Every finding on record at Superb Hospice Inc

Upon patient record review, 6 of 14 (Patients #2, 6, 7, 8, 9, and 10) did not contain evidence that the Plan of Care included all services necessary for the palliation and management of the terminal illness and related conditions, including the following: A detailed statement of both the scope and frequency of services necessary to meet the specific patient and family needs: Patient #2: All of the IDG updates between 09/01/23 and 01/12/24 listed, "SC 1x per month and p.r.n."; without including a quantifier for such anticipated p.r.n. visit frequency. Patients #6, 7, 9: Current POC lists, "MSW 1x per month and as needed"; without including a quantifier for such anticipated p.r.n. visit frequency. Patient #8: Current POC lists, "SC monthly and as needed"; without including a quantifier for such anticipated p.r.n. visit frequency. Patient #10: Current POC lists both "MSW and SC as, "1x per month and as needed"; without including a quantifier for such anticipated p.r.n. visit frequency.

Upon patient record review, 1 of 14 (Patient #7) did not contain evidence that the Plan of Care included all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments: Patient #7: A verbal order was obtained on 12/11/23 for, "Cleanse left posterior lower leg with wound cleanser and gauze, pat dry, apply Collagen Sheet to wound bed, apply barrier cream to peri-wound, then ABD, Kerlix, and tape. Change every 3 days and prn soiling." Surveyor was not able to locate documented evidence of the Hospice nurses having provided such wound care a minimum of every 3 days. Upon interview of the Alternate Clinical Manager, she showed Surveyor a nursing progress note documenting that the ALF staff had been trained and were providing the every 3 day wound care in the absence of the Hospice nurse. The order 12/11/23 is not a complete order as it does not designate who is responsible for providing the every 3 day wound care.

Upon patient record review, 1 of 14 (Patient #3) did not contain evidence that the Plan of Care included all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs: Patient #3: During Surveyor-attended home visit on 01/16/24 it was noted that the patient had a hospital bed. This was not included on the POC.

Upon patient record review, 1 of 14 (Patient #7) did not contain evidence that a revised Plan of Care included information from the patient's updated Comprehensive Assessment(s): Patient #7: The current POC continued to include the following orders: 1) Effective 12/21/23 Triple ATB Ointment QD wound care; and 2) Effective 12/21/23 Wash wound with Normal Saline QD. These wound care interventions were no longer applicable to the patient's care. The POC had not been updated accordingly.

Upon personnel record review, 1 of 12 (Personnel #8) did not contain evidence that a Skills Competency assessment had been conducted on the Aide, which included all CMS-required subject matter: Personnel #8: Was evaluated for competency on 03/14/2022. However, the following skill was not evaluated for: The physical, emotional, and developmental needs of, and ways to work with, the populations served by the Hospice.

Upon patient record review 1 of 14 (Patient #1) did not contain evidence that the Hospice Aide had provided care/services that were: • 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 Personnel #1: During Surveyor-attended home visit on 01/16/24 the Aide stated that she applies Calmoseptine under the patient's breasts and/or abdominal folds, if needed. This intervention had not been assigned by an RN on the Aide Plan of Care.

Upon patient record review, 1 of 14 (Patient #10) did not contain evidence that all entries were legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures, and currently accepted standards of practice: Patient #10: The home visits made by a Hospice Aide on 12/31/23, 01/07/24, and 01/11/24 had all been signed by an RN. The Alternate Clinical Manager reported that when an RN goes into an Aide visit note to review it, that the visit note only retains the last entered signature, not necessarily the clinician who had provided the care/services.

Upon patient record review, 2 of 14 (Patients #11 and 12) did not contain evidence of a completed Discharge Summary that included all CMS-required content, as follows: Patients #11 and 12: These DC Summaries dated 04/01/23 and 10/23/23 respectively, did not include the following CMS-required content: • A summary of the patient's stay, including treatments, symptoms and pain management • The patient's current Plan of Care • The patient's latest Physician orders