Every finding on record at Shirkey Diversified Health Services, Inc.

Upon patient record review 1 of 19 (Patient #6) 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 6:The patient was admitted to hospice on 8/7/23. There is no evidence of a spiritual comprehensive assessment completed until 8/15/23.

Upon patient record review, 2 of 19 (Patient #4,#14) 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 4 and 14:Upon admission, the medication profile included an entry for Miralax 17 g daily. The entry did not include the type and amount of diluent needed.

Upon patient record review, 2 of 19 (Patient #5,#8) 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 5:The patient was admitted for End Stage Liver Disease. There is no evidence of problem statements with goals, interventions and progress toward outcomes related to liver disease on the plan of care. Patient 8:On admission there is nursing documentation that patient had a gastrostomy tube for nutrition. There is no evidence of problem statements with goals, interventions and progress toward outcomes related to enteral nutrition on the plan of care.

Upon patient record review, 2 of 19 (Patient #4,#14) 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 4:Upon admission, the plan of care included on order for MiraLAX 17 g daily. The order did not include the type and amount of diluent needed. On 9/15/23 there is a wound care orders added for wounds to the right upper buttocks, left lower leg and coccyx. There is not evidence that the order includes who is to perform care. Patient 14:Upon admission, the plan of care included on order for MiraLAX 17 g daily. The order did not include the type and amount of diluent needed.

Upon patient record review, 2 of 19 (Patient #4, #5) 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 4:On 9/25/23 the plan of care was updated with orders for wound care to be provided to the right upper buttocks, left lower leg and coccyx. There is no evidence of goals and interventions for the problem statement of altered skin integrity. Patient 5:The medical record includes nursing documentation on 10/25/23 that patient had new onset of unsteady gait and reported pain in left shoulder that was "killing" him. There is no evidence of interventions provided or collaboration with physician to revise the plan of care related to the newly identified issues.

Upon patient record review, 2 of 19 (Patient #4,#8) 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 4 and 8:The aide plan of care on admission indicates tasks of bed bath and shower to be performed every visit.

Upon patient record review 2 of 19 (Patient #7,#9) 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 7:The aide visit frequency was initially ordered as 3 visits per week. The week of 9/6/23, 9/17/23 and 10/6/23 there is evidence of only 2 visits completed by aide. Patient 9:The aide visit frequency was initially ordered as 3 visits per week effective 9/15/23. There is no evidence of aide visits completed the week of 9/15/23.