Every finding on record at Prairie Grace Hospice, LLC

Upon observation, there was no evidence of contracts/agreements with other facilities/agencies/hospices to receive patients in the event the hospice cannot provide care to their patients during an emergency.

Upon personnel record review, 3 of 11 (Personnel #1,#2,#7) did not have evidence Emergency Preparedness training including: • Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles • Demonstrate staff knowledge of emergency procedures • Provide emergency preparedness training at least annually • Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others • Maintain documentation of all emergency preparedness training Personnel 1,2,7: There was no evidence the personnel completed the EPP training. Agency added to personnel assignments in Relias prior to survey end.

Upon patient record review, 4 of 11 (Patients #1,#2,#3,#4) 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 1: The medication profile contained quetiapine 25mg twice daily and 50mg at bedtime without instructions regarding timing and if to be taken together. The profile also contained venlafaxine ER 150mg and 75mg both daily in the morning without instructions to take together. Corrected on site. Patient 2: The medication profile contained Biofreeze and diclofenac gel with no area defined for administration. Corrected on site. Patient 3: The medication profile contained Aspercreme area not defined for administration. Upon home visit medication review, the facility MAR had PRN Tylenol not on the hospice medication profile. Corrected on site. Patient 4: The medication profile contained Miralax with no instructions for a diluent. Corrected on site.

Upon patient record review, 1 of 11 (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: The medical record contained an order for spiritual care frequency of 1 PRN visit with no evidence of a routine frequency.

Upon patient record review, 4 of 11 (Patients #1,#2,#3,#4) 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 medical record contained orders for quetiapine 25mg bid and 50mg at bedtime with no instructions regarding timing of each administration and if to be administered together. There was also orders for venlafaxine ER 150mg and 75mg both daily in the morning without instructions to take together. Corrected on site. Patient 2: The medical record contained orders for Biofreeze and diclofenac topical gel with no area defined for administration. Corrected on site. Patient 3: The medical record contained an order for Aspercreme with no area defined for administration. Corrected on site. Patient 4: The medical record contained an order for Miralax with no instructions for a diluent. Corrected on site.

Upon patient record review, 4 of 11 (Patients #2,#3,#4,#8) 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 equipment and supply needs. Patient 2: The plan of care did not contain orders for a hospital bed, half rails, walker, over bed table. Corrected on site. Patient 3: The plan of care did not contain orders for a Hoyer lift, hospital bed, over bed table, commode. Corrected on site. Patient 4: The plan of care did not contain orders for an EZ stand. Corrected on site. Patient 8: The plan of care did not contain an order for a wheelchair.

Upon client record review, 3 of 11 (Patients #1,#4,#8) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 1: The medical record contained an order for social work visits twice monthly. There was documentation of 3 visits completed in July. Patient 4,8: The medical record contained an order for social work visits twice monthly. There was no evidence of visits completed.

Upon patient record review, 8 of 11 (Patients #1,#2,#3,#4,#5,#7,#8,#9) did not have evidence in the patient record that hospice aide assignments and duties are specific to patient needs. Patient 1: The aide care plan contained the task to obtain vital signs without parameters of when to report findings to the RN. It also contained the following tasks without frequencies: toileting, incontinence care, transfers, oral care, make bed, change linens, tidy patient area, and shaving. Patient 2: The aide care plan contained the task to obtain vital signs without parameters of when to report findings to the RN. It also contained the following tasks without frequencies: toileting, incontinence care, assist ambulation, lotion, and make bed. Patient 3: The aide care plan contained the task to obtain vital signs without parameters of when to report findings to the RN. It also contained the following tasks without frequencies: assist commode, incontinence care, use of Hoyer, transfer, assist eating, lotion, nail care, make bed, and tidy patient area. Patient 4: The aide care plan contained the task to obtain vital signs without parameters of when to report findings to the RN. It also contained the following tasks without frequencies: incontinence care, transfers, oral care, make bed, and tidy patient area. Patient 5,6: The aide care plan contained the task to obtain vital signs without parameters of when to report findings to the RN. Patient 7: The aide care plan contained the task to obtain vital signs without parameters of when to report findings to the RN. It also contained the following tasks without frequencies: incontinence care, turn and position, transfer, lotion, oral care, and tidy patient area. Patient 9: The aide care plan contained the task to obtain vital signs without parameters of when to report findings to the RN. It also contained the following tasks without frequencies: toileting, incontinence care, assist with ambulation, lotion, and tidy patient area.

Upon patient client record review, 1 of 11 (Patient #7) did not have evidence that each patient record contains Physician certification and recertification of terminal illness. Patient 7: There was no evidence of a CTI from the attending physician elected by the patient/responsible party.