Every finding on record at Sehaj Hospice Care Inc

Upon patient record review 1 of 14 (Patient #1) 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 #1: There is evidence in the record that the patient was admitted on 6/7/24. The psychosocial assessment was completed on 6/22/24.

Upon patient record review 3 of 14 (Patient #1, #4, #6) 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 #1: There is no evidence in the record that a spiritual assessment was completed as part of the comprehensive assessment. Patient #4: There is no evidence in the record that a spiritual assessment was completed as part of the comprehensive assessment. Patient #6: There is no evidence in the record that a spiritual assessment was completed as part of the comprehensive assessment.

Upon patient record review, 10 of 14 (Patient #1-10) did not have evidence in the patient record that the comprehensive assessment takes into consideration the imminence of death. Patient #1: There is no evidence in the record that the comprehensive assessment takes into consideration the imminence of death. Patient #2: There is no evidence in the record that the comprehensive assessment takes into consideration the imminence of death. Patient #3: There is no evidence in the record that the comprehensive assessment takes into consideration the imminence of death. Patient #4: There is no evidence in the record that the comprehensive assessment takes into consideration the imminence of death. Patient #5: There is no evidence in the record that the comprehensive assessment takes into consideration the imminence of death. Patient #6: There is no evidence in the record that the comprehensive assessment takes into consideration the imminence of death. Patient #7: There is no evidence in the record that the comprehensive assessment takes into consideration the imminence of death. Patient #8: There is no evidence in the record that the comprehensive assessment takes into consideration the imminence of death. Patient #9: There is no evidence in the record that the comprehensive assessment takes into consideration the imminence of death. Patient #10: There is no evidence in the record that the comprehensive assessment takes into consideration the imminence of death.

Upon patient record review, 2 of 14 (Patient #2, #3) 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 #2: During the home visit, the agency medication record listed Naproxen and Seroquel. According to the caregiver, the patient stopped taking the Seroquel weeks ago and the Naproxen was recently discontinued. (Corrected on site.) Patient #3: There is evidence in the record of a physician order on 6/6/24 for Oxygen 2-3 L/min via nasal cannula as needed for shortness of breath. Oxygen was not listed on the medication record. (Corrected on site.)

Upon patient record review, 2 of 14 (Patient #1, #4) 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 #1: There is evidence in the record that the patient was admitted on 6/7/24. The bereavement assessment was completed on 6/22/24. Patient #4: There is evidence in the record that the patient was admitted on 5/17/24. The bereavement assessment has not been completed.

Upon patient record review, 3 of 14 (Patient #1, #3, #5) 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: There is documentation by the nurse in the admission narrative of 6/7/24 "Patient takes a soft diet and swallows pills with applesauce and is high risk for aspiration". Risk for aspiration is not included in the Plan of Care. (Corrected on site.) Patient #3: There is evidence in the record the patient is being treated for pancreatic cancer and is taking pain medication. There is no care plan addressing pain. (Corrected on site.) Patient #5: There is documentation in the admission narrative "patient is a feeder on pureed food due to swallowing difficulty; prone to aspiration. There is no care plan addressing swallowing difficulty. (Corrected on site.)

Upon patient record review, 3 of 14 (Patient #1, #4, #6) 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 medication record contains an order for Oxygen PRN, there is not an indicator noted. Patient #4: The medication record contains an order for Oxygen PRN, there is not an indicator noted. Patient #6: There is a narrative note on admission "condom catheter in place". There is no evidence in the record of an order for an external urinary catheter on admission. (Corrected on 6/27/24 with an order for an external catheter.)

Upon patient record review, 3 of 14 (Patient #1, #5, #7) 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: There is documentation by the nurse on 6/7/24 "patient is high risk for aspiration". Aspiration precautions is not included in the HHA plan of care. (Corrected on site.) Patient #5: There is documentation in the admission narrative "patient is a feeder on pureed food due to swallowing difficulty; prone to aspiration. Aspiration precautions in not included in the HHA plan of care. (Corrected on site.) Patient #7: There is documentation in the nursing assessment that the patient is NPO. The HHA plan of care indicates the patient is on a soft diet.

Upon patient record review 1 of 14 (Patient #4) 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 #4: The HHA plan of care indicates ambulate every visit. On 5/24, 5/28 and 5/31/24 the task was not completed. Patient #6: There is no evidence in the record that an external catheter was in place and ordered on admission 6/19/24. The RN added external catheter care to the HHA plan of care. (An order was obtained on 6/27/24 for an external urinary catheter and the HHA plan of care was updated at that time.)

Upon patient client record review, 10 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: There is evidence in the record, the Election of Benefits staff signature was illegible and did not contain credentials. In addition, the emergency guidelines form completed on admission has multiple blank areas including: safe space location in home for earthquake and wild fire, etc. Patient #2: There is evidence in the record, the Election of Benefits staff signature was illegible and did not contain credentials. In addition, the emergency guidelines form completed on admission has multiple blank areas including: safe space location in home for earthquake and wild fire, etc. Patient #3: There is evidence in the record, the Election of Benefits staff signature was illegible and did not contain credentials. In addition, the emergency guidelines form completed on admission has multiple blank areas including: safe space location in home for earthquake and wild fire, etc. Patient #4: There is evidence in the record the emergency guidelines form completed on admission has multiple blank areas including: safe space location in home for earthquake and wild fire, etc. Patient #5: There is evidence in the record, the Election of Benefits staff signature was illegible and did not contain credentials. In addition, the emergency guidelines form completed on admission has multiple blank areas including: safe space location in home for earthquake and wild fire, etc. Patient #6: There is evidence in the record the emergency guidelines form completed on admission has multiple blank areas including: safe space location in home for earthquake and wild fire, etc. Patient #7: There is evidence in the record, the Election of Benefits staff signature was illegible and did not contain credentials. In addition, the emergency guidelines form completed on admission has multiple blank areas including: safe space location in home for earthquake and wild fire, etc. Patient #8: There is evidence in the record, the Election of Benefits staff signature was illegible and did not contain credentials. In addition, the emergency guidelines form completed on admission has multiple blank areas including: safe space location in home for earthquake and wild fire, etc. Patient #9: There is evidence in the record, the Election of Benefits staff signature was illegible and did not contain credentials. Patient #10: There is evidence in the record, the Election of Benefits staff signature was illegible and did not contain credentials. In addition, the emergency guidelines form completed on admission has multiple blank areas including: safe space location in home for earthquake and wild fire, etc.