Every finding on record at St Joseph Healthcare Agency Inc

Upon patient record review, 2 of 5 (Patient #1, 2) 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: Patient #1: (4/26/24 POC IDG Review) Patient admitted 4/3/24 with infected diabetic wounds of toe right foot and thermal wound left foot. Had MD order for IV antibiotic (initiated by attending physician prior to hospice admission) and continued through current admission. (4/3/24 Ampicillin/Sulbactam 3 g in NS 100 cc. IV daily. 4/23/24: Ampicillin/Sulbactam 3 g in NS 100 cc. IV 3x/day until 5/15/24) for wound infection. The order is not clear regarding accountability for administration. The patient also has a PICC line and the only related order is PICC line dressing change 1x week or prn if soiled. By reading “or” it is unclear if dressing should be changed weekly or only if soiled. Education provided. The dressing was reportedly changed weekly, but only documented 4/12/24 visit note. The previously referenced orders are unclear regarding procedure and accountability for administration of antibiotic infusion and PICC line/site management. Patient #2: Admitted 3/23/24. SN comprehensive assessment identifies suprapubic in GU section of assessment. There is a 4/12/24 order stating Suprapubic catheter incision: Wash the area around catheter every day with mild soap and water. Pat dry. Apply triple antibiotic ointment and gauze. Secure with tape daily and prn. (prn is not qualified) and accountability not clear. There is a supply order for 16 Fr. 10 cc. balloon Foley catheter, although change/replace or size is not specified in a suprapubic catheter management order. 4/20/24 SN note regarding suprapubic removed. There was no details of circumstance, implication and there was no order and no documented communication with MD in regards to removal. 4/29/24 SN visit note SN documented Inserted a 14 Fr catheter. Inflated balloon with 10 cc. Foley catheter moderate. Patient tolerated well. There was a 4/29/24 MD order for Vaginal Foley Catheter change every month or prn. (no size and change prn is not qualified). Interview occurred and staff agreed should have read urethral catheter. (Questionable language barrier influencing this error) Education provided.

Upon patient record review, 1 of 5 (Patient #1) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient #1: 4/26/24 Most recent IDG POC review does not include problems/goals/ interventions related to Infusion and/or PICC line and/or dressing changes at time of survey.

Upon client record review, 2 of 5 (Patient #1, 3) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1: Patient admitted with initial and ongoing SN frequency of SN 2/wk and 3 prn; RN q14 days and recert. Only documented visits were 4/12 LVN, 4/17 RN, 5/01/24 RN. Patient #3: 3/25/24 Left lower posterior leg diabetic wound. Cleanse with wound cleaner. Pat dry. SSD 1% topical cream. Cover with Kerlix gauze every 3 days and prn soiled or dislodged. 4/22/24 SN visit note under integumentary: Stage 1 wound. SN documented cleanse with wound cleanser pat dry, pack wound with Santyl cover with Kerlix gauze every 3 days and prn soiled or dislodged. Nurse notes did not reflect following current physician order for wound care.

Upon patient record review, 1 of 14 (Patient #7) did not have evidence that the hospice obtained the patient's or representative's signature confirming that they received a copy of the Patient's Rights and Responsibilities, due to patient signing own consents with Primary Diagnosis of Alzheimer's Disease. Patient #7: Records indicate that patient signed own admission consent forms with Primary Diagnosis of Alzheimer's Disease.

Upon patient record review, 1 of 14 (Patient #7) did not have evidence that if a state court has not adjudged a patient incompetent, any legal representative designated by the patient in accordance with state law may exercise the patient's rights to the extent allowed by state law. Patient #7: Records indicate that patient signed own admission consent forms with Primary Diagnosis of Alzheimer's Disease.

Upon patient record review, 14 of 14 (Patient #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, and #14) did not have evidence that the patient chooses a health care provider, including an attending physician. In addition, Patient #7: Records indicate that patient signed own admission consent forms with Primary Diagnosis of Alzheimer's Disease.

Upon patient record review, 1 of 14 (Patient #7) did not have evidence of the appropriate documentation for release of confidential information. Patient #7: Records indicate that patient signed own admission consent forms with Primary Diagnosis of Alzheimer's Disease.

Upon patient record review, 1 of 14 (Patient #7) did not have evidence that the patient received information about the services covered under the hospice benefit, due to patient signing own consents with Primary Diagnosis of Alzheimer's Disease. Patient #7: Records indicate that patient signed own admission consent forms with Primary Diagnosis of Alzheimer's Disease.

Upon patient record review, 1 of 14 (Patient #7) did not have evidence that the patient received information about the scope of services that the hospice will provide and specific limitations on those services. Patient #7: Records indicate that patient signed own admission consent forms with Primary Diagnosis of Alzheimer's Disease.

Upon patient record review 1 of 14 (Patient #14) 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 #14: There was no evidence of psychosocial or spiritual comprehensive assessment performed by any discipline.

Upon patient record review, 6 of 14 (Patient #2, #3, #5, #6, #7. #9) 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: Record indicates ordered pain therapy, Tylenol Arthritis 650mg 1 capsule every 6 hours as needed and Norco 5/325mg 1 tablet PO every 4 hours as needed. No evidence of maximum dose of 4G within a 24 hour period on medication profile. Patient #3: Medication profile indicates patient is ordered Acetaminophen 325mg 2 tablets PO every 4-6 hours as needed for pain in addition to, Hydrocodone Bitartrate/Acetaminophen 5/325mg, one tablet every 4-6 hours as needed . No evidence of maximum dose of 4G within a 24 hour period on medication profile. Patient #5: Record patient is on oxygen however, this is not listed on medication profile. Patient #6: Record indicates patient has oxygen however, this is not listed on Medication profile. Patient #7: Records indicate upon RN Initial Assessment on 02/09/24 of patient short of breath with minimal exertion. No evidence of oxygen order on medication profile.

Upon patient record review, 1 of 14 (Patient #14) 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 #14: There was no evidence of a bereavement assessment.

Condition of Participation: Interdisciplinary Group, Care Planning, and Coordination of Services. L536

Upon patient record review, 1 of 14 (Patient #9) 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 #9: Upon admission, 1/15/24 a wound was identified in RN documentation however, there was no documentation of assessment of the wound or measurements. The next visit on 1/26 performed by LVN did not contain evidence of assessment of the wound either.

Upon patient record review, 10 of 14 (Patient #1, #3, #4, #5, #6, #7, #8, #9, #10, #11) 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: The patient admitted with a G-tube however, there was no evidence of problems, interventions, goals developed. In addition, Initial Assessment indicates on 01/13/24 that patient is bed bound with stage four decubitus and potential problem for skin breakdown with no interventions or goals in Plan of care to address risk for skin integrity. Record indicates Primary Diagnosis Neuro due to CVA with no problems, goals, interventions. Patient #3, 4, 5, 6, 7, 8, 9, 10, 33: The record indicated that the patient was a Full Code and has not yet prepared end of life decisions. No evidence of Advanced Directives in Plan of Care with goals and interventions. Patient #7: The admission documentation indicates on 02/09/24 patient and family are seeking placement with no evidence of discussion in Social Worker Initial Assessment, plan of care with goals and interventions. Patient #8: There was no evidence of a Neuro Care Plan with goals and interventions on Initial Plan of Care on 02/03/24. Primary Hospice Diagnosis: Neuro/Parkinson's Disease. RN initial assessment indicates in narrative patient is confused and disoriented on 02/03/24. Patient #4: The admission documentation indicates on 02/21/24 patient and family are seeking placement with no evidence of discussion in Social Worker Initial Assessment, plan of care with goals and interventions. Patient #5: The admission documentation indicates on 02/19/24 patient and family are interested in placement with no evidence of discussion in Social Worker Initial Assessment, plan of care with goals and interventions. Patient #6: The admission documentation indicates on 02/15/24 patient and family are seeking placement with no evidence of discussion in Social Worker Initial Assessment, plan of care with goals and interventions. Patient #7: The admission documentation indicates on 02/09/24 patient and family are seeking placement with no evidence of discussion in Social Worker Initial Assessment, plan of care with goals and interventions. Patient #8: There was no evidence of a Neuro Care Plan with goals and interventions on Initial Plan of Care on 02/03/24. Primary Hospice Diagnosis: Neuro/Parkinson's Disease with no problems, interventions, goals. The admission documentation indicates on 02/03/24 patient and family are seeking placement with no evidence of discussion in Social Worker Initial Assessment, plan of care with goals and interventions. Patient #10: The admission documentation indicates on 01/08/24. Patient and family are seeking placement with no evidence of discussion in Social Worker Initial Assessment, plan of care with goals and interventions.

Upon patient record review, 1 of 14 (Patient #7 ) did not have evidence that the plan of care includes all services necessary for the palliation and management of the terminal illness and related conditions which including interventions to manage pain and symptoms. Patient #7: Record indicates on RN Comprehensive assessment on 02/23/24 indicated patient exhibited active symptoms of nausea, vomiting and anxiety with no updated plan of care with interventions or goals.

Upon patient record review, 1 of 14 (Patient #2) 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 #2: Recertification Plan of Care Cardiac interventions indicate the same medication with different directions Hydralazine Hydrochloride 25mg 1 tablet, PO BID on 02/16/24 and Hydralazine Hydrochloride 25mg 1 tablet by mouth daily (give additional dose PRN every 8 hours for Systolic Blood Pressure greater than 190 as of 10/03/23).

Upon patient record review, 3 of 14 (Patient #5, #6, #7 ) 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 #5: Record patient is on oxygen however, DME is not on plan of care. Patient #6: Record indicates patient has oxygen however, DME is not on plan of care. Patient #7: Record indicates patient has oxygen however, DME is not on plan of care.

Upon patient record review, 1 of 14 (Patient #7) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient #7: Comprehensive Assessment 02/23/24 notes patient symptoms of anxiety with no evidence of problems, goals and intervention on plan of care.

Upon patient record review, 2 of 14 (Patient #13 and #14 ) did not have evidence the hospice offers bereavement counseling that includes: • Making bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. • Ensuring that bereavement services reflect the needs of the bereaved • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery. Patient #13 and #14: Records indicated there was no evidence of Bereavement Plan of Care with interventions or goals.

Upon patient record review, 2 of 14 (Patient #1 and #3) 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: The aide plan of care indicated type of clothing (pajamas) and not task of dressing patient on 12/27/23. Corrected on site. Patient #3: The aide plan of care indicated type of clothing (street clothes) and not task of dressing patient on 01/13/24. Corrected on site.

Upon patient record review 1 of 14 (Patient #3) 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 # 3 has Aide visit ordered with no evidence of visits from Admission date 01/13/24

Upon patient record review 1 of 14 (Patient #1) 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: Record indicates no supervisory Aide visit due on 03/11/24, per Agency Policy of every 14 days with last documented HHA Supervisory visit completed on 2/19/24.

Upon patient client record review, 14 of 14 (Patient #1,#2,#3,#4,#5,#6,#7,#8,#9,#10,#11,#12,#13,#14) 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 #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, and #14: There was not evidence that the patient chooses a health care provider, including an attending physician. Patient #1: Record indicates patient son signed Medicare Election Benefit consent form and patient signed other agency consent forms with no evidence of Power of Attorney documentation or reason patient was unable to sign own consent forms on 12/16/23. Patient #7: Records indicate that patient signed own admission consent forms with Primary Diagnosis of Alzheimer's Disease.

Upon patient client record review, 1 of 14 (Patient #12) did not evidence that each patient record contains physician orders. Patient #12: Patient discharged for extended prognosis however, there was no evidence of Physician Discharge order.

Upon patient client record review, 2 of 14 (Patient #2, #6) 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 admission consent form Artificial Tears documented as only prescribed medication on Admission, 03/03/23, Medication form with blank signature and date. Patient #6: Records indicate signature designated for Hospice Director on Agency admission form is blank without date. In addition, Initial Plan of Care on 02/15/24 indicates in Respiratory Care Plan that patient refuses oxygen therapy. RN Comprehensive Assessment completed on 02/29/24 and 03/14/24, indicates patient is short of breath with mild exertion and performing ADL's that is resolved by oxygen at 2L via Nasal cannula as needed which is conflicting information.

Upon observation, there was no evidence a copy is provided of the hospice written policies and procedures on the management and disposal of controlled drugs to the patient or patient representative and family. Patient #7: Records indicate that patient signed own admission consent forms with Primary Diagnosis of Alzheimer's Disease.

Upon observation, there was no evidence the hospice discussed the policies and procedures for managing the safe use and disposal of controlled drugs with the patient or representative and the family in a language and manner that they understand to ensure that these parties are educated regarding the safe use and disposal of controlled drugs. Patient #7: Records indicate that patient signed own admission consent forms with Primary Diagnosis of Alzheimer's Disease.

Upon client record review, 1 of 14 (Patient #7) did not have evidence that the written policies and procedures for managing controlled drugs was provided and discussed. Patient #7: Records indicate that patient signed own admission consent forms with Primary Diagnosis of Alzheimer's Disease.