Every finding on record at Standard Care Hospice Inc

Upon observation, there was no evidence the agency has conducted exercises to test the emergency plan every two years.

Upon patient record review, 2 of 14 (Patient #6,#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 #6-Medication profile indicated clotrimazole 1% 2-4g topical daily. The was no indication for area of application. Corrected on-site. #9-Medication profile indicated clotrimazole 1% topically 2xday to affected area. There was no indication for area of application. Corrected on-site.

Upon patient record review, 1 of 14 (Patient #9) 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. #9-The patient was admitted on 04/17/24. A bereavement assessment was not completed until 05/17/2024.

Upon patient record review, 2of 14 (Patient #6,#9) 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. #6-Order indicated clotrimazole 1% 2-4g topical daily. The was no indication for area of application. Corrected on-site. #9-Order indicated clotrimazole 1% topically 2xday to affected area. There was no indication for area of application. Corrected on-site.

Upon patient record review, 3 of 14 (Patient #4,#9,#10) 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. #4-Upon observation at patient visit, patient utilizing low air loss mattress and full bed rails. The items were not listed on the plan of care. Corrected on-site. #9-04/19 Communication note indicates low air loss mattress, bed rails and rail paddings being delivered to patient. The items not listed on the plan of care. Corrected on-site. #10-Upon observation at patient visit, patient utilizing four-prong cane. Cane is not listed on the plan of care. Corrected on-site.

Upon client record review, 5 of 14 (Patient #3,#4,#8,#9,#10) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. #3-The frequency for SN was indicated at 1x per week. The was no evidence of a SN visit for the week of 09/15. #4-The frequency for SN was indicated at 3x week. SN made 2 visits week of 09/01. #8-The frequency for SC was indicated at 1x per month. SC was visiting patient 2x per month in June, July, August and September. Corrected on-site. #9-SW did not have order for visit frequency. SW visits made monthly since admission. Corrected on-site #10-The frequency for SN was indicated at 2-3x per week. SN made one visit week of 08/25.

Upon patient record review, 1 of 14 (Patient #7) did not have evidence in the patient record that hospice aide assignments and duties are: • 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. #7-Aide frequency is indicated 2x per week. Aide care plan lists visit frequency at 1x per week. Corrected on-site.

Upon patient record review 2 of 14 (Patient #4,#10) 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 #4-Aide frequency is indicated at 3x per week. Aide completed two visits on week on 09/01. Corrected on-site. #10-Aide care plan lists visit frequency as 3x per week. Aide visited patient 1x per week, for weeks of 08/25, 09/01, and 09/15. Corrected on-site.

Upon inpatient contract review, 1 of 3 (Rowntree Gardens) did not have evidence that the hospice retains responsibility for ensuring that the training of personnel who will be providing the patient's care in the inpatient facility has been provided and that a description of the training and the names of those giving the training are documented.

Upon SNF/NF contract review, 1 of 3 (Rowntree Gardens) did not have evidence that it is the SNF/NF's responsibility to continue to furnish 24 hour room and board care, meeting the personal care and nursing needs at the same level of care that would have been provided by the family at the facility before hospice care was elected.