Every finding on record at Reflections Hospice Inc

Upon observation, there was no evidence that during the initial assessment visit in advance of furnishing care, the hospice provided the patient and/or family with verbal (meaning spoken) and written notice of the Patient's Rights and Responsibilities in a language and manner that the patient understands. Patient#1: Patient only speaks and reads Armenian. Daughter lives in home and speaks Armenian and English. There is no evidence in home or in chart that Patient Rights and Responsibilities have been provided in language patient understands. Corrected on site to bring into current compliance. Patient#2: Patient only speaks and reads Spanish. Family lives in home and speaks Spanish and English. There is no evidence in home or in chart that Patient Rights and Responsibilities have been provided in language patient understands. Patient signed her own papers on admit. Corrected on site to bring into current compliance. Patient#3: Patient only speaks and reads Armenian. Family lives in home and speaks Armenian and English. There is no evidence in home or in chart that Patient Rights and Responsibilities have been provided in language patient understands. Patient signed his own papers on admit. Corrected on site to bring into current compliance.

Upon patient record review, 4 of 14 (Patient #1,#2,#6,#10) 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 observation of home visit and medication reconciliation, the medication profile contained Furosemide which was not found in the home. It was confirmed that this is a current medication. Corrected on site by the nurse contacted the office and ordered a refill to be delivered the same day. Patient#2: The medication profile contained hydrocortisone 1% Topical twice a day as needed for itching with no area defined for administration. The medication profile contained Voltaren Arthritis Pain 1% Topical with no area defined for administration. The medication profile contained Nitroglycerin 0.4mg take 1 tab under tongue every 5 minutes as needed for chest pain with no indication of a maximum of 3 doses. Corrected on site. Patient#6: The medication profile contained hydrocortisone 2.5% topical cream with no area defined for administration. Corrected on site. Patient#10: The medication profile contained Diclofenac Sodium 1% topical gel with no area defined for administration. Corrected on site.

Upon patient record review, 8 of 14 (Patient #1,#2,#3,#4,#5,#6,#7,#8) 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#1: The record indicates patient has an order for mechanical soft diet, thickener, and ensure. There is also a physician order for patient to care to include the following precautions: bleeding, skin integrity, oxygen safety, and infection control. Nursing documentation indicates patient is bladder and bowel incontinent. There is no evidence of problems, goals, or interventions for these needs on plan of care. Corrected on site. Patient#2: The record indicates there is a physician order for care to include the following precautions: aspiration, bleeding, oxygen safety, skin breakdown, and infection control. The record also indicates patient has been ordered and uses glucometer and ensure. There is no evidence of problems, goals, or interventions for these needs on plan of care. Corrected on site. Patient#3: The record indicates there is a physician order for care to include the following precautions: Skin breakdown and aspiration. The record also indicates the patient has an order for low sodium diet. There is no evidence of problems, goals, or interventions for these needs on plan of care. Corrected on site. Patient#4: The record indicates there is a physician order for care to include the following precautions: Skin integrity, aspiration, and COVID. There is no evidence of problems, goals, or interventions for these needs on plan of care. Corrected on site. Patient#5: The record indicates there is a physician order for care to include the following precautions: skin integrity, aspiration, universal, and COVID. The patient also an order for no added sodium diet. There is no evidence of problems, goals, or interventions for these needs on plan of care. Patient#6: The record indicates there is a physician order for care to include the following precautions: bleeding, aspiration, oxygen safety, and universal. There is no evidence of goals, or interventions for these needs on plan of care. Corrected on site. Patient#7: The record indicates there is a physician order for care to include the following precautions: Skin integrity, universal precautions, and COVID. There is also an order for use of glucometer, and diet of no added sodium and no concentrated sugar. There is no evidence of goals, or interventions for these needs on plan of care. Corrected on site. Patient#8: The record indicates patient is ordered mechanical soft diet, no added sodium and no concentrated sugar. There is no evidence of goals or interventions related to these items found on plan of care.

Upon patient record review, 3 of 14 (Patient #2,#6,#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#2: The medical record contained an order for hydrocortisone 1% Topical twice a day as needed for itching with no area defined for administration. The medical record contained an order for Voltaren Arthritis Pain 1% Topical with no area defined for administration. The medical record contained an order for Nitroglycerin 0.4mg take 1 tab under tongue every 5 minutes as needed for chest pain with no indication of a maximum of 3 doses. Corrected on site. Patient#6: The medical record contained an order for hydrocortisone 2.5% topical cream with no area defined for administration. Corrected on site. Patient#10: The medical record contained an order for Diclofenac Sodium 1% topical gel with no area defined for administration. Corrected on site.

Upon patient record review, 1 of 14 (Patient #6) 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#6: The record indicated a physician order was placed on 2/19/24 referring patient for podiatrist care. There is no evidence of follow-up on this referral, or if podiatrist saw patient, and no revised plan of care was found.

Upon client record review, 1 of 14 (Patient #5) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient#5: The record indicates MSW frequency is ordered as initial visit within 5 days and 1 visit per recert. There is evidence of 2 visits made in October on 10/23/24 (initial) and 10/25/24. There is no evidence of an order for the 10/25 visit. The record indicates nurse frequency is ordered as SN visit 1 time per week and RN visit every 14 days. There is no evidence of a nurse visit being made the week of 2/16/25. There is no evidence of a missed visit documented.

Upon patient record review, 2 of 14 (Patient #1,#2) did not have evidence that the medical director or physician designee provides written certification that it is anticipated that the patient's life expectancy is 6 months or less if the illness runs its normal course. The physician must consider the following when making this determination: • The primary terminal condition • Related diagnosis • Current subjective and objective medical findings • Current medication and treatment orders • Information about the medical management of any of the patient's conditions unrelated to the terminal illness Patient#1and#2: The record indicates the initial CTI was completed by the medical director. However, the physician narrative on the certification did not have any evidence of subjective and objective findings related to the individual patient. The narrative stated the patient age, diagnosis, and that patient is eligible for recert and to continue symptom management, palliative care, and comfort care.

Upon patient client record review, 2 of 14 (Patient #1,#10) 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 record indicated RN completed LVN supervisory visits on 1/25/25, 2/1, 2/8, 2/14, 2/21. The documentation indicated in comments that LVN was following plan of care, educating family on medications and symptom management, and LVN demonstrates & teaches the caregiver on the effective use of medical equipment & supplies. However, LVN did not have a documented visit until 2/25/25. There was no evidence an LVN was providing care during the dates these supervisory visits were performed. Patient#10: The order states spiritual care to provide initial assessment within 5 days and then services declined thereafter. Initial assessment was completed on 4/30/25. There was no evidence of a spiritual visit after the initial. However, the Chaplin documented in the narrative for the initial assessment that he will continue to make visits 1 time per month.