Every finding on record at Residential Hospice of Southern Illinois, LLC

Upon patient record review 1 of 23 (Patient #6) 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 6: The medical record includes documentation that the patient was admitted on 5/9/24. The spiritual care comprehensive assessment and the psychosocial comprehensive assessment are noted as completed on 5/15 24 which is greater than 5 days post admission.

Upon patient record review, 7 of 23 (Patient #1,#3,#5,#6,#9,#10,#13) 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:The medication profile includes an entry on admission of oxygen 2 liters per minute as needed for shortness of breath. There is no evidence that the medication profile includes route of administration for oxygen. The medication profile includes entries for acetaminophen 325 mg 2 tabs po q 6 hours as needed and Acetaminophen 650 mg suppository q 4 hours as needed for pain. There is no evidence that the medication profile includes instructions on a maximum daily dosage of acetaminophen. COS Patient 3:The medication profile includes entries for Acetaminophen 325 mg po q 6 hours as needed and Acetaminophen 650 mg suppository as needed q 4 hours. There is no evidence that the medication profile includes instructions on a maximum daily dosage of acetaminophen. COS Patient 5:The medication profile includes duplicate oxygen therapy entries. This includes an entry on 12/05/23 for oxygen 2 liters per minute via nasal cannula as needed for shortness of breath and an entry on 5/6/24 for oxygen 2 liters per minute via nasal cannula continuous. The medication profile includes an entry on 2/7/24 for Keflex 250 mg 1 cap daily x 3 months post procedure. Keflex remains on medication profile on 7/16/24 with no current order on plan of care. COS Patient 6:The medication profile includes an entry on admission of oxygen 2 liters per minute as needed for shortness of breath, may titrate up to 5 liters per minute as needed. There is no evidence that order on the plan of care includes instructions to titrate oxygen up to 5 liters per minute. The medication profile includes entries for Acetaminophen 325 mg 2 tabs po q 6 hours as needed and Acetaminophen 650 mg suppository as needed q 4 hours. There is no evidence that the medication profile includes instructions on a maximum daily dosage of acetaminophen. COS Patient 9:The medication profile includes an entry on admission of oxygen 2 liters per minute as needed for shortness of breath. There is no evidence that the medication profile includes route of administration for oxygen. Patient 10: The medication profile includes an entry for MiraLAX 17 gm daily for constipation. There is no evidence of a type and amount of diluent used for the administration of the medication. Patient 13: The plan of care includes an order on 7/2/24 for oxygen mask for use at night. There is no evidence that an oxygen mask is included in the oxygen therapy entry as an alternate route. The medication profile includes entries for Acetaminophen suppository 650 mg q 4 hours as needed and acetaminophen 500 mg po twice daily. There is no evidence that the entries include instructions of a maximum daily dose of acetaminophen.

Upon patient record review, 1 of 23 (Patient #1) 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 1:The plan of care include an order for wound care to be provided by the caregiver and assessments by RN. There is nursing documentation that wound care assessments were completed on 5/3/24, 5/31/24 and 6/25/24. There is no evidence that assessments were completed weekly per agency policy.

Upon patient record review, 4 of 23 (Patient #2,#5,#9,#10) did not have evidence that each patient and family received education and training provided as appropriate to their responsibilities for the care and services identified in the plan of care. Patient 2:The medical record contains documentation that the patient's medication regimen includes the use of levsin, acetaminophen and haloperidol. There is no evidence that education was provided on purpose, directions for use and side effects of the medications. Patient 5: The medical record contains documentation that the patient's drug regimen includes Bisacodyl, levsin and lorazepam. There is no evidence that education was provided on purpose, directions for use and side effects of the medications. Patient 9: The medical record contains documentation that the patient's drug regimen includes albuterol sulfate, aspirin, levothyroxine,potassium Chloride ER, sertraline, trelegy, hydrocodone, and loperamide. There is no evidence that education was provided on purpose, directions for use and side effects of the medications. Patient 10:The medical record contains documentation that the patient's drug regimen includes Aspirin, Compazine, Lexapro, Zofran, simvastatin, Spiriva, acetaminophen, meclizine, hydrocodone, MiraLAX, morphine concentrate. There is no evidence that education was provided on purpose, directions for use and side effects of the medications.

Upon patient record review, 5 of 23 (Patient #1,#11,#12,#14,#17) 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 medical record contains nursing documentation of a comorbid diagnosis of dysphagia, risk of aspiration and current diet ordered as pureed. There is no evidence that the plan of care includes problems, goals and interventions to manage dysphagia and the risk of aspiration. COS Patient 11:The medical record contains nursing documentation that the patient has a PleurX catheter drain in place with orders present to drain twice weekly. There is not evidence that the plan of care includes goals and interventions for the management of the PleurX drain. COS Patient 12:The medical record contains nursing documentation on admission that the patient has a gastrostomy tube for to meet nutritional needs with notes on 5/28/24 and 5/30/24 specifying increased difficulty with swallowing. There is no evidence that the plan of care includes problems, goals and interventions for the management and safe use of a gastrostomy tube, dysphagia or the risk of aspiration. COS Patient 14:The medical record includes documentation that the patient remains a full code. There is no evidence that the plan of care includes problems goals and interventions to reflect need for advanced directives. COS Patient 17:The medical record includes nursing documentation that the patient is at high risk for falls with 3 occurrences on 5/9/24 and 1 occurrence on 7/1/24 that required an ER visit. There is no evidence that the plan of care includes problems, goals and interventions for safety and management of fall risk.

Upon patient record review, 4 of 23 (Patient #1,#3, #9,#13) 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:The plan of care includes an order on admission of oxygen 2 liters per minute as needed for shortness of breath. There is no evidence that the order includes route of administration for oxygen. Patient 3:The plan of care includes an order for oxygen to be delivered at 5 liters per minute via nasal cannula. The medical record contains nursing documentation that the patient is using oxygen at 6 liters per minute via nasal cannula during visits on 7/2/24, 7/5/24 and 7/8/24. Patient 9:The plan of care includes an order on admission of oxygen 2 liters per minute as needed for shortness of breath. There is no evidence that the order includes route of administration for oxygen. Patient 13:The medical record contains nursing documentation of a skin tear to right outer forearm on 7/2/24 with subsequent wound care order to cleanse with wound cleanser, pat dry, cut to fit xeroform, cover with telfa pad and wrap with kerlex and secure with tape every 2 days. There is no evidence that the order includes who is to perform wound care.

Upon patient record review, 3 of 23 (Patient #4,#7,#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 4:The medical record contains nursing documentation that the patient uses a wheelchair for mobility. There is no evidence that the plan of care includes a wheelchair. COS Patient 7:The medical record contains nursing and aide documentation that the patient uses a shower chair for bathing. There is no evidence that the plan of care includes a shower chair. COS Patient 10: The medical record contains nursing documentation that the patient uses a walker and oxygen equipment and supplies. There is no evidence that the plan of care includes a walker or oxygen equipment and supplies.

Upon patient record review, 1 of 23 (Patient #15) 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 15:The medical record contains nursing documentation on 6/6/24 of 3+ pitting edema to bilateral lower extremities with pharmacological intervention of Lasix 20 mg po daily initiated on 6/24/24. There is no evidence of updates to problems, goals and interventions for management of symptom of edema.

Upon patient record review, 6 of 23 (Patient #1,#6,#7,#11,#15,#17) 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, 6, 7 and 15: The medical record contains documentation that the patient is at risk for aspiration due to dysphagia. There is no evidence that the aide plan of care includes aspiration precautions. COS Patient 11: The aide plan of care includes the task of bathing/shower assigned. There is no evidence that the task of undressing and dressing patient is assigned. COS Patient 17: The medical record contain documentation that the patient is a high risk for falls. There is no evidence that the aide plan of care includes fall precautions.

Upon patient record review 1 of 23 (Patient #16) 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 16: The Aide plan of care developed on 4/3/24 includes the task of shampoo hair ordered weekly with the aide documentation noting that the task was completed every visit form 4/8/24 through 5/22/24. The patient's visit frequency for the aide was 2 times weekly.