Every finding on record at Silverstone Hospice Care Inc

Upon patient record review, 6 of 7 (Patient #1,2,3,4,5,6) 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. 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: There is evidence on the medication profile for MiraLAX Powder 17 gm 1 capful daily as needed. The profile does not include a diluent. In addition the initial nursing assessment notes the patient is on Oxygen 5 L/min via nasal cannula continuously. Oxygen is not listed on the medication profile. Additionally, there is a nurses note 9/10/24 "patient threw up twice yesterday advised PCG to give Zofran as needed. The Zofran is not listed on the medication profile. Patient #2: There is evidence on the medical record for a Oxygen 8L concentrator. Oxygen is not included on the medication profile with route and frequency. Patient #3: There is evidence on the medical record for a Oxygen 5L concentrator. Oxygen is not included on the medication profile with route and frequency. Patient #4: There is evidence on the medical record for a Oxygen 3L concentrator. Oxygen is not included on the medication profile with route and frequency. Patient #5: There is evidence on the medical record of a nurses note on admission "Oxygen 2L/min via NC". The oxygen is not listed on the medication profile. Patient #6: There is evidence on the medical record for Oxygen 3L concentrator. Oxygen is not included on the medication profile with route and frequency.

Upon patient record review, 7 of 7 (Patient #1,2,3,4,5,6,7) 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 #1,2,3,4,5,6,7: There is no evidence in the medical record that the patient had a bereavement assessment was completed on admission.

Upon patient record review, 5 of 7 (Patient #1,2,4,5,7) 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 #1: There is evidence in the medical record that the patient was admitted with unspecified diastolic heart failure. The initial plan of care did not include a problem/intervention/goal for cardiovascular. In addition, the patient was on Oxygen 5 L/min via NC continuously and there was no problem for respiratory including oxygen safety. Patient #2: There is evidence in the medical record that the patient was admitted with unspecified heart failure and 3+ pitting edema. The initial plan of care did not include a problem/intervention/goal for cardiovascular. Patient #4: There is evidence in the medical record nursing assessment 7/3/24 "patient has decreased appetite and taking less than 50% of meals. The initial plan of care does not include a problem/intervention/goal for Nutrition. Patient #5: There is evidence in the medical record that the patient was admitted with chronic heart failure. The initial plan of care did not include a problem/intervention/goal for cardiovascular. Patient #7: There is evidence in the medical record nursing assessment 5/8/24 "patient has dysphagia...inadequate nutritional intake". The plan of care does not include a problem/intervention/goal for nutrition or swallowing difficulty.

Upon patient record review, 1 of 7 (Patient #1) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient #1: There is evidence in the medical record of the SN making visits to the patient. There is no order for nursing visit frequency.

Upon patient record review, 6 of 7 (Patient #1,2,3,4,5,6) 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: There is evidence on the medication record for MiraLAX Powder 17 gm 1 capful daily as needed. The order does not include a diluent. In addition the initial nursing assessment notes the patient is on Oxygen 5 L/min via nasal cannula continuously. There is no order for Oxygen. Additionally, there is a nurses note 9/10/24 "patient threw up twice yesterday advised PCG to give Zofran as needed. There is not a medication order for Zofran. Patient #2: There is evidence on the medical record for DME Oxygen 8L concentrator. There is no detailed order for Oxygen. Patient #3: There is evidence on the medical record for DME Oxygen 5L concentrator. There is no detailed order for Oxygen. Patient #4: There is evidence on the medical record for DME Oxygen 3L concentrator. There is no order for Oxygen. Patient #5: There is evidence on the medical record of a nurses note on admission "Oxygen 2L/min vis NC". There is no order for Oxygen. Patient #6: There is evidence on the medical record for DME Oxygen 3L concentrator. There is no detailed order for Oxygen.

Upon patient record review, 7 of 7 (Patient #1,2,3,4,5,6,7) did not have evidence that the IDG in collaboration with the attending physician reviewed, revised and documents the individualized plan as frequently as the patient's condition requires but no less frequently then every 15 calendar days. There was no evidence a chaplain attended the interdisplinary group on 9/18/24. The interdisciplinary group note was not signed by the chaplain and there was no sign in sheet to provide evidence of attendance per the agency policy.

Upon patient record review, 1 of 7 (Patient #1) 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 evidence in the aide plan of care nursing instructions for the aide to "check vital signs only if patient is not feeling well or family request". There are no parameters for vital signs and if the patient is cognizant of making the decision to determine the task needing to be completed.

Upon patient record review 2 of 7 (Patient #1,2) 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 #1: There is evidence in the plan of care for aide visits to be 5xweek. On the week of 8/11/24, the aide visited 3 times. The week of 8/18/24 and 8/25/24, the aide visited 2 times per week. Patient #2: There is evidence in the plan of care for aide visits to be 5xweek. The week of 8/18/24, 8/25/24 and 9/1/24, the aide visited 2 times per week.

Upon patient record review 2 of 7 (Patient #1,2) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs. Patient #1: There is evidence in the patient record that the RN did not document aide supervision between 8/6/24 and 9/10/24. Patient #2: There is evidence in the patient record that the RN did not document aide supervision between 8/1/24 and 9/10/24.

Upon contract review, 1 of 3 (Ventura Medstaff) did not have evidence the agreement to furnish any services under arrangement included that the hospice must retain administrative and financial management, and oversight of staff and services for all arranged services, to ensure the provision of quality care. Arranged care/services are supported by written contract/agreement that requires all care/services are: • Delivered in accordance with the patient's plan of care