicates the agency is providing boost for supplemental nutrition. There is no evidence of a physician order regarding amount or frequency to take the boost for nutritional needs.

Upon patient record review, 5 of 14 (Patient #1,2,3,5,6) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient#1: There is documentation in record of wound care being provided on admit for sacral pressure wound. There is no evidence of wound care physician order. Documentation indicates on 10/18/24 that a pressure wound to sacrum was noted. No evidence of a physician order is found. Patient#2: There is no evidence of physician order for foley catheter placed on 11/11/24. Corrected on site. Patient#3: There is no evidence of RN visit between the dates of 8/25/24- 9/13/24. There was a missed visit on 09/08. Patient#5: The record indicates nurse frequency of visits for nurse is 1 time per week. There is evidence of 2 visits in the same week on 9/3 and 9/5. There is no evidence that one of these visits as PRN. Corrected on site. Patient#6: No order for 3/13/24 to keep foley for patient/family request. There is no evidence of an order for foley to be changed on 3/7. There is no evidence of an order to remove foley on 7/11. Corrected on site.

Upon patient record review 2 of 14 (Patient #1,6) IDG ensures that the care and services provided are based on all assessments of the patient and family needs. Patient #1: The record indicates a Podiatry referral was made on 2/20/24. There is no evidence of follow up or visit being made. Per agency staff this visit did occur. Corrected on site. Patient#6: The record indicates PT was requested for patient on 3/4/24. There is no evidence that the visits occurred.

Upon patient record review, 2 of 14 (Patient #3,#5) did not have evidence that each patient record contains Advance Directives. Patient#3: The record indicates patient has a POA who signed consents. There is no evidence of the POA documents in the chart. Documents were obtained and Corrected on site. Patient#5: The record indicates patient has a POA who signed consents. There is no evidence of the POA documents in the chart. Documents were obtained and Corrected on site.

Upon patient record review, 1 of 5 (Patient #1) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient #1: Consent form section pertaining to physician of patient choice was left blank. The hospice Medical Director served as their physician while on hospice services. It is unclear who the patient wanted to serve as their physician while on hospice and no evidence to support the patient chose the hospice Medical Director.

Upon patient record review, 1 of 5 (Patient #1) did not have evidence in the patient record that the comprehensive assessment identifies the 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 #1: No evidence of a comprehensive Spiritual Care assessment being completed.

Upon client record review, 4 of 5 (Patient #2, #3, #4, #5) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #2: SN ordered 1xwk on the POC. Week of 5/17 and 5/22/2020, 2 SN visits were provided. Patient #3: SN ordered 1xwk on the POC. Week of 11/3/2021, 2 SN visits were provided. Patient #4: SN ordered 1xwk on the POC. Week of 9/20 and 10/24/2021, 2 visits were provided. Patient #5: SN ordered 1xwk on the POC. Week of 11/2/2021, 2 SN visits were provided.

Upon patient client record review, 1 of 5 (Patient #1) did not have evidence that each patient record contains a signed election statement in accordance with 418.24. Patient #1: Consent form section pertaining to physician of patient choice was left blank.

Upon patient client record review, 1 of 5 (Patient #2) 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. Patient #2: Patient has a completed POLST form listing them as a Full Code. Plan of Care has patient listed as a DNR. Agency reports that patient is a DNR and POLST form was filled out in error.

Upon personnel record review, 3 of 4 applicable (Personnel #1, #2, #3) did not have evidence the hospice obtained a criminal background check on all contracted individuals who have direct patient care and access to patient records.