Every finding on record at Terrace Home Health Springfield LLC

Upon patient record review, 3 of 5 (Patients #1,#4,#5) 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 1: The medication profile contained duplicative trazodone instructions listed and zithromax for five days started 5/22/24 that are still active. Corrected on site. Patient 4: The medication profile contained differing tylenol 500mg tablet instructions with 2 tabs every 6 hours prn dated 6/7/24 and 1 tab every 6 hours prn dated 6/14/24 with no instructions to differentiate when different doses would be appropriate. Patient 5: The medication profile contained salonpas lidocaine topical patch with no area defined for administration. Corrected on site.

Upon patient record review, 1 of 5 (Patient #1) 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: The medical record contained nursing documentation since admission identifying patient use of a walker and commode. There was no evidence of orders for the equipment included in the plan of care. Corrected on site.

Condition of Participation: Initial and Comprehensive Assessment of the Patient.

Upon patient record review 3 of 14 (Patient #12,13,14) 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 12: The pt was admitted 3/22/24 the MSW did not completed the initial assessment until 4/2/24. There is no evidence of a refusal or communication as to why the assessment was late. There is no evidence the RN completed the psychosocial assessment in the RN comprehensive assessment. Patient 13: The medical record does not contain evidence a MSW performed a comprehensive assessment with in 5 days of admission. There is no evidence the RN completed the psychosocial assessment in the RN comprehensive assessment. Patient 14: The medical record does not contain evidence of a SC performing a comprehensive assessment with in 5 days of admission. There is no evidence the RN completed the spiritual assessment in the RN comprehensive assessment.

Upon patient record review, 6 of 14 (Patient #1,2,3,5,7,12) 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: Patient 1: The medication profile contains an order for Miralax powder 17 gm daily with no diluent. Upon home visit finding pt is taking cepacol lozenges and a probiotic and states has been since being in the hospital this is not new. Corrected on site. Patient 2: The medication profile has Morphine listed. There is no evidence of an order for morphine. The morphine has since been discontinued. The medication profile contains an order for Insulin Lispro to be given in addition to the sliding scale insulin. There is no evidence of an order for sliding scale insulin. Corrected on site. The nursing home visit finding is pt is using pro powder 3 times daily with meals. This is not included in the hospice medication profile. Corrected on site. Patient 3: Upon home visit finding, the nursing home has pt taking Bisacodyl, protein shakes TID, Dulcolax and Mag Citrate. These were not included on the hospice POC. Corrected on site. Patient 5: The medication profile has Xarelto listed, there is no evidence of an order for Xarelto. The POC contains an order for O2. This was not included on the medication profile. The Xarelto has since been discontinued. Oxygen corrected on site. Patient 7: The medication profile contains an order for Miralax with no diluent. Corrected on site. Patient 12: The POC contains an order for Miralax 17 gm daily mix with fluid. It does not say how much fluid.

Upon patient record review, 3 of 14 (Patient #6,7,13) 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 6: The comprehensive assessment by the RN has documented "Bereavement assessment to be completed by the SC". There is no evidence any discipline completed a Bereavement assessment. Patient 7: The medical record does not contain evidence of a bereavement assessment being completed with in 5 days. No initial bereavement assessment completed. Patient 13: The medical record does not contain evidence of an bereavement assessment being completed with in 5 days.

Condition of Participation: Interdisciplinary Group, Care Planning, and Coordination of Services. L536

Upon client record review, 2 of 14 (Patient #1, #2) did not have evidence that the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions as identified in the comprehensive assessment. Patient 1: The RN documented in the comprehensive assessment 1/19/24 pt in need of a PT/OT eval for sit/stand and transfers. This order was never put in to the POC. The pt has not had a PT/OT eval and there is no evidence of a refusal. Patient 6: The LPN documented on 5/6/24 "wound changed, a picture taken and updated in chart, wound saturated with a foul odor". There is no evidence the RN or the MD was notified regarding this finding. This finding was no discussed in IDG.

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 1: Upon home visit finding the SN is setting up the pill box weekly. There is no evidence of this task being included in the care plan for continuity of care. Corrected on site.

Upon patient record review, 7 of 14 (Patient #1,2,3,6,7,12,14) 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 1: The POC contains an order for Miralax powder 17gm daily with no diluent. Corrected on site. The POC contains orders for Foley catheter with no use of sterile technique documented. Corrected on site. Upon home visit finding pt is taking Cepacol lozenges and a probiotic and states has been since being in the hospital this is not new however, there was not orders. Corrected on site. Patient 2: The POC contains an order for Insulin Lispro to be given in addition to the sliding scale insulin. There is no evidence of an order for sliding scale insulin. Corrected on site. The POC contains an intervention for the aide to perform nail care unless pt is diabetic. Pt is diabetic and it was still ordered as an intervention for the aide to perform. The nursing home visit finding is pt is using pro powder 3 times daily with meals. This is not included in the Hospice POC. Corrected on site. Patient 3: Upon home visit finding, the nursing home has pt taking Bisacodyl, protein shakes TID, Dulcolax and Mag Citrate. These were not included on the hospice POC. Corrected on site. Patient 6: The POC 3/25/24 contains wound care orders though does not state who will perform the wound care. Corrected on site. Patient 7: The POC contains an order for Miralax with no diluent. The POC contains an order for the foley but does not include using sterile technique. Corrected on site. Patient 12: The POC contains an order for Miralax 17gm daily mix with fluid. It does not say how much fluid. The medical record contains evidence of pt having a Foley catheter. There is no evidence of an order for a Foley catheter. Patient 14: The RN documented in the comprehensive assessment pt has a G tube for feedings, is on Pepcid 1.5 calorie 3 times daily via gravity. There are no orders on the POC for G tube feedings or site care. The POC has orders for Novolog with sliding scale. The sliding scale orders were not on the POC.

Upon patient record review, 1 of 14 (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 equipment and supply needs. Patient 2: The comprehensive assessment indicates the pt has Bedside commode, hospital bed, side rails. These items were not included on the POC. Corrected on site.

Upon client record review, 4 of 14 (Patient #1,5,6,8) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 1: The POC 3/14/24 contains an order for SN 2 times per week. There is evidence the SN saw the pt on 4/15,4/17,4/20 in the same Medicare week. There is no evidence the visits were PRN or an order for an extra visit that week. The POC contains an order for SC eval, after the eval the pt/caregiver declined SC. The pt went in to respite care at a facility and the SC made a visit with out an order or permission from pt/caregiver. Patient 5: The POC contains an order for SN twice weekly. The SN made 3 visits 4/13, 4/17, 4/18 all in the same Medicare week. There is no evidence the extra visit was PRN and there was no order for the extra visit. The week of 4/26-5/1 the nurse saw the pt 1 time. There is no missed visit documentation. Patient 6: The POC contains an order for SN 2 times per week. The SN has documented routine visits on 4/9, 4/11, 4/12 with no evidence of them being PRN or an order for an extra visit that Medicare week. Patient 8: The medical record contains documentation by the SN on 4/30 and 5/6 "SN applied compression stockings and applied dressing to fluid filled bunion. There is no evidence of an order for the compression stockings or dressing.

Condition of Participation: Hospice Aide and Homemaker Services. L607

Upon personnel record review, 1 of 13 (Personnel #6 ) 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 6: The aide competency did not include sponge, tub, sink, and bed bath.

Upon patient record review, 6 of 14 (Patient #1,#2,#4,#5,#6,#7) 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: The aide POC contains the following interventions: May trim or file any long finger or toe nails the intervention must be specific aide cannot choose which and has no frequency, perform skin care does not state what type of skin care or a frequency, home management this is not specific and there is no frequency, peri care, shampoo both with no frequencies. Corrected on site. Patient 2,4,5: The aide POC contains interventions for the aide with no frequencies. Corrected on site. Patient 6: The aide POC contains orders to make bed PRN, assist with transfers with no frequency and trim/file nails if needed. Corrected on site. Patient 7: The aide POC contains orders for assisting to toilet, nail care and peri care with no frequency. Corrected on site.

Upon patient record review 3 of 14 (Patient #1,5,9) 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 Educate staff of requirement. Perform chart audits to ensure compliance. Patient 1: The POC contains an order for aide 2 times per week, the week of 4/21-4/27 the aide saw the pt 4/24 with no second visit that week and no evidence of communicating with RN. Patient 5: The POC contains orders for aide 2 times per week. The aide only made one visit the week of 4/19-4/25 there was no evidence of a refusal or notification to the RN. The aide then made 3 visits the week of 4/26-5/1. There is not evidence of an order for this extra visit. Patient 9: The medical record contains an order dated 4/13-6/1 for Aides 2 times per week. There were no visits made on 4/13 as it was a Saturday. The week of 4/21-4/27 the aide saw the pt on 4/24 there was no second visit made as ordered.

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 had evidence of tracking volunteer hours from Oct 2023-Mar 2024 The most they had was 6% in October then they range from 0.2% February 2024 to 2.9% in December 2023. These hours did not equal 5 percent of the total patient care hours of all paid hospice employees and contract personnel.

Upon personnel record review, 1 of 13 (Personnel #12) did not have evidence that a skills competency assessment, specific to each discipline had been conducted for all personnel including volunteers initially during orientation. Personnel 12: The personnel file did not contain evidence of an skills competency being performed.

Condition of Participation: Clinical Records.

Upon patient client record review, 9 of 14 (Patient #1,2,3,4,6,8,9,10,11,) did not have evidence that each patient record contains: Patient 1,6,10,11: The medical record contains an election of benefits form that indicates the patient chose an attending. This form is filled out by the RN and there is no place for a pt signature. It does not include the following items required by Hospice Election Requirements: The patient's or representative's (as applicable) acknowledgment that the patient has been given a full understanding of hospice care, particularly the palliative rather than curative nature of treatment; The patient's or representative's acknowledgment that the patient understands that certain Medicare services are waived by the election. Patient 2,3,4,8,9: The medical record contains an election of benefits form that indicates the patient chose an attending. This form is filled out by the RN and there is no place for a pt signature. It does not include the following items required by Hospice Election Requirements: The patient's or representative's (as applicable) acknowledgment that the patient has been given a full understanding of hospice care, particularly the palliative rather than curative nature of treatment;The patient's or representative's acknowledgment that the patient understands that certain Medicare services are waived by the election. The form also did not include the date of election. The space was left blank.

Upon patient client record review, 3 of 14 (Patient #6,9,10) did not have evidence that each patient record contains Physician certification and recertification of terminal illness. Patient 6: The medical record contains evidence the patient chose an attending physician other than the Hospice medical director. The attending did not complete a CTI. Patient 9: The medical record contains evidence the patient chose an attending physician other than the Hospice medical director. The attending did not complete a CTI. Patient 10: The medical record contains evidence the patient chose an attending physician other than the Hospice medical director. The attending did not complete a CTI.

Upon patient client record review, 4 of 14 (Patient #1,2,6,9) 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 1: The SN documented on 5/2 and 5/6 dressing change per POC. There is evidence that the wound had been healed and the dressing changes were discontinued. Patient 2: The medical record contains and order for daily wound care and the following wound care is documented by the SN: 4/12/24 "wound cleansing and dressing change per POC", 4/17/24 "No s/s of infection with some drainage to right knee wound", 4/24/24 "wound care performed per POC", 5/1 "This nurse gathered all wound care supplies and changed all dressings per protocol" with no evidence of details of dressing change. Patient 6: The SN documented 4/9/24 and 4/11/24 "Dressing change to buttocks per orders using technique, pt tolerated well". The SN documented 4/30/24 "Wound was cleaned, dried and new bandage applied" and on 3/27/24 "Wound care to buttocks completed per POC". There is no evidence of details of dressing change. Patient 9: The SN documented on 4/12 "wound care per POC", on 5/8 "Pt's wound cleaned and packed", 5/6 "No dressing on spine, this nurse cleansed it and replaced bandage". There is no evidence of details of dressing change.

Upon client record review, 1 of 14 (Patient #11) did not have evidence that if a patient revokes the election of hospice care or is discharged from hospice in accordance with §418.26, the hospice must forward to the patient's attending physician: Patient 11: The medical record did not contain a discharge summary so there was nothing sent to the physician.

Upon client record review, 1 of 14 (Patient #11) did not have evidence that the discharge summary includes all required information. Patient 11: The medical record does not contain a discharge summary.

Upon patient record review, 1 of 14 (Patient #2) did not have evidence that if a drug order is verbal or given via an electronic transmission, it is given to a Registered Nurse, Nurse Practitioner, pharmacist, physician or other licensed individuals as designated by state regulations. The person receiving the order records and signs it immediately and has the prescribing person sign it in accordance with state and federal regulations. Patient 2: The medical record contains a note by the RN on 5/1/24 "Nurse called nurse back with order for Haldol 5mg IM to give along with Lorazepam 0.25mg po Q4 hours times 14 days". In the orders section the nurse documents in the orders "Per Lori nurse at Dr Wyatt's office". The physician did end up signing the order but nurses cannot accept verbal orders from nurses.

Upon inpatient contract review, 1 of 3 (Quail) did not have evidence that the hospice patient's inpatient clinical record includes a record of all inpatient services furnished and events regarding care that occurred at the facility; that a copy of the discharge summary be provided to the hospice at the time of discharge; and that a copy of the inpatient clinical record is available to the hospice at the time of discharge.

Upon inpatient contract review, 1 of 3 (Quail) did not have evidence that the inpatient facility has identified an individual within the facility who is responsible for the implementation of the provisions of the agreement.

Upon SNF/NF contract review, 1 of 3 (Quail) did not have evidence that it is the SNF/NF's responsibility to continue to furnish 24 hour room and board care, meeting the personal care and nursing needs at the same level of care that would have been provided by the family at the facility before hospice care was elected.

Upon SNF/NF contract review, 1 of 3 (Quail) did not have a delineation of the responsibilities of the hospice and the SNF/NF to provide bereavement services to SNF/NF personnel.

Upon client record review, 1 of 14 (Patient #2) did not have evidence that the hospice plan of care identifies the care and services that are needed and specifically identify which provider (nursing facility or hospice) is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care. Patient 2: The POC contains an order for daily wound care to left leg and right knee, pt is in a facility and the order does not state who is to perform the wound care. Corrected on site.

Upon observation, there was no evidence the organizational chart matches the hospice's information submitted to CMS and/or State licensing agencies for ownership and management personnel. The agency did not update their organizational chart since their change of Administrator and DPCS for survey. Corrected on site.