Every finding on record at The 7c's Hospice, Inc.

Upon observation, there was no evidence that during the initial assessment visit in advance of furnishing care, the hospice provided the patient and/or family with verbal (meaning spoken) and written notice of the Patient's Rights and Responsibilities in a language and manner that the patient understands. Patient#2: During home visit the patient indicated he speaks and reads only a little English. There is no evidence Patient Rights and Responsibilities in Spanish was provided to the patient. Patient did sign his own consents. A family member was available for verbal translation. Corrected on site.

Upon patient record review, 2 of 14 (Patient #4,#8) 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#4: The record indicates that medical profile list hydrocortisone 1% topical apply twice a day as needed. The is no evidence of specified area of application. Corrected on site. Patient#8: The record indicates Theraworx foam ordered to apply topically twice a day. There is no evidence on medication profile that there were instruction on application of specified area of application. Corrected on site.

Upon patient record review, 1 of 14 (Patient #5) 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#5: The record indicates the initial bereavement assessment was completed within 5 days. However, assessment was incomplete as there was no primary bereaved indicated in assessment. Corrected on site.

Upon patient record review, 3 of 14 (Patient #6,#8,#10) 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#6: The record indicates that patient has diabetes, uses a Libre to monitor blood sugar, and is taking Jardiance per nurse documentation. There is no evidence of problems goals or interventions related to diabetic needs. Corrected on site. Patient#8: The record indicates Oxygen 2-3LPM PRN is ordered. There is no evidence of goals or interventions related to this. Corrected on site. Patient#10: The record indicates the patient is diabetic and takes metformin. There is no evidence of problems, goals, or interventions related to these needs. Corrected on site.

Upon patient record review, 1 of 4 (Patient #1,#4) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient#1: Upon review of record the LVN frequency is ordered at one time per week. There is no evidence of a completed visit for week of 9/10 and 9/17. Visit was on calendar. Upon discussion with Alt DPCS, visit was completed. Per policy documentation is to be completed within 1 week of visit. Corrected on site with late entry documentation. Patient#4: Upon review of record the LVN frequency is ordered at one time per week. There is no evidence of a completed visit for 11/8 - 11/28. Upon discussion with Alt DPCS, visit was completed. Per policy documentation is to be completed within 1 week of visit. Corrected on site with late entry documentation.

Upon patient record review 1 of 14 (Patient #3) did not have evidence that the IDG ensures that the care and services provided are based on all assessments of the patient and family needs. Patient#3: The record indicates an order was placed on 9/18 for labs including CBC and BMP. There is no evidence of labs being completed nor is there any evidence of documentation of any follow up. Per discussion with Alt DPCS, the nurse stated patient refused the labs. Corrected on site. Late documentation entry completed.

Upon patient record review, 2 of 14 (Patient #2,#8) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient#2, #8: The record indicates that patient elected to receive addendum at admit. There is no evidence patient received addendum. Corrected on site.

Observed in Record Review. In 3 of 6 patient records reviewed, The organization did not ensure the patient's plan of care had goals and interventions based on the problems identified in the comprehensive assessment. For example: in review of the record for HV#1 in was identified and reported in the IDG meeting on weeks 5,7,9, and 11 that the patient was suffering from lower extremity edema. There was no care plan open within the organizations adopted EMR record to address cardiovascular issues and edema, nor any updates to existing care plans to address the noted issue. Example #2, in record review for HV#1, HV#2, and HV#3 it was noted in the initial comprehensive assessment that the patient was at high risk for falls per the fall risk assessment. There was no care plan open within the organizations adopted EMR record to address the patients safety and injury prevention. These observations were reviewed with the Administrator Designee, CFO, and Secretary.

Observed in Patient Home. In 1 of 3 home visits conducted, the organization did not identify a potential safety hazard related to the storage of an oxygen tank, as referenced in the Oxygen Safety Assessment and Education. For example: in HV#2 there were 2 oxygen tanks noted in the patient home sitting upright and unsecured. The staff were given the entirety of the visit to correct the hazard and provide education to the family. This observation was reviewed with the clinician on site and the Administrator Designee.