Every finding on record at Supportive Hands Hospice Inc.

Upon personnel record review, 1 of 12 (Personnel # 8) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) ·Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff. ·Reading and recording temperature, pulse, and respiration ·Safe transfer techniques and ambulation. ·Normal range of motion and positioning ·Appropriate and safe techniques in personal hygiene and grooming that include-- ·(A) Bed bath ·(B) Sponge, tub, and shower bath ·(C) Shampoo, sink, tub, and bed ·(D) Nail and skin care ·(E) Oral hygiene ·(F) Toileting and elimination The other subject areas in this section may be evaluated through written examination, oral examination or after observation of a Hospice Aide with a patient. Personnel # 8) Upon review of the personnel file, there was no evidence the employee received the competency assessment regarding communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff.

Upon patient record review, 11 of 14 (Patients # 1, 2, 3, 4, 6, 7, 8, 9, 10, 12, 13) 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) Upon review of the patient record, the 03/26/25 hospice aide plan of care did not contain frequencies for the assigned tasks. Patient # 2) Upon review of the patient record, the 03/14/25 hospice aide plan of care did not contain frequencies for the assigned tasks. Patient # 3) Upon review of the patient record, the 10/03/24 hospice aide plan of care did not contain frequencies for the assigned tasks. Patient # 4) Upon review of the patient record, the 06/02/25 hospice aide plan of care did not contain frequencies for the assigned tasks. Patient # 6) Upon review of the patient record, the 02/24/25 hospice aide plan of care did not contain frequencies for the assigned tasks. Patient # 7) Upon review of the patient record, the 06/05/25 hospice aide plan of care did not contain frequencies for the assigned tasks. Patient # 8) Upon review of the patient record, the 04/15/25 hospice aide plan of care did not contain frequencies for the assigned tasks. Patient # 9) Upon review of the patient record, the 02/24/25 hospice aide plan of care did not contain frequencies for the assigned tasks. Patient # 10) Upon review of the patient record, the 04/08/25 hospice aide plan of care did not contain frequencies for the assigned tasks. Patient # 12) Upon review of the patient record, the 06/26/24 hospice aide plan of care did not contain frequencies for the assigned tasks. Patient # 13) Upon review of the patient record, the 01/07/25 hospice aide plan of care did not contain frequencies for the assigned tasks.

Upon observation, there was no evidence the annual report documents the use of volunteers providing day to day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract personnel. The agency did not utilize at least 5% of the total patient care hours in 2024. The total usage was 4.39%.

Upon patient record review, 1 of 14 (Patient # 11) did not have evidence that the hospice forwarded a summary and a copy of the patient record, if requested, to a facility when transferring the patient to that facility. Patient # 11) Patient's medical record did not contain evidence that a transfer summary was sent to the receiving organization.

Upon patient record review, 1 of 5 records (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. Patient 2: The medication profile contains Excedrin Extra Strength with no defined dosage for tablets.

Upon patient record review, 1 of 5 records (Patient #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 medications and treatments. Patient 2: The medical record contains an order for Excedrin Extra Strength with no defined dosage for tablets.

Upon patient record review, 1 of 5 records (Patient #3) 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 2: Upon observation during the home visit, patient was witnessed using a walker for ambulation. There is no evidence of the walker included as DME on the plan of care. Patient 3: The medical record contains nursing documentation upon admission identifying patient use of hospital bed and over bed table. There is no evidence of the bed and table included as DME on the plan of care. Corrected on site.