Every finding on record at Rosewood Hospice, Inc.

Observed in Record Review. In 6 of 14 patient records reviewed, During HV#1 record review it was noted lack of goals identified by the spiritual counselor on the POC. During RR#2 it was noted the following goals were not individualized for the patient: ADL needs are met to an optimal level within the whole episode. Under the musculoskeletal system deficits: Increase strength/energy for optimal functional activities, provide Activities appropriate to patients disease progression, and the pcg will verbalized right diet to avoid gout flare ups. During RR#3 it was noted the following goal was not individualized to the patient care: under the musculoskeletal system POC: Increase strength/energy for optimal functional activities, provide activities appropriate to patients disease progression and Pcg will verbalized right diet to avoid gout flare ups. During RR#5 it was noted some of the goals were not individualized to the patient care: goals: Increase strength/energy for optimal functional activities within the whole period and will discuss during IDG meeting, optimal bowel elimination and comfort, reduce discomfort with improved bowel elimination status. During RR#6 it was noted some of the goals were not individualized to the patient care: Facilitate bowel movement -Pt/Family/PCG will verbalize having elimination needs met at an acceptable level. Increase strength/energy for optimal functional activities. During RR#5 it was noted lack of MSW goals on the POC. This was discussed with the DPCS and the Administrator.

Observed in Record Review. In 2 of 14 patient records reviewed, It was noted during HV#1 record reivew lack of interventions identified by the spiritual counselor on the POC. During RR#5 it was noted lack of MSW interventions on the POC. This was discussed with the DPCS and Administrator.

Observed in Record Review. In 9 of 14 patient records reviewed, During HV#1 record reivew it was noted lack of the number of PRN visits ordered for the spiritual counselor and the MSW. The MSW visits were as follows: Initial Assessment then 1x/month and as needed and every recertification for emotional and psychosocial support. The SC visit were as follows: Initial Assessment then 1x/month and as needed and every recertification for spiritual support and counseling. During RR#1 it was noted lack of the number for PRN visits for the MSW as documented: MSW visit for Initial Assessment then 1x/month and as needed and every recertification for emotional and psychosocial support. During HV#2, HV#3 record reviews and RR#3, RR#4, RR#5 and RR#6 it was noted the MSW visits and RN visits lacked the number of PRN visits to be performed if indicated: MSW visit for Initial Assessment then as needed for emotional and psychosocial support and RN visit to do Initial Assessment and Admission if appropriate then to do supervisory visit, Recertification assessment and as needed. During RR#7 it was noted the RN visit frequency lacked the number of PRN visits to be performed if indicated: RN visit to do Initial Assessment and Admission if appropriate then to do supervisory visit, Recertification assessment and as needed. This was discussed with the DPCS and Administrator.

Observed in Record Review. In 1 of 14 patient records reviewed, During RR#5 it was noted lack of a documented MSW visit in April 2023 that did not follow the POC frequency order of 1x/month. This was discussed with the DPCS and Administrator.

Observed in Individual Tracer. In 1 of 3 home visits conducted, During HV#1 it was noted the SN did not adhere to the organization Hand Hygiene Policy #9-009 and entered her bag multiple times without removing her gloves. In addition during patient care after her gloves were removed before donning a clean pair the SN did not disinfect her hands. This was discussed with the DPCS.

Observed in Record Review. In 4 of 14 patient records reviewed, During RR#2 it was noted dressing change orders were added to the POC in April 2024. The hospice aide assignment form was not updated to reflect the provision of personal care changes related to the wound dressings. During RR#4 it was noted the hospice aide assignment form was not updated to reflect the provision of personal care changes related to the wound dressings in July 2023. During RR#6 it was noted the hospice aide assignment form was not updated to reflect the provision of personal care changes related to the wound care dressing in March 2024. During RR#7 it was noted an order for O2 @L/nasal cannula (NC) continuously. The aide assignment has O2 at 2L/ NC listed as PRN. This was discussed with the DPCS and Administrator.

Observed in Patient Home. In 3 of 3 home visits conducted, During HV#1- #3 it was noted lack of documented emergency preparedness plan for each patient that was based on the patient’s priority level, and was individualized to the patient’s needs. This was discussed with the DPCS.

Observed in Document Review. During reivew of the Skilled Nursing Facility (SNF) contract it was noted lack of a provision that the SNF, NF, or ICF/IID notifies the hospice immediately when there is a significant change in the patient’s physical, mental, social, or emotional status. This was discussed with the Administrator.

Observed in Document Review. During review of the SNF contract it was noted it lacked a provision stating that the hospice will report all mistreatment, neglect, or verbal, mental, sexual, and physical abuse to the SNF, NF, or ICF/IID administrator within 24 hours of the hospice becoming aware of the alleged violation, including injuries of unknown source, and misappropriation of patient property by anyone unrelated to the hospice. This was discussed with the Administrator

Observed in Document Review. During reivew of the SNF contract it was noted lack of a delineation of the responsibilities of the hospice and the SNF, NF, or ICF/IID to provide bereavement services to SNF, NF, or ICF/IID staff. This was discussed with the Administrator.