Every finding on record at Silver City Hospice and Palliative Care

Upon patient record review, 2 of 14 (Patient #7 & 8) 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 7: Patient had Suprapubic catheter present upon admission. There is no evidence of MD order for the presence of catheter, change or further nursing management of the catheter. Patient 8:Patient had Foley catheter present upon admission. There is no evidence of MD order for the presence of catheter, change or further nursing management of the catheter.

Upon client record review, 5 of 14 (Patient #1, 2, 3, 8, 14) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 1: The MSW conducted telehealth visits for the initial assessment on 6/7/24 and for the monthly visit on 7/6/24. The plan of care does not specify the need for, or approval of the MD for telehealth visits. Patient 2: The MSW conducted telehealth visits for the monthly visits on 2/19/24, 4/20/24, & 7/8/24. The plan of care does not specify the need for, or approval of the MD for telehealth visits. Patient 3: Frequency order states LVN once weekly. There have been 2 LVN visits each week since September of 2023. No evidence of order to increase frequency. Patient 8 & 14: The MSW initial assessment was conducted via telephone with no evidence of this need or approval on the plan of care.

Upon patient record review, 2 of 14 (Patient #2 & 5) 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 2: RN documentation reflects decreased visual acuity at the 6/24/24 visit and again on 7/8/24. The aide instructions were not updated to include any visual disturbance or safety needs related to this. Patient 5: Pt. is HOH with decreased visual acuity per nursing documentation. These needs are not reflected on the aide instructions. The aide instructions indicate catheter care each visit but there is no evidence found of urinary catheter.