Every finding on record at Regal Hospice and Palliative Care Inc

Upon patient record review, 1 of 14 (Patient #3) did not have evidence that the hospice informed and provided written information to the patient concerning its policies on advance directives, including a description of applicable state law. Patient #3, Consent did not have documentation of Advance Directive provided.

Upon patient record review 2 of 14 (Patient #11,12) 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 #11, 12, No evidence of spiritual care assessment completed as patient denied visit per spiritual care documentation. Incomplete spiritual assessment on RN comprehensive assessment.

Upon patient record review, 1 of 14 (Patient #3) 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. Patient #3, Patient has no pain upon initial RN assessment however, RN documented pain interventions instructed. No care plan for pain.

Upon patient record review, 2 of 14 (Patient #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 equipment and supply needs. Patient #6, Patient has walker documented on Aide care plan, no documentation of any DME on POC. Patient #10, Patient has cane documented on Aide care plan, no documentation of any DME on POC.

Upon client record review, 12 of 14 (Patient #1,2,3,4,5,6,7,8,9,10,13,14) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1,2,3,4,5,6,7,8,9,10,13,14, SC provided telephone assessment without a order for a telephone visit. Patient #3, Frequency order for RN every 14 days, LVN every week. RN visits 11/29/23, 12/6/23, 12/13/23, 12/27/23, 1/10/24. LVN visits 1/2/24, 1/9/24, 1/19/24.

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 #2,3,RN entered her nursing bag and set up equipment to take vitals, temp, blood pressure cuff, thermometer, pulse ox before washing her hands per agency policy.

Upon patient record review, 5 of 14 (Patient #1,3,4,8,12) 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 #1,3,4,8,12, Aide care plan states bath, no check mark in front of shower, tub, bed, check mark in front of shower chair. Care plan did not identify what type of bath.

Upon patient record review 4 of 14 (Patient #2,9,11,13) 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 #2,9,11,13, Aide documented shower was given however, care plan states shower chair without identifying type of bath.

Upon patient client record review, 4 of 14 (Patient #7, 8, 12, 13) did not have evidence that each patient record contains Advance Directives. Patient #7,8,12,13, Consent documented patient has Advanced Directive, no evidence of copy in patient chart.

Upon patient client record review, 1 of 14 (Patient #13) 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 #13, Documented order to discharge due to death on 7/26/23, patient actually died on 7/29/23.

Upon client record review, 2 of 14 (Patient #11.12) did not have evidence that the discharge summary includes all required information. Patient #11,12, no evidence of patient treatments, symptoms and pain management in discharge summary.

Upon client record review, 1 of 14 (Patient #14) did not have evidence that the hospice plan of care reflects the participation of the hospice, the SNF/NF or ICF/IID and the patient/caregiver. Patient #14, No evidence of SNF involvement with plan of care documented.