Every finding on record at Statim Care Hospice, Inc.

Upon patient record review, 1 of 14 (Patients #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 Patient #3: The medication reconciliation during home visit had additional medications that were not on the current medication list. These medications were- Zyprexa 2.5mg, Neurontin 100mg, Klor-Con 8MeQ, Atorvasatin 8omg and Omesartan Medoxomil 5mg. Corrected on site.

Upon patient record review, 1 of 14 (Patients #3) did not have evidence the plan of care (POC) must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #3: The medication reconciliation during home visit had additional medications that the hospice did not have orders for which were- Zyprexa 2.5mg, Neurontin 100mg, Klor-Con 8MeQ, Atorvasatin 8omg and Omesartan Medoxomil 5mg . Corrected on site.

Upon patient record review, 2 of 14 (Patients #3,7) 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 #3: This patient had a nebulizer machine. This was not included on the Plan of Care. Corrected on site. Patient #7: The record reflected that this patient had a wheel chair. This was not included on the Plan of Care. Corrected on site.

Upon client record review, 1 of 14 (Patient #7) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #7: The POC listed Spiritual Counselor (SC) visit frequency of, 1 X's per month. In January, the SC visited on 1/24/25 and 1/28/24.

Upon patient record review 1 of 14 (Patient #7) 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 #7: The Aide had been visiting this patient 2x week from 1/17/25 to 4/4/25. The RN completed Aide Care Plan. The RN had forgotten to additionally chart MD order for these services. Late Entry during survey. Corrected on site.

Upon patient record review 1 of 14 (Patient #7) 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 #7: The Aide had been visiting this patient 2x week from 1/17/25 to 4/4/25. There is no documentation that the RN assessed the Aide services.

Upon personnel record review, 4 of 13 (Personnel #2,5,9,13) did not have evidence the hospice employees and contract employees have received orientation on the hospice philosophy. Personnel #2,5,9,13: Did not have evidence the CMS required topic "Hospice Philosophy" had been completed per personnel orientation paperwork in their files.

Upon patient client record review, 1 of 14 (Patient #12) did not have evidence that each patient record contains: • Signed election statement in accordance with 418.24 Patient #12: The effective date for hospice to begin was left blank on space provided on the election statement form.

Upon patient client record review, 1 of 14 (Patient #7) 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 #7: The RN provided a supervisory visit for the LVN on 1/22/25. However, the LVN had not began visiting this patient until 1/29/25.

Upon client record review, 2 of 14 (Patients #11,12) did not have evidence that the discharge summary (DC) includes all required information. Patient #11: The DC Summary did not include summary of the patient's stay, including treatments, symptoms and pain management or patient's current plan of care Patient #12: The DC Summary did not included the patient's current plan of care.

Upon patient record review, 1 of 6 (Patient #2) 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 Upon home visit and med review, the patient has Diclofenac 1% gel that he applies to his left knee for pain that is not included in the medication profile. Also has Paroxetine 10mg filled on 3/3/22 which is not included in the medication profile.

Upon patient record review, 2 of 6 (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 equipment and supply needs. Patient #1 There is evidence in the patient record that the patient uses assistive devices for ambulation, including a walker and a cane, but this is not included in the plan of care. Patient #2 There is evidence in the patient record that the patient uses a cane and a walker for ambulation, but this is not included in the plan of care.

Upon patient record review, 3 of 6 (Patient #1, 2, 3) 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 The plan of care is not updated to reflect the interventions, goals and outcomes for the management of the patients elevated blood pressure and pain management issues. The patient record shows evidence of needs for continual interventions, instruction and encouragement for symptom control. Patient #2 The plan of care is not updated to include the continued management of BLE edema or his frequent symptoms of shortness of breath. The patient record shows evidence of needs for continual interventions, instructions and encouragement for symptom control. Patient #3 The patient has reported pain increasing to a 6/10 on 3/28 but the POC is not updated to reflect the continual interventions/goals needed for pain management.

Upon client record review, 1 of 6 (Patient #5) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #5 The plan of care specifies that the patient will have nursing visits 2 x week starting 7/6/21, but the patient received only 1 visit per week from 7/6/21 - 8/9/21.