Every finding on record at Peace & Comfort Hospice & Palliative Care Inc

Upon patient record review, 1 of 14 (Patient #5) did not contain a current/comprehensive Medication Profile: Patient #5: An RN entered the following note on the 04/17/24 IDG Meeting, "At a recent home visit the patient complained of itching on chest and back. RN assessed, and writes that it appears as though it could be mosquito or flea bites. There is a dog in the home. RN recommended that patient/family begin to use Calamine/Benadryl lotion to effected areas to assist with itching. This medication was not added to the Medication Profile.

Upon patient record review, 1 of 14 (Patient #9) did not contain evidence that a Registered Nurse had been designated to ensure continuous assessment of the patient and family's needs: Patient #9: The IDG POC contained an order, beginning 02/16/24, for "Left foot dermatitis. Cleanse with warm soap and water or wound cleanser, pat dry. Apply Triamcinolone 1% Cream, apply dry dressing every day for 30 days." The 02/24/24 nursing visit documented the wound section as "none"; and there was no mention of her assessment of, or the status of, such left foot dermatitis.

Upon patient record review, 9 of 14 (Patients #1, 2, 3, 4, 5, 6, 7, 8, and 9) 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, including the following: A detailed statement of both the scope and frequency of services necessary to meet the specific patient and family needs: Patients #1, 2, 3, 4, 5, 6, 7, 8, and 9: The most recent IDG Plan(s) of Care for each of these patients included the following 'frequency' of visits: 1) MSW: Once a month, and as needed, and every recertification period; and 2) Spiritual Counselor: As needed, and every recertification period. This MSW visit frequency statement does not include a quantitative amount for the 'as needed' visit frequencies. Nor is it clear as to what exactly the frequency of 'and every recertification period' indicates. This Spiritual Counselor visit frequency statement orders visits at a frequency of 'as needed' without a baseline visit frequency. Nor is it clear as to what exactly the frequency of 'and every recertification period' indicates.

Upon patient record review, 1 of 14 (Patient # 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 #10: The initial IDG POC dated 04/25/24 included: 1) May change 24 F foley catheter monthly and as needed, without an indication for such needed change; and 2) May flush 24 F foley catheter with Normal Saline every SN visit as needed, without an indication for such flushes.

Upon patient record review, 2 of 14 (Patients #1 and 2) 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, including equipment and supply needs: Patient #1: During Surveyor-attended home visit on 04/20/24 it was noted that the patient had the following DME in the home: 1) Hospital bed; 2) Overbed table; 3) Air mattress; and 4) Wheel chair. These DME were not included on the current POC. Patient #2: During Surveyor-attended home visit on 04/20/24 it was noted that the patient had the following DME in the home: 1) Commode; and 2) Gait Belt. These DME/Supply were not included on the current POC.

Upon patient record review, 4 of 14 (Patients #1, 2, 5, and 6) did not contain evidence that the revised Plan of Care included information from the patient's updated comprehensive assessment(s): Patient #1: A 12/23/23 SOC order was obtained for, "May suction as tolerated". This intervention had not been included/forwarded on to the most current/updated IDG POC. Patient #2: A 10/07/23 SOC order was obtained for, "May suction as tolerated". This intervention had not been included/forwarded on to the most current/updated IDG POC. Patient #5: A 09/21/23 SOC order was obtained for, "May suction as tolerated for excessive secretions". This intervention had not been included/forwarded on to the most current/updated IDG POC. Additionally, the SOC Consent reflected that the patient had a DPOA-Healthcare. (The Clinical Manager confirmed this). This pertinent Advance Directive information was not included on the most current IDG POC. Patient #6: The SOC Consent reflected that the patient had a DPOA-Healthcare. (The Clinical Manager confirmed this). This pertinent Advance Directive information was not included on the most current IDG POC.

Upon patient record review, 2 of 14 (Patients #13 and 14) did not contain evidence that the Hospice offers Bereavement counseling that includes: The development of a Bereavement Plan of Care that notes the kind of Bereavement services to be offered, and the frequency of such service delivery: Patient #13: Died 11/26/23, with a post-death Bereavement Risk Assessment conducted on 11/28/23. The Bereavement Counselor, per Surveyor phone interview, stated that the intent was for the bereaved to receive a Sympathy card, and 'multiple' monthly mailings. However, there was not a fully developed Bereavement POC located. Rather, the Bereavement Counselor had added a notation at the bottom of his post-death Bereavement Risk Assessment to send a Sympathy card within 2 weeks of death, and a 1-month mailing within one month of death. These had been sent. Patient #14: Died 11/19/23, with a post-death Bereavement Risk Assessment conducted on 11/21/23. The Bereavement Counselor, per Surveyor phone interview, stated that the intent was for the bereaved to receive a Sympathy card, and 'multiple' monthly mailings. However, there was not a fully developed Bereavement POC located. Rather, the Bereavement Counselor had added a notation at the bottom of his post-death Bereavement Risk Assessment to send a Sympathy card within 2 weeks of death, and a 1-month mailing within one month of death. These had been sent.

Upon personnel record review, 1 of 11 (Personnel #7) did not contain evidence that their initial Aide Skills Competency Assessment had been performed while the Aide was providing care to a patient: Personnel #7: An RN conducted and Aide Skills Competency Assessment prior to the Aide providing independent patient care/services. However, the following tasks were not evaluated for while the Aide was providing patient care: ·Bed bath ·Nail and Skin care ·Normal Range of Motion

Upon patient record review, 2 of 14 (Patients #5 and 6) did not contain evidence that each patient record contains Advance Directives: Patient #5: The SOC Consent reflected that the patient had a DPOA-Healthcare. (The Clinical Manager confirmed this). However, this Advance Directive had not been added to the filed California POLST document as such. Patient #6: The SOC Consent reflected that the patient had a DPOA-Healthcare. (The Clinical Manager confirmed this). However, this Advance Directive had not been added to the filed California POLST document as such.

Upon patient record review, 1 of 14 (Patient #1) did not contain evidence that all entries were legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice: Patient #1: All of the home visit signature entries made by Aide (TS) did not include the Aide's credentials.

Upon patient record review, 2 of 14 (Patients #11 and 12) did not contain evidence that the Discharge Summary included all CMS-required information: Patients #11 and 12: The 04/25/24 and 04/02/24 respective DC Summaries did not include the following content: • 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