Every finding on record at Presbyterian Homes Hospice Inc

Upon patient record review, 1 of 8 (Patient #2) 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 2: Patient has a current medication order for Eliquis (anticoagulant) without a risk for bleeding care plan with appropriate goals and interventions.

Upon observation, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient 2: Nursing "Bag Technique Policy" No. 6-013.1 was not followed on observation visit, the RN did not use a clean surface and hand washing was not performed according to policy.

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 patient record review 1 of 8 (Patient #5) did not have evidence that the hospice Registered Nurse must complete an initial assessment within 48 hours after the election of hospice care in accordance with §418.24 Patient #5: There was not evidence that the patient entered the effective date for the hospice to start care. The area in the body of the election statement in which the patient/representative enters the effective date that the patient wishes to start hospice was blank. The consents and all admission paper work was signed on 5/9/25. Care was started on 5/13/25. Initial assessment by the RN was completed on 5/23/25.

Upon patient record review, 7 of 8 records (Patient #1,#2,#3,#4,#6,#7,#8) 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 Polyethylene Glycol 17 GM 1 capful for constipation daily without evidence of a diluent. Also, the medication profile contained 4 different morphine dose/directions: Morphine 2.5mg q1h prn pain/SOB, Morphine 2.5mg q6h SOB, Morphine 5mg 4x/day and Morphine 5mg q1h prn pain or SOB. Patient #2: The medication profile contained Polyethylene Glycol 17GM for constipation daily without evidence of a diluent. Patient #3: The medication profile contained Acetaminophen 500mg 2 tabs BID and Acetaminophen 325mg 2 tabs q4h prn pain or fever. There was not evidence of a parameter for fever or a maximum allowable dose per 24hours. Patient #4: The record contained Acetaminophen 325mg, 2 tabs 3x/day and Acetaminophen 325mg, 2 tabs q4h prn and Acetaminophen 325mg 2 tabs q6h prn. There was not evidence of a maximum allowable dose per 24 hours. Patient #6: The medication profile contained Acetaminophen 325mg, 2 tabs q4h prn pain or fever. There was not evidence of a parameter for fever. Patient #7: The medication profile contained Acetaminophen for pain or fever with no evidence of a parameter for fever. Patient #8: Nurse documentation indicated that the patient was on intermittent oxygen. There was not evidence that this was on the medication profile.

Upon patient record review, 1 of 8 records (Patient #2) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient #2: The patient was admitted on 5/21/25. The record indicated that the bereavement assessment was completed on 6/6/25.

Condition of Participation: Interdisciplinary Group, Care Planning, and Coordination of Services. L536

Upon patient record review, 2 of 8 records (Patient #2,#7) did not have evidence that an Registered Nurse ensured continuous assessment of the patient and family's needs and coordinated 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 #2: Documentation indicated a deep tissue injury on the patient's coccyx, date 6/16/25. There was not evidence of an assessment including measurements, until 7/7/25. Patient #7: The record indicated that the patient had a wound on her left great toe and under her right breast. There was not evidence of a wound assessment.

Upon patient record review, 1 of 8 records (Patient #4) 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 #4: The patient was admitted with a diagnosis of cerebral atherosclerosis. Her memory was impaired and she was in a memory care unit. She had a functional decline, complained of dizziness and had visual disturbances. There was not evidence of neurological care plan that reflected patient/family goals related to her neurological issues.

Upon patient record review, 7 of 8 (Patient #1,#2,#3,#4,#6,#7,#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 medications and treatments. Patient #1: The record contained an order for Polyethylene Glycol 17 GM 1 capful for constipation daily without evidence of a diluent. Also, the record contained orders for 4 different morphine dose/directions: Morphine 2.5mg q1h prn pain/SOB, Morphine 2.5mg q6h SOB, Morphine 5mg 4x/day and Morphine 5mg q1h prn pain or SOB. Patient #2: The record indicated 2 wound care orders dated 6/6/25, 'Cleanse skin tear with wound cleanser or soap and water. Apply non-adherent bandage or tegaderm. Change 1x/week. The second order stated to change prn. There was not evidence of a location, or a reason to change the dressing prn. Also, the record contained an order for Polyethylene Glycol 17 GM for constipation daily without evidence of a diluent. Patient #3: The record contained orders for Acetaminophen 500mg 2 tabs BID and Acetaminophen 325mg 2 tabs q4h prn pain or fever. There was not evidence of a parameter for fever or a maximum allowable dose per 24h. Patient #4: The record contained Acetaminophen 325mg, 2 tabs 3x/day and Acetaminophen 325mg, 2 tabs q4h prn and Acetaminophen 325mg 2 tabs q6h prn. There was not evidence of a maximum allowable dose per 24 hours. Patient #6: The medication profile contained Acetaminophen 325mg, 2 tabs q4h prn pain or fever. There was not evidence of a parameter for fever. Patient #7: The medication profile contained Acetaminophen for pain or fever with no evidence of a parameter for fever. Patient #8: Nurse documentation indicated that the patient was on intermittent oxygen. There was not evidence of an order.

Upon patient record review, 3 of 8 records (Patient #1,#2,#3) 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 #1: The record indicated that the patient used a walker and a wheelchair. There was not evidence that this equipment was a part of the plan of care. Patient #2: The documentation revealed that the patient was chair bound and also that a hospital bed was ordered on admission. There was not evidence that this equipment was on the plan of care. Patient #3: The record indicated that the patient was wheelchair bound and had a wheeled walker. There was not evidence that this equipment was on the plan of care.

Upon patient record review, 2 of 8 records (Patient #3,#5) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient #3: The record indicated that the patient was started on Cefuroxime for pneumonia on 6/27/25. He had a chronic cough, was started on Guaifenesin and Stiolto inhaler. There was not evidence that the care plan was revised to include these respiratory changes. Patient #5: The documentation indicated that the patient had multiple wounds including but not limited to forehead, right elbow right wrist, left forearm, left wrist, right thigh, and left knee. There was not evidence that the care plan was revised to include goals and interventions related to these wounds.

Upon patient record review, 5 of 8 records (Patient #1,#2,#3,#5,#6) 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 #1: The aide plan of care dated 5/23/25 indicated to provide bathing, tub bath/shower, and hair care as needed. Patient #2: The aide plan of care dated 6/26/25 indicated for the tasks of nail care and shampoo per patient request. Patient #3: The aide plan of care indicated for the tasks of nail care, oral care, hair care, shave and stand-by assistance as needed. Patient #5: The aide plan of care indicated to provide bathing, tub bath/shower, and nail care per patient request. patient #6: The aide plan of care indicated to provide bathing, tub bath/shower, nail care prn. In addition,shampoo, shave, skin care and transfer bed to chair, and chair to bed did not contain a frequency for the tasks.

Upon patient client record review, 2 of 8 records (Patient #5,#6) did not have evidence that each patient record contains: • Signed election statement in accordance with 418.24 Patient #5: There was not evidence that the patient entered the effective date for the hospice to start care. The area in the body of the election statement in which the patient/representative enters the effective date that the patient wishes to start hospice was blank. The consents and all admission paper work was signed on 5/9/25. Care was started on 5/13/25. Patient #6: There was not evidence that the patient entered the effective date for the hospice to start care. The area in the body of the election statement in which the patient/representative enters the effective date that the patient wishes to start hospice was blank. The consents and all admission paper work was signed on 3/26/25. Care was started on 3/26/25.

Upon patient record review, 1 of 8 records (Patient #4) 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: Wound care for a coccyx wound was documented, 'wound care per wound care order.'