Every finding on record at Stellar Hospice Care Inc.

Upon patient record review 1 of 14 (Patient #11) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient 11: The patient was admitted on 7/7/23, the initial psychosocial assessment was completed on 7/17/23.

Upon patient record review, 3 of 14 (Patient #7, 11, 12) 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 07: The medication profile includes Miralax 17g once a day as needed, it does not include a diluent. The medication profile includes orders for Collagen particles, Hydrocolloid dressing and Tetracyte spray, apply to wound bed 3 times a week as needed, it does not include an application site. The patient has 3 different wounds. Patient 11: The initial comprehensive assessment on 7/7/23 includes information that the patient receives Novolog 20units SQ TID and Levemir 45 units QHS to manage his diabetes, the medications are not included in the medication profile. Patient 12: The medication profile includes Hydrocortisone 0.5% topical cream, apply to affected area twice a day, it does not specify an application site. The medication profile includes Nizoral 2% topical cream, apply 2 times per day, it does not include an application site.

Upon patient record review, 1 of 14 (Patient #11) 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 11: The patient was admitted on 7/7/23, the initial bereavement assessment was completed on 7/17/23.

Upon patient record review, 1 of 14 (Patient #1) 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 01: The patient was admitted on 3/10/23 with a primary diagnosis of Alzheimer's disease, the plan of care does not include a problem statement with interventions and goals for the management of the neurological condition.

Upon patient record review, 3 of 14 (Patient #7, 11, 12) 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 07: The medication order on 7/8/23 for Miralax 17g once a day as needed, does not include a diluent. Treatment orders on 7/26/23 for Collagen particles, Hydrocolloid dressing and Tetracyte spray, apply to wound bed 3 times a week as needed, does not include an application site. The patient has 3 different wounds. Patient 11: The initial comprehensive assessment on 7/7/23 includes information that the patient receives Novolog 20units SQ TID and Levemir 45 units QHS to manage his diabetes, the plan of care does not include orders for the medications. Patient 12: Orders on 7/19/23 for Hydrocortisone 0.5% topicall cream, apply to affected area twice a day, do not specify an application site. Orders on 11/13/23 for Nizoral 2% topical cream, apply 2 times per day, do not include an application site.

Upon patient record review, 2 of 14 (Patient #1, 6) 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 01: The patient medication profile includes orders for oxygen and duoneb breathing treatments, the oxygen concentrator and nebulizer are not included in the plan of care. Patient 06: The patient record indicates that the patient is incontinent of bladder and bowel, the plan of care does not include incontinent supplies.

Upon client record review, 2 of 14 (Patient #2, 10) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 02: A patient visit was performed by the RN on 3/19/24 reported by agency however, there was no documentation for the visit to support it was performed. Patient 10: A patient visit was performed by the LVN on 2/27/24 and 3/12/24 and a patient visit was performed by the RN on 3/20/24 reported by agency however, there was no documentation for the visits to support these were performed.

Upon patient record review, 1 of 14 (Patient #2) 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 02: The hospice aide task assignment for linen changes does not include a frequency.