Every finding on record at Pure Care Hospice, Inc.

Upon patient record review, 4 of 5 (Patients #1,2,4,5) 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. Patients #1,2,4,5: Have nebulizer machine on POC. These patients are currently not on nebulizer meds. Per agency, the nebulizer machine is part of DME package sent to all patient homes and most patients at end of life will eventually receive nebulized medications.

Upon observation, there was no evidence the Emergency Plan communication plan includes all of the following: • Names and contact information for the following: • Hospice employees • Entities providing services under arrangement • Patients' physicians • Other hospices Corrected on site.

Upon patient record review, 3 of 14 (Patients #5,#8,#10) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications. Patient 5: The medication profile identified a nebulized albuterol treatment ordered. There was no evidence of the medication in the home upon visit. Facility identified artificial tears as part of patient's administered medications. There was no evidence the eye drops were included on the medication profile. Corrected on site. Patient 8: The medication profile contained nystatin and hydrocortisone topical medications with no area defined for administration. Corrected on site. Patient 10: The medication profile contained triamcinolone topical medication with no area defined for administration. Corrected on site. Upon home visit medication reconciliation, the home had 500 mg acetaminophen with medications instead of the 325 mg tablets identified in the physician orders.

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

Upon patient record review, 1 of 14 (Patient #2) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate 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: There was no evidence of wound measurements and assessments documented since the start of care.

Upon patient record review, 4 of 14 (Patients #3,#4,#7,#10) 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: The medical record contained nursing documentation upon recertification 2/1/24 identifying patient issues with dysphagia and risk for skin breakdown. There was no evidence of problems, goals, and interventions related to dysphagia and skin impairment included in the plan of care. Corrected on site. Patient 4: The medical record contained nursing documentation upon admission identifying patient issues with dysphagia. There was no evidence of problems, goals, and interventions related to dysphagia included in the plan of care. Corrected on site. Patient 7: The medical record contained nursing documentation upon admission identifying patient issues with risk for skin impairment. There was no evidence of problems, goals, and interventions related to skin impairment included in the plan of care. Corrected on site. Patient 10: The medical record contained nursing documentation upon admission identifying patient issues with dysphagia. There was no evidence of problems, goals, and interventions related to dysphagia included in the plan of care. Corrected on site.

Upon patient record review, 10 of 14 (Patients #1,#2,#3,#4,#5,#6,#7,#8,#9,#10) 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. Patients 1-10: The medical records contained orders for Social Work and Spiritual Care frequencies every recertification and as needed. There was no allowable quantity defined for PRNs. The records also contained differing frequency orders in the plan of care update orders that did not match the current orders in the profile. Corrected on site.

Upon patient record review, 3 of 14 (Patients #5,#8,#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 5: Upon observation during the home visit, the caregivers identified the patient is administered artificial tears. There was no evidence of an order for artificial tears included in the plan of care. Corrected on site. Patient 8: The medical record contained orders for nystatin and hydrocortisone topical ointments with no area defined for administration. Corrected on site. Patient 10: The medical record contained an order for triamcinolone topical no are defined for administration. Corrected on site.

Upon patient record review, 7 of 14 (Patients #1,#2,#3,#4,#5,#6,#7) 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 medical record contained nursing documentation identifying patient use of an air mattress. There was no evidence of an order for the equipment included in the plan of care. Corrected on site. Patient 2: The medical record contained nursing documentation identifying patient use of an air mattress. There was no evidence of an order for the equipment included in the plan of care. Corrected on site. Patient 3: The medical record contained nursing documentation identifying patient use of an air mattress and walker. There was no evidence of an order for the equipment included in the plan of care. Corrected on site. Patient 4:The medical record contained nursing documentation identifying patient use of a Hoyer lift. There was no evidence of an order for the equipment included in the plan of care. Corrected on site. Patient 5: The medical record contained nursing documentation identifying patient use of a walker. There was no evidence of an order for the equipment included in the plan of care. Corrected on site. The care plan identified oxygen and nebulizer required for patient care. There was no evidence of the equipment on site during home visit. Corrected on site. Patient 6: The medical record contained nursing documentation identifying patient use of a walker. There was no evidence of an order for the equipment included in the plan of care. Corrected on site. Patient 7: The medical record contained nursing documentation identifying patient use of a walker. There was no evidence of an order for the equipment included in the plan of care. Corrected on site.

Upon client record review, 4 of 14 (Patients #3,#4,#11,#12) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 3: The medical record contained an ordered nursing frequency for once weekly. There was evidence of two scheduled visits completed the week of 2/18/24. Patient 4: The medical record contained an ordered nursing frequency for skilled nursing once weekly and RN visit every 14 days. There was evidence of 2 LVN visits the weeks of 2/4/24, 2/18/24, and 3/3/24. Patient 11: The medical record contained an ordered nursing frequency for skilled nursing once weekly and RN visit every 14 days. There was evidence of two scheduled LVN visits the weeks of 8/15/23 and 8/20/24. Patient 12: The medical record contained an ordered nursing frequency for skilled nursing once weekly and RN visit every 14 days. There was evidence of two scheduled LVN visits the weeks of 6/13/23, 6/25/23, and 7/2/23.

Upon personnel record review, 1 of 14 (Personnel #6) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) ·Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff. ·Reading and recording temperature, pulse, and respiration ·Safe transfer techniques and ambulation. ·Normal range of motion and positioning ·Appropriate and safe techniques in personal hygiene and grooming that include-- ·(A) Bed bath ·(B) Sponge, tub, and shower bath ·(C) Shampoo, sink, tub, and bed ·(D) Nail and skin care ·(E) Oral hygiene ·(F) Toileting and elimination The other subject areas in this section may be evaluated through written examination, oral examination or after observation of a Hospice Aide with a patient. Personnel 6: There was no evidence of observation of obtaining vital signs, ambulation, sponge, tub, and shower for bathing, or sink and tub for shampooing.

Upon patient record review 2 of 14 (Patients #2,#4) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient 2: The medical record contained ordered aide frequency of twice weekly. There was no evidence of a second visit completed the week of 3/10/24. Second visit completed per route sheet but not documented per agency policy of completion within 48 hours. Patient 4: The medical record contained ordered aide frequency of twice weekly. There was no evidence of a second visit completed the weeks of 2/4/24 and 2/25/24.

Upon personnel record review, 1 of 14 (Personnel #6) did not have evidence in the hospice aide personnel file that a registered nurse made an annual on-site visit to the location where a patient is receiving care in order to observe and assess each aide while he or she is performing care. Personnel 6: There was no evidence of an annual on-sit visit.

Upon observation, there was no evidence the hospice documents and demonstrates viable and ongoing efforts to recruit and retain volunteers.

Upon observation, there was no evidence the hospice is directed by a Board of Directors/governing body which assumes full legal authority and responsibility for the operation of the hospice. The governing body meeting minutes did not reflect evidence of periodic review of bylaws, policies, procedures, and human resource management. Corrected on site with meeting held 3/27/24.

Upon personnel record review, 2 of 14 (Personnel #12,#13) did not have evidence the hospice employees and contract employees have received orientation on the hospice philosophy. Personnel 12: There was no evidence of orientation on the hospice philosophy. Corrected on site. Personnel 13: There was no evidence of orientation on the hospice philosophy.

Upon patient client record review, 7 of 14 (Patients #1,#3,#4,#6,#7, #8, #9) 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 1,3,6,7,8,9: There was no evidence the QIO identification and contact information was given with the election forms and addendum to receive the Notification of Non-Covered Items. Patient 4: The Notification of Non-Covered Items did not identify non-covered medications to match the medication profile.

Upon patient client record review, 1 of 14 (Patient #4) did not have evidence that each patient record contains Advance Directives. Patient 4: The patient profile inaccurately identified patient as DNR, the POLST identified patient as full code. Corrected on site.

Upon patient client record review, 1 of 14 (Patient #1) 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 1: The medical record contained consents incomplete with no identifying reason beneficiary is unable to sign and representative's relationship to beneficiary in the space provided on the forms.

Upon personnel record review, 3 of 14 (Personnel #12,#13,#14) did not have evidence the hospice obtained a criminal background check on all contracted individuals who have direct patient care and access to patient records. Personnel 12,13,14: There was no evidence of criminal background checks in the contracted personnel files. The agency submitted on site, however no results were received by end of survey.