Every finding on record at Primrose Hospice Care Inc

Upon patient record review, 1 of 9 (Patient #1) 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: During home visit, noted discrepancies between hospice and ALF medication list. ALF included Acetaminophen, Flonase, Cetirizine, Memantine and hospice did not. The hospice profile included Depakote. The ALF did not. RN states, and presented discontinue order in hospice EMR, although med still active on hospice med profile. The nurse identified as EMR "glitch" and submitted work order to EMR software vendor.

Upon patient record review, 1 of 9 (Patient #3) 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 4/2/26. 4/3/26 Order for Oxygen 2LPM by NC. Problems, goals and interventions include Oxygen, but exclude Oxygen related safety precautions.

Upon personnel record review, 1 of 13 (Personnel #11) did not have evidence that a skills competency assessment, specific to each discipline had been conducted for all personnel including volunteers initially during orientation. Personnel #11: Volunteer has only job description and competency for administrative/non-patient facing volunteer. Volunteer and Administrator/DCS confirm intent to train/validate competency for patient facing volunteer service.

Upon patient client record review, 4 of 9 (Patient #6, 7, 8, 9) 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. Patients #6, 7, 8, 9: Discharge summaries identify reason for discharge as Patient no longer eligible for hospice, but Patients #6, 8, 9 include additional comment that patient no longer desires hospice. Patient #7, contained additional comment is that patient moved.

Upon client record review, 4 of 9 (Patient #6, 7, 8, 9) 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 Patients #6,7,8,9: Upon review of live discharge records, there was no evidence that discharge summaries were forwarded to attending physician.

Upon client record review, 4 of 9 (Patient #6, 7, 8, 9) did not have evidence that the discharge summary includes all required information. Patient #6, 7, 8, 9 : DC Summary is incomplete and ambiguous in reason for discharge. Documents patient is no longer terminally ill and Patients #6, 8, 9 include additional comment that Patient no longer desires hospice services and Patient #7 additional comment is that patient moved out of service area. There is no summary of treatments, symptom management, no reference to current plan of care, MD orders or any other clinical documentation of patient's hospice admission.

Upon patient record review, 5 of 5 (Patient #1,2,3,4,5) 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. All 5 patients: Aide, SW, and SC only have PRN orders on POC. No evidence of routine visits on plan of care. No evidence of a frequency for PRN visits. 4 active charts corrected during survey.

Upon personnel record review, 3 of 9 (Personnel #7,8,9) did not have evidence that a skills competency assessment, specific to each discipline had been conducted for all personnel including volunteers initially during orientation. Personnel 7,8,9: No evidence that a skills competency assessment was completed.

Upon patient client record review, 1 of 5 (Patient #3) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient 3: Hospice election statement missing the effective date of election and signature of the beneficiary not in the correct line. Beneficiary signed on line where the name of the hospice should have been listed.

Upon client record review, 1 of 5 (Patient #5) 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 5: No evidence that discharge summary was sent to the attending physician.

Upon client record review, 1 of 5 (Patient #5) did not have evidence that the discharge summary includes all required information. Patient 5: No evidence that a discharge summary was completed.