Every finding on record at Ss Help Hospice Inc

Upon observation, there was no evidence that during the initial assessment visit in advance of furnishing care, the hospice provided the patient and/or family with verbal (meaning spoken) and written notice of the Patient's Rights and Responsibilities in a language and manner that the patient understands. Patient#1: During home visit patient indicated he understands very little English and is unable to read English as his primary language is Spanish. Patient did sign his own admission papers. His granddaughter was present at admit to interpret. Patient and family indicated they did not receive Patient's rights and responsibilities written in the language that the patient understands. Corrected on site. Patient#2,#3: During home visit these patients indicated they understand very little English and do not read English well. Their Primary language is Armenian. A staff member interpreted at admit. The patients indicated they have not received the Patient's rights and responsibilities written in the language which they understand. Corrected on site.

Upon patient record review, 1 of 14 (Patient #8) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient#8: Upon review it was noted that on the consent form the patient indicated she elected to choose an attending physician however, the physician name is blank. Corrected on site.

Upon patient record review, 1 of 14 (Patient #4) did not have evidence of the appropriate documentation for release of confidential information. Patient#4: There is also a form for acknowledgement of Privacy Practice. On this form the patient name was blank and the sister signed in the patient signature location instead of the patient representative. Corrected on site.

Upon patient record review, 3 of 14 (Patient #2,3,10) 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#2, #3: The record indicates patient was ordered Diclofenac sodium 1% topical and A&D ointment topical. There is no evidence of a specified area of application indicated on medication profile for either of these medications. Corrected on site. Patient#10: The record indicates patient was ordered ciclopirox 0/77% topical and Lidocaine 5% topical. There is no evidence of a specified area of application indicated on medication profile for either of these medications. The record also indicates Lidocaine 5% transdermal patch. There is no evidence of specific application area and instructions. Corrected on site.

Upon patient record review, 1 of 14 (Patient #10) 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#10: The record indicates the initial bereavement assessment was completed within 5 days. However, there is no primary bereaved identified in the assessment. Corrected on site

Upon patient record review, 1 of 14 (Patient #6) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient#6: The record indicates that patient was admitted with a stage one pressure wound that is still present and receiving wound care. There is no evidence of wound measurements or wound assessments in documentation after the admit assessment of 8/31/24.

Upon patient record review, 4 of 14 (Patient #1,#3,#5,#10) 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,#3,#5: The record indicates per nurse documentation, that the patient and family require education on monitoring patient blood sugar and use of glucometer. There is no evidence of interventions or goals related to this on plan of care. Corrected on Site Patient#5,#10: The record indicates the patient was ordered and provided Ensure supplement to assist with dietary needs of patients. There is no evidence of interventions or goals related to this on plan of care. Corrected on site.

Upon patient record review, 3 of 14 (Patient #2,#3,#4) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient#2: The record indicates that there is no evidence of documentation in patient chart for nurse visit scheduled on 9/19/24 and 9/26. Frequency is ordered at one time per week. There is no evidence of any other nurse visit made for those weeks. Corrected on site. Patient#3: The record indicates that there is no evidence of documentation in patient chart for nurse visit scheduled on 9/20/24 and 9/27. Frequency is ordered at one time per week. There is no evidence of any other nurse visit made for those weeks. Corrected on site. Patient#4: The record indicate patient has condom catheter 29mm. The nurse documents that it is to be changed per MD order. There is no evidence of order indicated change or care of condom catheter. The record indicates Normal saline ordered for weekly IV bolus on 11/26/24. There is no evidence of physician order for initiating or discontinuing the peripheral IV access. Corrected on site.

Upon patient record review 1 of 14 (Patient #5) 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#5: The record indicates aide visit frequency is ordered 3 times per week. There is no evidence of aide visits documented after 9/27/24. There is no evidence of missed visits or continued services being declined. Corrected on site. Late order entered for discontinuing of services per family request.

Upon patient record review, 2 of 14 (Patient #5,#7) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient#5: Upon review of record it is noted that the top of the election of benefits form the patient name area is blank. Corrected on site Patient#7: The record indicates patient elected to receive notice of non covered items. There is no evidence this was provided to patient. Corrected on site

Upon patient record review, 1 of 14 (Patient #5) did not have evidence that each patient record contains responses to medications, symptom management, treatments, and services. Patient#5: The record indicates the patient was ordered an x-ray of right foot on 10/21/24. There is no evidence in record of this being completed. Per conversation with the Administrator, the x-ray was completed. Records were obtained from radiology company and uploaded during the survey. Corrected on site

Upon patient record review, 2 of 14 (Patient #4,#5) did not have evidence that each patient record contains Advance Directives. Patient#4: The agency form indicating patient has a POA or representative signing was blank. Corrected on site. Patient#5: Upon review of the documents, the DNR is uploaded into chart. However, it is not signed by the patient. Corrected on site.

Upon patient record review, 1 of 14 (Patient #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#4: The record indicates that the patient identification form in the admit papers was blank and not completed. The admit pack also includes a checklist form that indicates a list of items received by the patient/family. This form was checked off however there is no evidence of a signature. Corrected on site with late entry.