Every finding on record at Saint Luka Hospice, Inc.

Upon patient record review, 5 of 15 (Patients #2,3,4,7,9) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient #2: The initial bereavement risk assessment was not completed. Patient #3: The initial bereavement risk assessment was not completed. Patient #4: The initial bereavement risk assessment was not completed. Patient #7: The initial bereavement risk assessment was not completed. Patient #9: The initial bereavement risk assessment was not completed.

Upon patient record review, 15 of 15 (Patients #1,2,3,4,5,6,7,8,9,10,11,12,13,14,15) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs Patient #1: The MSW visit frequency read as needed (11/1/23). This frequency did not include a baseline visit frequency. Patient #2: The MSW and SC visit frequency read 1X then PRN (10/18/23). These frequencies did not include a baseline visit frequency. Patient #3: The MSW and SC visit frequency read 1X then PRN (11/6/23). These frequencies did not include a baseline visit frequency. Patient #4: The MSW and SC visit frequency read 1X then PRN (9/15/23). These frequencies did not include a baseline visit frequency. Patient #5: The MSW and SC visit frequency read 1X then PRN (8/8/22). These frequencies did not include a baseline visit frequency. Patient #6: The MSW and SC visit frequency read 1X then PRN (8/25/22). These frequencies did not include a baseline visit frequency. Patient #7: The MSW and SC visit frequency read 1X then PRN (7/21/22). These frequencies did not include a baseline visit frequency. Patient #8: The MSW and SC visit frequency read 1X then PRN (8/24/22). These frequencies did not include a baseline visit frequency. Patient #9: The MSW and SC visit frequency read 1X then PRN (6/20/22). These frequencies did not include a baseline visit frequency. Patient #10: The MSW and SC visit frequency read 1X then PRN (7/28/22). These frequencies did not include a baseline visit frequency. Patient #11: The MSW and SC visit frequency read 1X then PRN (1/23/23). These frequencies did not include a baseline visit frequency. Patient #12: The MSW and SC visit frequency read 1X then PRN (6/22/22). These frequencies did not include a baseline visit frequency. Patient #13: The MSW and SC visit frequency read 1X then PRN (8/11/22). These frequencies did not include a baseline visit frequency. Patient #14: The MSW and SC visit frequency read 1X then PRN (8/27/22). These frequencies did not include a baseline visit frequency. Patient #15: The MSW and SC visit frequency read 1X then PRN (7/13/22). These frequencies did not include a baseline visit frequency.

Upon patient record review, 1 of 15 (Patient #2) 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 #2: The record reflected that this patient had a nebulizer medications. There was not a nebulizer machine included on the Plan of Care.

Upon observation, there was no evidence the hospice investigates all adverse events, incidents, accidents, variances or unusual occurrences that involve patient care and develops a plan of correction to prevent the same or similar event from occurring again. The aide performed handwashing and used bare hand to turn off faucet instead of disposable towel as indicated in Policies and Procedures.. He then proceeded to use hand sanitizer before visiting patient thus no infection risk.

Upon personnel record review, 1 of 13 (Personnel #10) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) Personnel #10: did not have normal range of motion and positioning observed on initial competency for the Aide.

Upon patient record review 1 of 15 (Patient #3) 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 #3: The POC listed Aid visit frequency of, 1 X per week. For first benefit week there was only 1 visit on 11/6/23. The visit frequency was not met.

Upon patient client record review, 1 of 15 (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: The record indicated the patient was discharged for non-compliance (9/16/22). However, there was a revocation form (9/16/22) in the chart that was signed by patient. This discharge reasons do not match.

Upon client record review, 3 of 15 (Patient #6,7,8) did not have evidence that the discharge summary includes all required information. Patient #6: This patient was transferred to another hospice, there was no evidence aŸŸ copy of signed consents for care, copy of the certification of terminal illness or Advanced Directives were included in Discharge Summary. Patient #7: This patient was transferred to another hospice, there was no evidence aŸŸ copy of signed consents for care or a copy of the certification of terminal illness were included in Discharge Summary. Patient #8: This patient was transferred to another hospice, there was no evidence aŸŸ copy of signed consents for care, copy of the certification of terminal illness or Advanced Directives were included in Discharge Summary.

Upon SNF/NF contract review, 1 of 4 (Country Villa contract) did not have a provision stating that the hospice reports all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by anyone unrelated to the hospice to the SNF/NF administrator within 24 hours of the hospice becoming aware of the alleged violation.