Every finding on record at Shanti Hospice LLC

Upon patient record review 5 of 14 (Patient #1,#2,#3,#6,#8) 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,#3: The record indicates chaplain met with patient to perform the initial spiritual assessment. There is no evidence that a comprehensive assessment was completed where patient needs were identified. Documentation indicates patient was awake, frequency of future visits, provided spiritual care encouragement and support, and closed visit with prayer. Patient#2: The record indicates chaplain met with patient to perform the initial spiritual assessment on 4/5. There is no evidence that a comprehensive assessment was completed where patient needs were assessed. Patient#6: The record indicates chaplain met with patient to perform the initial spiritual assessment. Documentation states chaplain met with a wife and a friend as patient unable to verbalize. Documentation states patient and care concerns were discussed. There is no evidence what the concerns or needs are. Patient#8: The record indicates chaplain met with patient to perform the initial spiritual assessment on 9/13. Documentation states patient was in a deep sleep during visit, frequency was listed and closed in prayer. There is no evidence that a comprehensive assessment was completed where patient needs were identified.

Upon patient record review, 5 of 14 (Patient #1,#2,#4,#5,#10) 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 record indicated for A&D zinc oxide cream to be applied one time daily. Thera is no evidence of a specific area of application. Corrected on site. Patient#2,#5,#10: The record indicated for A&D zinc oxide cream to be applied one time daily. There is no evidence of a specific area of application. Corrected on site. Patient#4: The record indicated for acetaminophen 325mg give 2 every 4 hours PRN pain/fever. There is no evidence of a parameter for when to administer for fever. Corrected on site.

Upon patient record review, 9 of 14 (Patient #1,#2,#3,#4,#6,#7,#8,#9,#10) 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,#2,#3,#4,#7,#8,#10: The record indicates the chaplain did make a visit to complete initial bereavement assessment. There is no evidence of a primary bereaved being identified. The assessment only stated the risk level. There is no evidence of of how the risk level was determined, topics assessed, or any needs, culture, or ability to cope. Patient#6,#9: The record indicates the chaplain did make a visit to complete initial bereavement assessment. The assessment only stated the risk level. There is no evidence of of how the risk level was determined, topics assessed, or any needs, culture, or ability to cope.

Upon patient record review, 1 of 14 (Patient #6) 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#6: The record indicates patient had a wound on admit visit 7/19 which the nurse documents wound was assessed and measured. There is no evidence of wound being assessed/measured after admit until nurse visit on 8/20.

Upon patient record review, 8 of 14 (Patient#2,#3,#4,#5,#6,#7,#8,#9) 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#2: The record indicated the patient was receiving wound care and was incontinent. There is no evidence of patient goals or interventions related to these needs on plan of care. COS. Patient#3: The record indicates patient has depression, incontinence, diabetes, and was receiving wound care. There is no evidence of patient problems goals or interventions related to these needs on plan of care. COS. Patient#4: The record indicates patient has aspiration precaution, dysphagia, and G tube care. There is no evidence of patient problems, goals or interventions related to these needs on plan of care. COS. Patient#5: The record indicates patient has diabetes (taking metformin), soft diet, dysphagia, and incontinence. There is no evidence of patient problems, goals or interventions related to these needs on plan of care. COS. Patient#6: The record indicate patient has dysphagia, puree diet, and thickened liquids. There is no evidence of patient problems, goals or interventions related to these needs on plan of care. On admit the documentation indicates patient had COVID. There is no evidence of problems, goals or interventions on plan of care. Patient#7: The record indicates the patient has incontinence. There is no evidence of patient problems, goals or interventions related to these needs on plan of care. COS. Patient#8: The record indicates the patient has ascites. There is no evidence of patient problems, goals or interventions related to these needs on plan of care. COS. Patient#9: The record indicates the patient has incontinence and dysphagia. There is no evidence of patient problems, goals or interventions related to these needs on plan of care. COS.

Upon patient record review, 1 of 14 (Patient #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 #6: The record indicates that the patient diet was changed to puree per nurse documentation on 9/3/24. There is no evidence of a physician order for change in diet. COS.

Upon patient record review, 8 of 14 (Patient #3,#4,#5,#6,#7,#8,#9,#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#3: The record indicates patient having oxygen concentrator, nebulizer, e tanks, protective underwear, incontinence supplies, and hygiene supplies There is no evidence these items on the plan of care. Corrected on site. Patient#4: The record indicates patient having Oxygen concentrator and supplies, suction, and wound care supplies. There is no evidence these items on the plan of care. Corrected on site. Patient#5: The record indicates patient having bed side table, shower bench, walker, hygiene supplies, incontinence supplies, and PPE supplies. There is no evidence these items on the plan of care. Corrected on site. Patient#6: The record indicates patient having hospital bed, special mattress, half rails, bed side table, reclining wheelchair, oxygen concentrator, hoyer lift, e tanks, incontinence supplies, hygiene supplies. There is no evidence these items on the plan of care. Corrected on site. Patient#7: The record indicates patient having walker, lift, shower chair, bedside table, incontinence supplies, hygiene supplies, and gloves. There is no evidence these items on the plan of care. Corrected on site. Patient#8: The record indicates patient having oxygen concentrator, E-tanks, hygiene supplies, gloves. There is no evidence these items on the plan of care. Corrected on site. Patient#9: The record indicates patient having wheelchair, hospital bed, bedside table, incontinence supplies, hygiene supplies, and gloves. There is no evidence these items on the plan of care. Corrected on site. Patient#10: The record indicates patient having wheelchair with foot rest, hospital bed, mattress, bedside table, oxygen concentrator, shower bench, incontinence supplies, hygiene supplies, and gloves. There is no evidence these items on the plan of care. Corrected on site.

Upon patient record review, 2 of 14 (Patient #6,#9) 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#6: The record indicates per nurses documentation on 9/3 the patient's diet was changed to puree. There is no evidence of an update to the plan of care reflecting problems/goals/interventions of this change. Patient#9: The record indicates per nurses documentation on 8/12 that patient diet was changed to soft diet and meds were to be crushed. There is no evidence of an update to the plan of care reflecting problems/goals/interventions of this change.

Upon patient record review, 3 of 13 (Patient #2, 3, 6) 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. Patient 2, 3, 6: Oxygen therapy appeared on the medication lists of these patients as oxygen 1-5L/min continuous inhalation via NC PRN for dyspnea and SOB. The oxygen cannot be ordered as both continuous and PRN/as needed simultaneously. (corrected on site)

Upon patient record review, 2 of 13 (Patient #5, 7) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient that reflects all problems identified in the initial and comprehensive assessments. Patient 5: On the comprehensive initial assessment, dated 09.16.2021, it was noted that the patient had difficulty swallowing; nectar thick liquids were ordered and a commercial thickener appeared on the patient's medication list for use. The SN note dated 10.27.2021 indicated the patient had developed aspiration pneumonia; the patient was treated with Levaquin and prednisone. There is no evidence of a care plan related to aspiration risk or swallowing status. (corrected on site) Patient 7: On the comprehensive initial assessment, dated 10.08.2021, it was noted that the patient was an elopement risk; the patient was transferred from an acute care hospital to an ALF, where he was then admitted for hospice services, largely due to previous elopements from his private home. SN note dated 10.26.2021 indicates the patient escaped the ALF twice during the previous week. There is no evidence of a care plan related to elopement risk. (corrected on site)

Upon observation, there was no evidence in the QAPI reports that the hospice maintains a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases. Patient 3: The SN note dated 10.19.2021 indicates the patient exhibited symptoms of a UTI and was treated with Bactrim. The SN note dated 10.21.2021 indicates the patient continued to have symptoms; Bactrim was discontinued and cipro was initiated for 10 days. This infection was not entered on the hospice's infection log for investigation.

Upon patient record review, 13 of 13 (Patient #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13) did not have evidence in the patient record that hospice aide assignments and duties include the tasks and the frequency of the tasks to be performed. Patient 1,2,3,4,5,6,7,8,9,10,11,12,13: The hospice aide care plan did not indicate a frequency for the tasks to be performed by the aide.

Upon patient client record review, 1 of 13 (Patient #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. Patient 10: The narrative portion of the MSW comprehensive initial assessment, dated 10.05.2021, reads 'Patient denies any mental health & denies any sadness or depression. Hey Siri. Pause that if it is time to go he is OK'. This is an unclear entry.