Every finding on record at Skye Healthcare Services, Inc.

Upon patient record review 5 of 5 (Patient #1, #2, #3, #4, #5) 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: There was no evidence of a psychosocial or spiritual care assessment of the patient or family. There is no evidence the RN completed this part of the comprehensive assessment. Patient #2: There was no evidence of a completed spiritual care assessment of the patient or family. Chaplain services were declined. There is no evidence the RN completed this part of the comprehensive assessment. Patient #3: There was no evidence of a psychosocial assessment of the patient or family. There is no evidence the RN completed this part of the comprehensive assessment. Patient #4: There was no evidence of a completed spiritual care assessment of the patient and family. Chaplain services were declined. There is no evidence the RN completed this part of the comprehensive assessment. Patient #5: There was no evidence of a spiritual care assessment of the patient or family. Chaplain services were declined. There is no evidence the RN completed this part of the comprehensive assessment.

Upon patient record review, 2 of 5 (Patient #1, #4) 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: The patient was admitted on 1/10/23. There was no evidence of a bereavement risk assessment at the time of survey. Patient #4: The patient was admitted on 12/30/22. There was no evidence of a bereavement risk assessment at the time of survey.

Upon patient record review, 2 of 5 (Patient #1 and 2) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual's attending physician, if any) • Changes that have taken place since the initial assessment • Information on the patient's progress toward desired outcomes • Reassessment of the patient's response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days Patient #1: RN visits only contained supervisory visits and do not contain an update to comprehensive assessment from 1/22/23 to 2/19/23. Patient #2: RN visits only contained supervisory visits and do not contain an update to comprehensive assessment from 1/22/23 to 2/19/23.

Upon client record review, 1 of 5 (Patient #2) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 2 there was an order to change the foley on the 17th of the month. No evidence this was performed in January or February.

Upon patient record review 1 of 5 (Patient #1) 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: The medical record contained an aide plan of care indicated for all tasks to be completed 2 x week starting 1/10/23. There was documentation that the tasks were completed 1x week during these weeks on 1/12/23 and 2/9/23.

Upon personnel record review, 8 of 14 (Personnel #2, #3, #4, #5, #6, #7, #8, #9) did not have evidence that a skills competency assessment, specific to each discipline had been conducted for all personnel including volunteers initially during orientation. Personnel #2, #3, #4: The initial competency on record was a self assessment competency. The competency assessment did not include the date skills were validated and/or validation method. Personnel #5: The LVN competency was signed by an RN and documents skills were reviewed and determined competent. The initial competency on record was a self assessment competency. There was no validation method or validation date on record. Personnel #6: The initial competency on record was a self assessment competency. There was no validation method or validation date on record. Personnel #7: There is not evidence on record the MSW had a competency performed by an RN or another MSW. The initial competency on record was a self assessment competency. There was no validation method and/or validation date. Personnel #8: There was not a skills competency on record for Spiritual Coordinator, Bereavement Coordinator, and Volunteer Coordinator. There was no validation method on record. The initial competencies on record were self assessment competencies. Personnel #9: There was not a skills competency on record for the Volunteer. There was no validation method or validation date on record. The initial competency on record was a self assessment competency.

Upon patient client record review, 2 of 5 (Patient #2, #4) 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 #2: The medical record contained a visit note by the RN dated 1/30/23 documenting the patient stands and ambulates unaided. The documentation conflicts with the narrative on the same date that the patient uses a cane, walker, and walls to hold onto when ambulating. Patient #4: The medical record contained documentation in the Nursing Comprehensive Assessment dated 12/30/22 that the patient has no family or social support. The record indicated the patient lives in an independent facility and the daughter comes to visit and provide ADL care.