Every finding on record at Personal Touch Hospice Care Inc

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 local emergency management agencies. Corrected on site.

Upon patient record review 1 of 14 (Patient #4) 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 #4: No evidence of a spiritual needs assessment by any discipline. Patient declined spiritual care discipline.

Upon patient record review, 3 of 14 (Patient #2,#12,#14) 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 #2: Order dated 9/27/2024 included Clotrimazole/betamethasone Dipropionate topical cream 0.05% apply to affected area BID. There was no evidence of an area to apply. During home visit two errors found on prescription bottles (error from pharmacy) Bottle for Ibuprofen 600mg one Q 6 hours PO PRN pain (Hospice order and medication profile was for Q 8 hours), and bottle for Clonidine hydrochloride stated to give medication if BP under 160 systolic (Hospice order and medication profile did not specify). Corrected on site (Ibuprofen order changed to Q6hr) Patient #12: Medication profile dated 11/7/2024 included Diclofenac Sodium topical gel 1% apply to affected area 3x day PRN, no evidence of an area to apply. Patient #14: Mediation profile dated 9/19/2024 included Diclofenac Sodium topical gel 1% apply to affected area 3x day PRN, no evidence of an area to apply. 9/19/2024 MiraLAX 17Gm oral PO as needed for laxative, no evidence of a diluent. On SN SOC assess identified patient is using O2 and on SN notes of 10/17/2024 O2 at 4L+, no evidence on medication profile for O2.

Upon patient record review, 8 of 14 (Patient #3,#4,#6,#7,#8,#9,#11,#14) 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 #3: SOC MSW assessment identified no mortuary plans, no evidence on POC for problem/Goals/interventions for funeral planning. Corrected on site. Patient #4: SOC MSW assessment identified no mortuary plans, no advance directive, no evidence on POC for problem/Goals/interventions for funeral planning and advance directives. Corrected on site Patient #6: SOC MSW assessment identified no mortuary plans "undecided", no evidence on POC for problem/Goals/interventions for funeral planning. Corrected on site Patient #7: SOC MSW assessment identified no mortuary plans "undecided", no evidence on POC for problem/Goals/interventions for funeral planning. Corrected on site Patient #8: SOC MSW assessment identified no mortuary plans, no evidence on POC for problem/Goals/interventions for funeral planning. Corrected on site Patient #9: SOC MSW assessment identified no mortuary plans, no evidence on POC for problem/Goals/interventions for funeral planning. Patient #11: SOC MSW assessment identified no mortuary plans, no evidence on POC for problem/Goals/interventions for funeral planning. Patient #14: SOC SN identified patient using O2 and MSW identified no mortuary planning. No evidence on POC for problem/goals/interventions for respiratory/O2 or funeral/mortuary planning.

Upon patient record review, 1 of 14 (Patient #2) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient #2: No evidence of detailed frequency of services, SOC 9/27/2024 order included MSW 1 visit within 5 days,as needed and recert. Spiritual Care 1 visit within 5 days, as needed and recert. Order corrected on site.

Upon patient record review, 3 of 14 (Patient #2,#12,#14) 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 #2: Order dated 9/27/2024 included Clotrimazole/betamethasone Dipropionate topical cream 0.05% apply to affected area BID. There was no evidence of an area to apply. During home visit two errors found on prescription bottles (error from pharmacy) Bottle for Ibuprofen 600mg one Q 6 hours PO PRN pain (Hospice order and medication profile was for Q 8 hours), and bottle for Clonidine hydrochloride stated to give medication if BP under 160 systolic (Hospice order and medication profile did not specify). Corrected on site(Ibuprofen order changed to Q6hr) . Patient #12: Order dated 11/7/2024 included Diclofenac Sodium topical gel 1% apply to affected area 3x day PRN, no evidence of an area to apply. Patient #14: Order dated 9/19/2024 included Diclofenac Sodium topical gel 1% apply to affected area 3x day PRN, no evidence of an area to apply. 9/19/2024 MiraLAX 17Gm oral PO as needed for laxative, no evidence of a diluent. On SN SOC assess identified patient is using O2 and on SN notes of 10/17/2024 O2 at 4L+, no evidence on POC of and order for O2.

Upon client record review, 1 of 14 (Patient #12) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #12: SOC order for MSW was initial within 5 days this was done. An additional visit was done on 10/10/24 with no evidence of an order. All IDG orders from SOC until current date include MSW declined by family- with no orders to visit.

Upon patient record review, 1 of 14 (Patient #14) 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 #14: SOC SN identified fall risk of 17>4 high risk, on Enoxaparin blood thinner and is using O2. No evidence on aide assignment of O2, bleeding or fall risk/precautions.

Upon observation, there was no evidence volunteers are used in day to day administrative and/or direct patient care roles. Only volunteer provides administrative functions, no evidence of ability to provide direct care volunteer.

Upon observation, there was no evidence the hospice documents and demonstrates viable and ongoing efforts to recruit and retain volunteers. Has a schedule to provide volunteer posters to churches in 2024, no actual dates or evidence provided that this was done. No retention efforts.

Upon personnel record review, 1 of 13 (Personnel #2) did not have evidence the alternate administrator's personnel record verifies that: • The employee has appropriate education and experience requirements • There is a signed job description for this role • The employee has been orientated to this role Personnel #2: Job Description for Director of Operations/Alternate Administrator included requirements of: Business degree in administration. Masters in health or related field. 3-5 years health care administration. This employee has the years of experience and is a BSN, does not have evidence of the education and experience required of the governing body as evidenced by the job description requirements. Corrected on site- GB held meeting 12/17/2024, updated Job description.

Upon patient client record review, 1 of 14 (Patient #10) did not evidence that each patient record contains physician orders. Patient #10: No evidence of a discharge order.

Upon patient client record review, 2 of 14 (Patient #4,#10) 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. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient #4: Patient information of front of file identified patient as a male. CTI SOC identifies patient 80 year old female, speaks of patient as "her" then states consents signed by "patient himself". CTI BP 2 identified patient as 80 year old male. Patient is in fact a male. Corrected on site. Patient #10: F2F signed and dated by physician for 9/26/2024 included "pt. weak, some SOB on mild exertion, uses walker for ambulation, eats 30-40% of meals, KPS 50%, dependent on max assist of 4 or > ADL's, due to state of health as well as decline life expectancy is 6 months or less if terminal illness runs normal course". CTI dated and signed by physician for 9/26/2024 describes same "steady decline" and is recertified for BP3. Dated 9/26/2024 is NOMNC form, and DC summary states discharge for extended prognosis and notes "per hospice physician patient condition remains stable and shows no signs of decline, Dr does not find it appropriate to recertify this patient for hospice benefit period 3. Pt dc'd"

Upon client record review, 1 of 14 (Patient #11) did not have evidence that the hospice forwarded a summary and a copy of the patient record, if requested, to a facility when transferring the patient to that facility. Patient #11: No evidence of transfer summary forwarded to the hospital patient was transferred.

Upon client record review, 3 of 14 (Patient #9,#10,#12) did not have evidence that if a patient revokes the election of hospice care or is discharged from hospice in accordance with §418.26, the hospice must forward to the patient's attending physician: • A copy of the hospice discharge summary • The patient's clinical record, if requested Patient #9: No evidence of a discharge summary forwarded to attending physician. Patient #10: No evidence of a discharge summary forwarded to attending physician. Patient #12: No evidence of a discharge summary forwarded to attending physician.

Upon client record review, 3 of 14 (Patient #9,#10,#12) did not have evidence that the discharge summary includes all required information. Patient #9: No evidence of a discharge summary (form blank). Patient #10: No evidence of any required elements on discharge summary. Patient #12: No evidence of any required elements on discharge summary.

Upon client record review, 1 of 14 (Patient #2) did not have evidence that all drugs and biologicals are labeled in accordance with currently accepted professional practice and include appropriate usage and cautionary instructions, as well as an expiration date, if applicable. Patient #2:During home visit two errors found on prescription bottles (error from pharmacy) Bottle for Ibuprofen 600mg one Q 6 hours PO PRN pain (Hospice order and medication profile was for Q 8 hours), and bottle for Clonidine hydrochloride stated to give medication if BP under 160 systolic (Hospice order and medication profile did not specify- and would have been intended for BP > 160 systolic per staff).