Every finding on record at Sublime Hospice

Upon patient record review, 3 of 14 (Patient #3, 5, 6) 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 #3, 5, 6: Oxygen 2L/NC. Safety precautions not addressed in problems, goals, interventions.

Upon patient record review, 6 of 14 (Patient #4, 5, 6, 7, 8, 9) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient #4,5,6,7,8,9 : POC current and recertification Plans of Care have MSW and SC prn frequency as needed without quantifying. MSW monthly and as needed. SC every recertification and as needed.

Upon patient record review, 2 of 14 (Patient #4, 11) 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 #4: 6/28/24 order for Keflex for UTI. Rx was reported to IDG 6/28 and 7/12/24, however no update to problems, goals and interventions. Patient #11: (2) Communication notes 5/18/24 regarding new order for Rocephin injections IM for 3 days for UTI. There were problem, goal, interventions for UTI as of 5/18/24, but was not updated with recurrent UTI.

Upon client record review, 1 of 14 (Patient #4) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #4: POC Effective 5/14/24 and continued currently, RN initial evaluation and then every 14 days thereafter for ongoing comprehensive assessment and SV visit. Recertification assessment per schedule for skilled assessment and intervention however, listed under frequencies section of POC, RN frequency is RN 2 per week. RN visits were made every 14 days vs. 2 per week.

Upon patient record review 1 of 14 (Patient #1) 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 #1: Aide frequency 2x/wk. Had (3) visits week of 8/12, 8/14, 8/16. There is a communication note that the patient requested extra visit 8/14/24 and that the MD and IDG were made aware. However, the record does not include verbal or written order by physician for the additional visit.

Upon patient client record review, 5 of 14 (Patient #1, 4, 9, 10, 11) did not have evidence that all entries are legible,practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient #1: Aide Visit Notes 8/14, 8/23/24: The signature line states Signed by SM, Admin Designee/DPCS Designee/RN to close note on behalf of staff assigned. Dated 8/18/24 and 8/26/24 respectively. Patient #4: Aide Visit Notes 8/23/24 The signature line states Signed by SM, Admin Designee/DPCS Designee/RN to close note on behalf of staff assigned. Dated 8/26/24. Patient #9: 04/01/24, 07/01/24 aide assignment sheets have no signature for who completed it. Aide visit notes for Aug 6, 13, 20, 28, July 27, 30, 2024 have electronic signatures but have no date/time stamp. Patient #10: Aide frequency 2x/wk. There is a communication note that the patient requested extra visit today 6/11/24 and that the IDG was made aware. However, there were only 2 visits provided that week, within the ordered frequency. Aide visit notes 8/1/24 signature line states Signed by SM, Admin Designee/DPCS Designee/RN to close note on behalf of staff assigned. Dated 8/12/24. Patient #11: (2) Communication notes 5/18/24 regarding new order for Rocephin injections IM for 3 days. One of the communication notes says simply "Noted and carried out. IDT team aware". No visit note to reflect administration of antibiotic and/or who administered. No documented order. Not listed on Rx profile. Upon staff interview, patient reportedly received injections for 3 days by ALF staff. Clinical record was unclear/incomplete regarding these details. (The patient revoked hospice benefit 5/24/24 for more aggressive treatment / hospitalization.)

Upon personnel record review, 1 of 13 (Personnel #1) did not have evidence of criminal background checks being obtained in accordance with state requirements. In the absence of state requirements, criminal background checks are obtained within three months of the date of employment for all states that the individual has lived or worked in the past 3 years. Personnel #1: The background check is a motor vehicle driving record only. A full background check requested Day 3 of survey, but requires 2 days for processing.