Every finding on record at Spear Business Enterprises LLC

Upon patient record review, 1 of 5 (Patient #3) 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 3: There is documentation in the medical record that patient was using oxygen. Oxygen is not listed on the medication profile. There is an order for morphine on the medication profile: morphine injection solution 1mg/mL, 1mL every 4 hours PRN. Instructions: 1mg/1mL by mouth every 4 hours as needed for pain/shortness of breath. There is no evidence of correct administration route for this order. In addition, there are physician’s orders in the medical record: 1) morphine sulfate 20mg/mL 0.5-1mL po/sl every 2 hours as needed for shortness of breath or pain. 2) Tylenol suppository 650mg rectally every 4 hours as needed for mild pain or fever. There is no evidence of these medications on the medication profile.

Upon patient record review, 1 of 5 (Patient #3) 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 3: Patient was admitted on 11/19/2024. Initial bereavement assessment was dated 11/18/2024. There is no evidence of a bereavement assessment after admission.

Upon patient record review, 4 of 5 (Patient #1,2,3,5) 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: Identified needs: weakness, fall risk, neuro/confusion, constipation, pain, edema, high risk for skin breakdown, dyspnea. There is no evidence of plans of care with problems, goals and interventions: fall risk, constipation, pain, edema, high risk for skin breakdown. Patient 2: Identified needs: weakness, fall risk, neuro/confusion, constipation, pain, edema, dyspnea. There is no evidence of plans of care with problems, goals and interventions: constipation, dyspnea, edema. Patient 3: Identified needs: oxygen use, respiratory, nutrition/g-tube use (feedings), constipation, weakness, fall risk, pain. There is no evidence of plans of care with problems, goals and interventions: oxygen use, respiratory, nutrition/gtube use (feedings), constipation. Patient 5: Identified needs: fall risk, neuro/confusion, constipation, pain, edema, oxygen use, nutrition/aspiration risk. There is no evidence of plans of care with problems, goals and interventions: pain, edema, oxygen use, nutrition/aspiration risk.

Upon patient record review, 1 of 5 (Patient #3) 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 3: There is documentation in the medical record that patient was using oxygen. There is no evidence of oxygen on the plan of care. There is an order for morphine on the plan of care: morphine injection solution 1mg/mL, 1mL every 4 hours PRN. Instructions: 1mg/1mL by mouth every 4 hours as needed for pain/shortness of breath. There is no evidence of correct administration route for this order. There are physician’s orders in the medical record: 1) morphine sulfate 20mg/mL 0.5-1mL po/sl every 2 hours as needed for shortness of breath or pain. 2) Tylenol suppository 650mg rectally every 4 hours as needed for mild pain or fever. There is no evidence of these medications on the plan of care.

Upon patient record review, 3 of 5 (Patient #1,2,4) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 1,4: Patient was admitted to hospice on 11/26/2024. There are multiple orders for MSW and SC visit frequencies written on 11/26/24. Order 1 states (for both disciplines): 1 visit within 5 days of admission and once per month. Order 2 states (for both disciplines): 1 time per month and 1 as needed. There are duplicate frequency orders. Patient 2: Patient was admitted to hospice on 11/26/2024. There are multiple orders for MSW and SC visit frequencies written on 11/26/24. Order 1 states (for both disciplines): 1 visit within 5 days of admission and once per month. Order 2 states (for both disciplines): 1 time per month and 2 as needed. There are duplicate frequency orders.

Upon patient record review, 4 of 4 (Patient #1, 2, 3, 4) 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: Patient has Dulcolax suppository on med profile, but also has Dulcolax pills in home. Patient does not have Miralax and docusate sodium and reports no longer taking. although remain on med profile. Patient has Acetaminophen tabs on med profile, but suppository in home and not on med profile. Patient #2: Acetaminophen suppositories in home. Tablets on med profile. No Colace in home -no longer taking. RN will obtain order to make prn. Patient #3: Seroquel 25 mg TID is in home and not on med profile. Miralax 17 gm in home and not on med profile. Patient #4: Donepezil 10 mg PO daily and Miralax 7 gm daily PO for constipation are listed on the plan of care, but not on med profile.

Upon patient record review, 3 of 5 (Patient #1, 2, 3) 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. Patients #1, 2, 3: Miralax 17 gm daily PO for constipation. No diluent included on the order. Patient #1: Patient has Dulcolax pills in home, but only order is for Dulcolax suppository. Patient has Acetaminophen suppository in home, but no order. Patient has orders for Miralax and docusate sodium and reports no longer taking. There is no order to discontinue. Patient #2: Patient has Acetaminophen suppository in home, but no order. Patient #3: Seroquel 25 mg TID and Miralax 17 gm is in home, but there is no order.

Upon patient record review, 1 of 5 (Patient #1) 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 #1: During home visit, patient had a hospital bed. There is no DME order for hospital bed in clinical record.

Upon patient record review, 2 of 5 (Patient #1, 4) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1, 4: Hospice Aide is providing volunteer services. The order for Volunteer is 3x/week. There were no specific volunteer visit notes for either record during initial record review. Day 2, Admin/DON presented (3) Volunteer notes dated Oct 2, Oct 4, Oct 7, 2024, with no name or signature.

Upon observation, there was no evidence the hospice is in compliance with accepted professional standards and principles for all non-core services which includes physical therapy, occupational therapy and speech-language pathology. Hospice aide notes turned in during survey where signed by the aide and caregiver which were for visit dates in the future for October/November 2024. In addition, volunteer visit notes were not available day 1 of survey but day 2 volunteer notes were made available but incomplete with no name or signature; unable to determine hospice aide visits and volunteer visits were being made and authentication of documentation for non core services.

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: Hospice Aide Care Plan 6/25/24 and 8/26/24 include frequency of 3/week and assignment for Bed bath everyday except assist to tub/shower weekly. Shower not provided 8/30-9/30/24. Informed agency in mini-exit that there were no notes filed past 9/30. On Day 2 of survey, the Administrator provided additional completed notes, appeared to be signed by hospice aide and caregiver. Dates for the notes/visits provided were: Oct 1, 2, 4, 7, 9, 11, 14, 16, 18, 21, 23, 25, 28, 30, and Nov 1, 2024.

Condition of Participation: Organization and Administration of Services.

Upon observation, there was no evidence the hospice is directed by a Board of Directors/governing body which assumes full legal authority and responsibility for the operation of the hospice. The Administrator holds full responsibility of oversight of the management of documentation of the hospice medical record. The Administrator provided hospice aide notes signed by the aide and caregiver which were for visit dates in the future for October/November 2024. In addition, volunteer visit notes not available day 1 of survey but made available day 2 that were incomplete with no name or signature.

Upon patient record review, 3 of 5 (Patient #1,4,5) 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. Patients #1, 4: There is not evidence of coordination of activities with other members of the IDG, as evidenced by inaccurate documentation in patient medical records for hospice aide services provided for a future date. Patient #4, 5: Discharged patients were discharged by revocation. When reviewing bereavement info, noted “Post death” bereavement assessments with date of death identified as same date as revocation. Also, bereavement care plans were created. Both documents included what appeared to be signature of bereavement coordinator. The administrator reported that the date of death was inaccurately typed and was able to present the original handwritten copy that did not have date of death.