Every finding on record at Star Care Hospice, Inc

Upon patient record review, 4 of 14 (Patient #1, 4, 5, 7) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient 1, 4, 5, 7: The portion of the election statement designated to ensure the patient/caregiver right to choose an attending physician shows no evidence that the conversation and choice took place. The pt/cg did not indicate a declination to choose or a chosen attending. This section is unaddressed in entirety.

Upon patient record review, 6 of 14 (Patient #1, 2, 4, 5, 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 1, 2, 4: Initial nursing assessment reveals the use of Oxygen. No evidence found of Oxygen therapy on the patient medication list. Patient 5: Norco present as needed "pain management" with Morphine Sulfate "mild pain/SOB". There are no further instructions on when to administer Norco versus Morphine Sulfate. Patient 7: Initial nursing assessment reveals the use of Oxygen. No evidence found of Oxygen therapy on the patient medication list. There is also Oxycodone as needed for pain found on medication list. There are no further instructions found on when to administer this medication versus Norco "as needed for pain-moderate" that is also present on medication list. Patient 9: Medication list reflects Lorazepam 1mg tablet PRN as well as Lorazepam liquid PRN. There are no further instructions on when to administer tablet versus liquid or to not administer both tablet and liquid resulting in medication error or overdose. Also, Norco as needed "pain management" with Morphine Sulfate "mild pain/SOB". There are no further instructions on when to administer Norco versus Morphine Sulfate.

Upon patient record review, 1 of 14 (Patient #8) 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 8: No evidence found of bereavement assessment completed within 5 days of admission.

Upon patient record review, 1 of 14 (Patient #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 2: RN completed initial assessment on 5/21/24. No further RN visits documented nor any evidence of missed/refused visits documented through current date of 6/12/24.

Upon patient record review, 1 of 14 (Patient #11) 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 11: Medical record indicates "discharge planning" to begin on 3/3/23 documented by the RN. No evidence of needs assessment, referrals, or other coordination of discharge plan.

Upon patient record review, 3 of 14 (Patient #1, 2, 8) 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: Initial nursing assessment reveals history of seizure disorder and recurrent falls/high fall risk. No evidence of interventions or goals on plan of care for either of these safety concerns. Patient 2: Initial nursing assessment reveals history of seizure disorder. There are no Seizure precautions or interventions or goals r/t seizure precautions and injury prevention. Patient 8: Initial nursing assessment reveals history of seizure disorder. There are no Seizure precautions or interventions or goals related to seizure precautions and injury prevention. Patient requires thickened liquids but there is no evidence found on plan of care of problem, goals, or interventions related to aspiration precautions.

Upon patient record review, 6 of 14 (Patient #1, 2, 4, 5, 7, 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. Patient 1: Oxygen 2LPM via NC as needed is utilized by patient per nursing initial assessment. No evidence found of Oxygen medication order nor problems, interventions, and goals related to the use, education, or safety precautions for Oxygen on the plan of care. Patient 2, 4: Initial nursing assessment reveals the use of Oxygen. No evidence found of Oxygen therapy on the patient plan of care. Patient 5: Norco 10mg-325mg present every 6 hours as needed "pain management" with Morphine Sulfate "mild pain/SOB". There are no further instructions on when to administer Norco versus Morphine Sulfate found in the order. Patient 7: Order present for Oxycodone 10mg every 6 hours as needed for pain. However, there are no further instructions found on when to administer this medication versus Norco 5mg-325mg every 6 hours as needed for pain-moderate. Patient 9: MD order reflects Lorazepam 1mg tablet PRN as well as Lorazepam liquid PRN. There are no further instructions on when to administer tablet versus liquid or to not administer both tablet and liquid resulting in medication error or overdose. Also, order for Norco as needed "pain management" with Morphine Sulfate "mild pain/SOB". There are no further instructions on when to administer Norco versus Morphine Sulfate.

Upon patient record review, 5 of 14 (Patient #1, 2, 4, 7, 8) 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: Nurses initial assessment on 5/29/24 reveals need for/use of: hospital bed, obt, wc, O2 concentrator. No evidence of this DME on patient plan of care. Further, there is no evidence that an emergency tank was supplied for Oxygen utilization in cases of power outage. Patient 2: Nurses initial assessment on 5/21/24 reveals need for/use of: overbed table and air mattress. No evidence of this DME on patient plan of care. Further, there is no evidence that an emergency tank was supplied for Oxygen utilization in cases of power outage. Patient 4: RN initial assessment reveals use of continuous Oxygen. There is no Oxygen concentrator or e-tanks present on the plan of care. Patient 7: SN documentation reveals use of Oxygen, cane, and nebulizer. This DME is not listed on the patient plan of care. Patient 8: SN documentation reveals at initial assessment and ongoing visits that pt requires hospital bed and hoyer lift. This DME is not present on the plan of care.

Upon client record review, 6 of 14 (Patient #2, 3, 5, 7, 8, 10) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 2: Plan of care visit frequency once weekly for MSW. There is no evidence of a visit being completed or documentation of a missed/refused visit for the week of 5/26/24. Visit frequency specifies RN every 2 weeks. No RN visit conducted since 5/21/24 through current date of 6/12/24. LVN frequency 2 x weekly. No evidence of missed/refused visits documented with no LVN visit completed since 6/3/24 as of 6/12/24. Patient 3: Plan of care frequency reflects SN visit frequency of: LVN 2 per week, RN 1 per 2 weeks. No evidence of LVN visit completion since 5/27/24 which does not satisfy the frequency as listed. The RN has visited once per two weeks as ordered, but has also made additional visits on 6/4/24 and 6/7/24. There is no evidence of frequency order increase for RN visits nor are these visits indicated as PRN. Due to the delineation of which licensed nurse will complete scheduled visits, the patient visit frequency as ordered is not met. Patient 5: Plan of care reveals MSW frequency of 1 per week and SC 1 per week. There have been no MSW visit documented. SC visit documented 6/3/24 with none since. Patient 7: Plan of care frequency MSW 1 x week and SC 1 x week. There have been no further visits by MSW or SC documented since initial assessments the week of 5/26/24 through current date of 6/13/24. Patient 8: There is no MSW visit frequency listed on the plan of care. MSW made in-person visit 6/5/24 with no evidence of supplemental order obtained or plan of care update. Also, RN visit frequency specified as 2 x weekly. The week of 6/2/24 there were 4 visits made with all documented as scheduled visits. There is no evidence found of frequency increase or utilization of PRN visits. Patient 10: LVN frequency specified on plan of care at 2 x weekly. Visit notes dated 6/3/24 and 6/6/24 are incomplete with only the date and time filled in. No further evidence that visit took place to satisfy ordered frequency.

Upon patient record review, 2 of 14 (Patient #13, 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. Bereavement counseling also extends to residents of a SNF/NF or ICF/IID when appropriate and identified in the bereavement plan of care • 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 & 14: No evidence found of post death bereavement services being completed or refusal by bereaved.

Upon patient record review, 4 of 14 (Patient #1, 2, 4,7) 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 & 2: Pt has a documented history of seizures and use of Oxygen. No seizure or oxygen precautions included on aide instructions. Patient 4, 7: Oxygen utilized by pt per nursing documentation. Oxygen precautions are not contained in aide instructions.

Upon patient record review 4 of 14 (Patient #2, 3, 4, 8) 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 2: Plan of care frequency for CHHA is 2 x weekly. Week of 5/21/24 only one visit is documented with no evidence found of refused/missed visit documentation. 3 CHHA visits completed the weeks of 5/26/24 & 6/3/24 with no evidence found of increased frequency order. Patient 3: Plan of Care CHHA frequency reflects once per week. The weeks of 5/19/24 & 5/26/24 CHHA visits were conducted 2 per week. The week of 6/2/24 3 visits were conducted. There is no evidence of frequency increases found in the plan of care. Patient 4: Plan of Care CHHA frequency 2 per week, Hospice services initiated 6/5/24. There are no CHHA visits that week with no evidence found on plan of care that services are to begin at a later date. CHHA services first visit date documented is 6/10/24. Patient 8: Plan of Care CHHA frequency 3 per week, Hospice services initiated 5/23/24. There is one CHHA visit documented that week with no evidence found on plan of care that services are to be less than 3 x week for week one, with 3 x weekly to begin at a later date.

Upon patient record review 1 of 14 (Patient #2) 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 2: No CHHA supervisory visit documented since initiation of services on 5/23/24.

Upon patient record review, 1 of 14 (Patient #9) did not have evidence that before the recertification period for each patient, the medical director or physician designee must review the patient's clinical information and provide written documentation that it is anticipated that the patient's life expectancy is 6 months or less. Patient 9: CTI present in the medical record dated for the period of 5/31/24-7/29/24 does not include that verbal authorization for recertification was obtained, there is no physician narrative present, and the form remains open and undated.

Upon patient client record review, 6 of 14 (Patient #1, 4, 5, 7, 8, 9) 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, 4, 5, 7, 8, 9: No evidence found on executed election statement of the pt/cg chosen election date to begin hospice services.

Upon patient client record review, 2 of 14 (Patient #4, 8) 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: Initial nursing assessment indicates Oxygen concentrator present in the home yet the respiratory assessment does not indicate Oxygen use. There is no physician order to initiate/continue or discontinue Oxygen use. It is unclear if this is truly a patient need, and if so, it is unclear as to the use indicated to control symptoms. Patient 8: RN supervisory visit documented 6/7/24 completes supervisory documentation for the LVN, naming visiting nurse by name. No evidence of an LVN visit conducted since services initiated. It is unclear whether LVN has not documented visits or if RN is inappropriately completing LVN supervisory function.

Upon client record review, 2 of 14 (Patient #11, 12) did not have evidence that if a patient revokes the election of hospice care or is discharged from hospice in accordance with §418.26, the hospice must forward to the patient's attending physician: • A copy of the hospice discharge summary • The patient's clinical record, if requested Patient 11 & 12: No evidence found of discharge summary or medical records being sent to the attending physician at the time of discharge.

Upon client record review, 2 of 14 (Patient #11, 12) did not have evidence that the discharge summary includes all required information. Patient 11: Discharge summary dated 3/21/23 includes a brief synopsis of patient stay but no evidence of : the patient's current plan of care, the patient's latest physician orders, or any other documentation that will assist in post-discharge continuity of care or that is requested by the attending physician or receiving facility. Patient 12: The discharge summary dated 11/2/22 contains only a statement explaining, " the patient does not believe she is dying and has the help she needs at this time. Revocation form explained and signed." No further information included.