Every finding on record at Reachwell Hospice Care Inc.

Upon patient record review, 2 of 5 (Patient #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 Patient 3: The medication list includes Robitussin long acting liquid 1 tsp po q 4-6 hours PRN cough; this is an incomplete entry as it does not indicate a dosage for the components in this over the counter medication. (corrected on site) Patient 4: The medication list contains a duplicate entry. Melatonin 10mg for nightly use was ordered on 03.24.2024, then melatonin 5mg for nightly use was ordered on 05.05.2024. The DPCS confirmed that the earlier order should have been discontinued when the 05.05.2024 order was obtained. (corrected onsite)

Upon observation, there was no evidence the Emergency Plan communication plan includes all of the following: • Names and contact information for the following: The communication plan included the previous Alternate Administrator as the main point of contract for emergency events, and did not include the current Alternate Administrator as a point person.

Condition of Participation: Initial and Comprehensive Assessment of the Patient.

Upon patient record review 6 of 14 (Patient #1, 2, 5, 7, 9, 14) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care Patient 1 admitted on 1/5/24. The initial spiritual assessment was completed on 1/21/24 and the initial psychosocial assessment was completed on 1/15/24. Patient 2 admitted on 9/8/23. The initial spiritual assessment was completed on 9/22/23. Patient 5 admitted on 1/5/24. The initial spiritual assessment was completed on 1/21/24 and the initial psychosocial assessment was completed on 1/15/24. Patient 7 admitted on 7/23/23. The initial psychosocial assessment was completed on 8/11/23. Patient 9 admitted on 10/19/23. The initial psychosocial assessment was completed on 10/27/23. Patient 14 admitted on 9/8/23. The initial spiritual assessment was completed on 1/20/24.

Upon patient record review 8 of 14 (Patient #3, 4, 7, 8, 9, 10, 11, 13) 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 3 initial spiritual care visit on 3/31/24 note is blank, no evidence of an initial spiritual assessment. Patient 4, 7, 9, 11, 13 no evidence of an initial spiritual assessment. Patient 8 no evidence of an initial spiritual or psychosocial assessment. Patient 10 no evidence of an initial psychosocial assessment.

Upon patient record review, 5 of 14 (Patient #1, 2, 8, 11, 12) 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 Oxygen is ordered and on the MAR but there is not any oxygen in the home. Lasix and Bisacodyl are ordered and on medication profile but these are not in home. Caregiver reports using Milk of Magnesium and there is not an order for MOM and it is not on the medication profile. and nursing visit on 4/17/24 documents advising the caregiver on the use of MOM. MOM is not on the medication profile. Patient 2 husband reported the patient has not been taking the Sertraline or the Senna for a while now, and these are ordered and on the medication profile. Patient 8 medication profile included Tylenol 325mg 2 tab Q8h prn, Norco 10-325mg 1 tab QID prn, Norco 5-325mg 1 tab Q12h prn, and did not include the max allowable for the Tylenol. Also did not include when to take either of the Norco doses both stated prn moderate pain. Patient 11 medication profile included Tylenol 650mg sup Q4h prn and Percocet 5/325mg 1 tab Q4h prn, no max dosing for the Tylenol. Patient 12 medication profile included Tylenol 650mg sup Q4h prn and Tylenol 500mg 1 tab Q6h, no max dosing for Tylenol.

Upon patient record review, 5 of 14 (Patient #3, 6, 7, 8, 11) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual's attending physician, if any) • Changes that have taken place since the initial assessment • Information on the patient's progress toward desired outcomes • Reassessment of the patient's response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 Patient 3 RN visits completed on 3/29/24 and 4/26/24 to update the comprehensive assessment. Patient 6 and 7, RN visits completed on 3/27/24 and 4/24/24 to update the comprehensive assessment. Patient 8 RN comprehensive assessment last completed on 4/13/24. Patient 11 RN visits completed on 3/19/24 and 4/4/24 to update the comprehensive assessment.

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

Upon patient record review, 14 of 14 (Patient #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12 ,13, 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 Patients 1, 2, 3, 5, 7, 8, 9, 10, 11, 12, 14 both social work and chaplain are involved and there is not evidence of psychosocial or spiritual problems, goals or interventions. Patients 4, 6, 13, social work is involved and there is not evidence of psychosocial problems, goals or interventions. Patient 1 POLST has patient as full code, no order for full code. Patient 2 Patient's POLST has DNR for code status, no evidence of an order for DNR. Patient had a scanned prescription order for soft restraints, and no evidence of a care plan for the use of restraints. Patient 3 no evidence of aspiration precautions or care plan, several nursing notes document patient is on aspiration precautions. Patient has a condom cath, no goals, problems, or interventions identified. Patient 7 no evidence of aspiration precautions or care plan, several nursing notes document patient is on aspiration precautions. Patient 10 POLST completed at admission as full code, POC has DNR.

Upon patient record review, 14 of 14 (Patient #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14) did not have evidence that the plan of care includes all services necessary for the palliation and management of the terminal illness and related conditions which including interventions to manage pain and symptoms. Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14 care plans included problems listed as completed, no active goals, problems or interventions for pain or symptom management.

Upon patient record review, 6 of 14 (Patient #1, 2, 3, 8, 11, 12) 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 nursing visit on 4/17/24 documents advising the caregiver on the use of MOM. There is not an order for MOM. Patient 2 had a faxed prescription with an order written for soft restraints, nothing else on the order. The order was not included into the EMR as an order and did not include any details for the use of the restraint. Patient 3 CTI and several nursing visits document that the patient has a condom cath, there is not an order for a condom cath. Patient 8 orders included Tylenol 325mg 2 tab Q8h prn, Norco 10-325mg 1 tab QID prn, Norco 5-325mg 1 tab Q12h prn, and did not include the max allowable for the Tylenol. Also did not include when to take either of the Norco doses both stated prn moderate pain. Patient 11 medication profile included Tylenol 650mg sup Q4h prn and Percocet 5/325mg 1 tab Q4h prn, no max dosing for the Tylenol. Patient 12 medication profile included Tylenol 650mg sup Q4h prn and Tylenol 500mg 1 tab Q6h, no max dosing for Tylenol.

Upon patient record review, 9 of 14 (Patient #1, 2, 3, 5, 6, 7, 8, 9, 10) 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 #1, 2, 3, 5, 6, 7, 8, 9, 10 Care plans did not have any problems, goals or interventions, all problems identified were documented as completed. No updates or progress on any problems that were initially identified and no new problems added. Patient 2 Nursing notes on 3/30/24 and 4/17/24 state pureed food and aspiration precautions. No evidence of aspiration precautions on the care plan.

Upon client record review, 6 of 14 (Patient #1, 3, 5, 7, 10, 11) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care Patient 1 MSW ordered 1x month and 3 prn. MSW visits on 2/13/24, 2/24/24, and 4/29/24 are all blank, unable to determine if these visits were made. Chaplain ordered 1x month and 3 prn. Chaplain visits on 2/9/24, 3/8/24, 4/9/24 are all blank unable to determine if visits were made. RN ordered 1x week and 3prn. RN visit on 4/24/24 is blank, unable to determine if visit was completed for the week. Patient 3 spiritual care ordered as 1x month and 3prn. Spiritual care visit on 3/31/24 is blank, unable to determine if visit was completed. No visit for the month of April. Patient 5 social work is ordered as 1xm and 3prn. Social work visits completed on 2/13/24 and 2/24/24 both documented as routine visits. Spiritual care ordered as 1xm and 3 prn. Spiritual care visits on 2/9/24, 3/8/24, and 4/9/24 and all are blank, unable to determine if visits were completed. Patient 7 spiritual care ordered as 1xm and 3prn. No evidence of a spiritual care visit for April. Patient 10 social work ordered as 1xm and 3prn. No evidence of a social work visit for February. Spiritual care ordered as 1xm and 3prn. Spiritual care visits documented on 3/19/24 and 4/10/24 and they are blank, unable to determine if visits were completed. Patient 11 spiritual care ordered as 1xm and 3prn. No evidence of spiritual care visit for the month of March.

Upon observation, there was no evidence the board of directors/governing body approves the frequency and detail of the data collection.

Upon observation, there was no evidence the number and scope of distinct QAPI projects conducted annually is based on the needs of the hospice's population and internal organizational needs and must reflect the scope, complexity, and past performance of the hospice's services and operations. the agency did not have a current QAPI project as ongoing, the last project was in 2023 and was one project on pain management however no documentation provided to identify pain management as an area that needed improvement.

Upon observation, there was no evidence the hospice documents what QAPI projects are being conducted, the reasons for conducting these projects, and the measurable progress achieved on these projects. The agency did not have a current QAPI project.

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 1 RN placed notebook on patient's walker without a barrier. The nurse reached into nursing bag for gloves after providing hands on care without sanitizing hands. Patient 2 LVN did not sanitize hands when changing gloves and reaching into nursing, notebook was placed on a chair and the bed without a barrier.

Upon personnel record review, 1 of 14 (Personnel #5) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient. Personnel 5 competency included general topics such as bathing and shampoo, it was not specific to the tasks outlined. The competency did not include ·(A) Bed bath ·(B) Sponge, tub, and shower bath ·(C) Shampoo, sink, tub, and bed ·(D) Nail care

Upon patient record review, 2 of 14 (Patient #1, 2) did not have evidence in the patient record that hospice aide assignments and duties are: • 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 aide care plan 3/27/24 included vitals signs (BP,Temp,Pulse,Resp) as needed. Patient 2 nursing notes document aspiration precautions, no evidence of aspiration precautions on aide care plan.

Upon patient record review 2 of 14 (Patient #1, 2) 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 Patient 1 aide care plan included several tasks to be completed every visit such as bath, shampoo, comb hair, assist dressing and more. Aide visits on 4/19/24, 4/22/24, 4/26/24, 4/29/24 are incomplete and only document a bath, unable to verify if all tasks were completed or not. Patient 2 aide visits on 4/23/24 and 4/26/24 include application of calmoseptine to the left side lower back to a small opening in the skin, this is not included on the aide care plan.

Upon personnel record review, 2 of 14 (Personnel #8 and 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 8 did not have a competency for the role of nurse practitioner. Personnel 9 did not have a competency for the role of volunteer coordinator.

Upon patient client record review, 9 of 14 (Patient #1, 2, 3, 4, 5, 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, 2, 3, 4, 5, 6, 7, 8, 9 election of benefit has a space for the BFCC-QIO name and contact information and these are either blank or include the caregiver information instead of the QIO.

Upon patient client record review, 3 of 14 (Patient #1, 9, 11) 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 RN visit on 4/17/24 documented wound on top of head completed per instructions. No evidence of what care was completed. Patient 9 Face to Face documented patient as a full code and the order was for a DNR. Patient 11 skilled nursing visit on 4/5/24 did not include the discipline with the signature.