Every finding on record at Sentara Home Care Services

Upon patient record review, 2 of 19 (Patient #3 and #6) 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 #3-There is no documented Initial Bereavement Assessment completed within the 5 days in the patient record. Patient #6-There is no documented Initial Bereavement Assessment completed within the 5 days in the patient record.

Upon patient record review, 1 of 19 (Patient #3) 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 #3-Bisacodyl 10 mg PR suppository documented as Bisacodyl 10 mg PR suppository PO daily. Conflicting medication route noted on the plan of care.

Upon client record review, 1 of 5 (Patient #3) did not have evidence that the hospice plan of care identifies the care and services that are needed and specifically identify which provider (nursing facility or hospice) is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care. Patient #3 - POC dated 04/12/2023 did not have evidence identifying which provider (nursing facility or hospice) is responsible for performing the wound care.

Upon patient record review 3 of 13 (Patient #2,#3,#5) 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 2: The patient was admitted 2-23-22. The medical record contains a MSW comprehensive assessment on 3-2-22 and the SC comprehensive assessment 3-18-22. The is no evidence the RN performed the SC or MSW comprehensive assessment. Patient 3: The patient was admitted 7-19-22. The medical record contains a SC comprehensive assessment on 7-27-22. The is no evidence the RN performed the SC comprehensive assessment. Patient 5: The patient was admitted 10-20-22. The medical record contains a SC comprehensive assessment on 11-18-22. The is no evidence the RN performed the SC comprehensive assessment.

Upon patient record review, 8 of 13 (Patient #3,#5,#6,#7,#8,#9,#12,#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: Patient 3: The medication profile contains Haloperidol 2m/ml take 1mg by mouth every 6 hours. The patient lives at home. There is no directive on how many ml's to give the patient to equal 1mg and no evidence of education provided to care giver. Morphine Concentrate 20mg/ml take 10mg by mouth every 2 hours prn pain. There is no directive on how many ml's to give patient to equal 10mg and no evidence of education provided to care giver. Miralax 17gm po 1 packet by mouth daily. There is no evidence of a diluent. On 3-17-23 the nurse documents "encouraged use of AYR nasal spray regularly along with Afrin TID for a few days". There is evidence that Afrin is ordered twice daily and no evidence of an order changed for the increased use of Afrin. Corrected on site. Patient 5: The medication profile contains Acetaminophen 500mg po take 500-1000mg by mouth every 6 hours for fever or moderate pain. There is no evidence on parameters of when to take 500mg and when to take the 1000mg dosages. Corrected on site. Patient 6: The medication profile contains Cranberry take by mouth once a day. There is no evidence of a dose. Magnesium po take by mouth once a day. There is no evidence of a dose. Corrected on site. Patient 7: The medication profile contains Haloperidol 2mg/ml give 1 mg by mouth every 6 hours prn nausea. This patient lives at home with a caregiver. There is no evidence of education given to caregiver regarding how many ml's makes 1mg. Morphine sulfate 5-10mg by mouth every 3 hours prn for pain or SOB. 0.5mg moderate pain and 10mg severe pain. There is no evidence of education given to caregiver regarding how many ml's makes 5 and 10mg dose. Corrected on site. Patient 8: The medication profile contains the following: Haloperidol 2mg/ml PO concentrate, dissolve 1mg under tongue every 4 hours prn delirium. This patient lives at home with a caregiver. There is no evidence of education given to caregiver regarding how many ml's makes 1mg, Morphine Sulfate 20mg/ml dissolve 5mg under tongue every 3 hours prn pain. There is no evidence of education given to caregiver regarding how many ml's makes 5mg, Miralax 17gm po daily with no evidence of a diluent, Compazine 10mg po take 1 tab by mouth every 6 hours prn with no indication. Corrected on site. Patient 9: The medication profile contains Miralax 17gm po daily with no evidence of a diluent. Corrected on site. Patient 12: The medication profile does not contain the following medications that are included in the plan of care: Bumetadine, Cholestyramine, Furosemide. The medication profile contains: Haloperidol 2mg/ml take 0.5mg po every 4 hours prn nausea. This patient lives at home with a caregiver. There is no evidence of education given to caregiver regarding how many ml's makes 0.5mg, Morphine 20mg/ml take 10mg po every 2 hours prn pain. This patient lives at home with a caregiver. There is no evidence of education given to caregiver regarding how many ml's makes 10mg. Corrected on site. Patient 13: The medication profile contains Haldol 2mg/ml take 1mg by mouth every 6 hours prn nausea. This patient lives at home with a caregiver. There is no evidence of education given to caregiver regarding how many ml's makes 1mg. Corrected on site.

Condition of Participation: Interdisciplinary Group, Care Planning, and Coordination of Services. L536

Upon patient record review, 5 of 13 (Patient #3, 7, 8, 12, 13) 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 3, 7, 8, 12, 13: The plans of care contained Haloperidol and/or Morphine dosed in mg (not ml) and did not provide education to the patient or caregiver on how to dose or administer the correct dose or amount of medication.

Upon patient record review, 1 of 13 (Patient #7) 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 7: The medical record contains a nursing narrative on 2-14-23 "Pt having more difficulty with transfers and weakness" and on 2-17-23 "Increase dizzy spells". There is no evidence of a care plan related to increasing weakness or a fall care plan was implemented.

Upon patient record review, 9 of 13 (Patient #1,#3,#5,#6,#7,#8,#9,#12,#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 contains Lorazepam 2mg/ml take 0.25ml by mouth every 4 days. This order was incorrectly written it was supposed to say every four hours. Corrected on site. Patient 3: The plan of care contains Haloperidol 2m/ml take 1mg by mouth every 6 hours. The patient lives at home. There is no directive on how many ml's to give the patient to equal 1mg and no evidence of education provided to care giver. Morphine Concentrate 20mg/ml take 10mg by mouth every 2 hours prn pain. There is no directive on how many ml's to give patient to equal 10mg and no evidence of education provided to care giver. Miralax 17gm po 1 packet by mouth daily. There is no evidence of a diluent. Corrected on site. Patient 5: The plan of care contains Acetaminophen 500mg po take 500-1000mg by mouth every 6 hours for fever or moderate pain. There is no evidence on parameters of when to take 500mg and when to take the 1000mg dosages. Corrected on site. Patient 6: The plan of care contains Cranberry take by mouth once a day. There is no evidence of a dose. Magnesium po take by mouth once a day. There is no evidence of a dose. The medical record contains a narrative by the nurse "Taking herbal laxative and fiber" and "Pt using Preparation H which is effective" and "She will take AZO and drink cranberry juice". There is no evidence herbal laxative, fiber, Preparation H or AZO is listed on the plan of care. Corrected on site. Patient 7: The plan of care contains Haloperidol 2mg/ml give 1 mg by mouth every 6 hours prn nausea. This patient lives at home with a caregiver. There is no evidence of education given to caregiver regarding how many ml's makes 1mg. Morphine sulfate 5-10mg by mouth every 3 hours prn for pain or SOB. 0.5mg moderate pain and 10mg severe pain. There is no evidence of education given to caregiver regarding how many ml's makes 5 and 10mg dose. The medical record contains documentation by the nurse on 2-17-23 "Foley 16 fr, drainage clear yellow urine". There is no evidence of foley catheter orders on the plan of care. Corrected on site. Patient 8: The medical record contains documentation by the nurse on 3-1-23 "Pt requested...Tylenol mostly BID, occasionally TID", on 3-28-23 "he now requests Tylenol 2-3 times per day". There is no evidence of Tylenol ordered on the plan of care. Oxygen is documented on the DME list though no evidence of orders for Oxygen. The plan of care contains the following: Haloperidol 2mg/ml PO concentrate, dissolve 1mg under tongue every 4 hours prn delirium. This patient lives at home with a caregiver. There is no evidence of education given to caregiver regarding how many ml's makes 1mg, Morphine Sulfate 20mg/ml dissolve 5mg under tongue every 3 hours prn pain. There is no evidence of education given to caregiver regarding how many ml's makes 5mg, Miralax 17gm po daily with no evidence of a diluent, Compazine 10mg po take 1 tab by mouth every 6 hours prn with no indication. Corrected on site. Patient 9: The plan of care contains Miralax 17gm po daily with no evidence of a diluent. Corrected on site. Patient 12: The plan of care contains: Haloperidol 2mg/ml take 0.5mg po every 4 hours prn nausea. This patient lives at home with a caregiver. There is no evidence of education given to caregiver regarding how many ml's makes 0.5mg, Morphine 20mg/ml take 10mg po every 2 hours prn pain. This patient lives at home with a caregiver. There is no evidence of education given to caregiver regarding how many ml's makes 10mg. Corrected on site. Patient 13: The plan of care contains Haldol 2mg/ml take 1mg by mouth every 6 hours prn nausea. This patient lives at home with a caregiver. There is no evidence of education given to caregiver regarding how many ml's makes 1mg. Corrected on site.

Upon patient record review, 9 of 13 (Patient #1,#2,#3,#4,#5,#6,#7,#12,#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 equipment and supply needs. Patients 1,2,3,4,5,6,7,12,13: The Plan of Care does not contain evidence that the equipment and supply needs are listed. Corrected on site.

Upon client record review, 5 of 13 (Patient #2,#3,#4,#5,#7,#8,#11) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 2: The medical record contains a note on 3-21-23 that patient has a new wound on Rt forearm that is red with slough and a small amount of drainage. The nurse applied foam dressing Alevyn. There is no evidence of an order for wound care. Corrected on site. Patient 3: The plan of care dated 2-24-23 has vital signs to be assessed every visit. There is no evidence vital signs were assessed or documentation of pt refusal on 3-17-23. Patient 4: The plan of care indicates the nurse is to assess pain every visit. There is no evidence the nurse assessed pain on 3-27-23. Patient 5: The medical record contains a narrative note by the nurse on 3-17-23: "encouraged use of AYR nasal spray regularly along with Afrin TID for a few days". There is evidence that Afrin is ordered twice daily and no evidence of an order changed for the increased use of Afrin. Patient 7: The plan of care contains orders for the nurse to assess pain every visit, there is evidence on 3-23-23 the nurse did not complete a pain assessment during visit. Patient 8: The plan of care contains orders for the nurse to assess pain every visit, there is evidence on 3-15-23 the nurse did not complete a pain assessment during visit. Patient 11: The plan of care contains orders for the nurse to assess pain every visit. There is a visit by the nurse on 3-23-23 with no evidence of pain being assessed.

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. Patient 5: The medical record contains a narrative note by the nurse on 2-27-23 "Pt leans to the right and falls in to the wall". There is no evidence there was an incident report completed.

Upon patient record review, 2 of 13 (Patient #5,#8) did not have evidence in the patient record that hospice aide assignments and duties are: Patient 5: The medical record contains documentation by the aide on 2-20-23,2-24,23,2-27-23 that patient refused linen changes. There is no evidence the aide care plan was updated. Patient 8: The medical record contains documentation by the aide on 3-14-23,3-17-23,3-21-23,3-24-23,3-28-23 that patient refused to have their linens changed, to be shaved, and transferred. There is no evidence the aide care plan was updated.

Upon patient record review 3 of 13 (Patient #2,#7,#9) did not have evidence documentation in the patient record that a hospice aide provides services that are: Patient 2: The medical record contains an aide visit on 2-17-23, 2-21-23 there was no evidence of any aide interventions being completed, no documentation of refusal. There is no evidence that the aide communicated with the nurse regarding care not completed. Patient 7: The medical record contains aide visits on 2-14-23,2-16-23,2-17-23 where catheter care is ordered by the nurse and not completed with no communication to the nurse or documentation why it was not completed. 2-20-23 lotion not applied to patient and 2-21-23 shampoo and lotion not completed. There is evidence these are ordered on the aide care plan. There is no evidence of refusal and no communication with the nurse. Patient 9: The medical record contains an aide visit on 2-27-23 which assist with oral care is ordered on the aide care plan but was not completed. There is no evidence of documentation of refusal and no communication with the nurse.

Upon patient record review 1 of 13 (Patient #1) did not have evidence in the patient record that the hospice aides report: Patient 1: The medical record contains documentation by the aide on 2-17-23 "pt fell last night and had lots of bruising". There is no evidence the aide communicated this finding with the nurse.

Upon patient client record review, 2 of 13 (Patient #4,#8) 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 4: The medical record contains a narrative note on 3-9-23 using "SWK", and on 3-21-23 a narrative by the chaplain with "+AS". There is no evidence that these are approved abbreviations. Patient 8: The medical record contains a narrative note by the chaplain on 1-30-23,3-20-23,3-27-23 at the end of the narrative "+AS" is documented. There is no evidence this is an approved abbreviation.

Upon patient record review, 2 of 13 (Patient #1,#2) did not have evidence that the hospice provided the following information: Patients 1 and 2: Upon nursing home visit the hospice binder did not contain and the nursing administrator unable to locate: Physician certification and recertification of the terminal illness specific to each patient, Names and contact information for hospice personnel involved in hospice care of each patient.