Every finding on record at The Legacy at Home, Inc

Upon patient record review 1 of 11 (Patient #7) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient #7 The patient was admitted on 3/14/22, there is no evidence of a SW assessment completed within 5 days and to date.

Upon patient record review, 1 of 11 (Patient #6) 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 #6 Wound care orders on 3/2/22 for treatment do not specify the location of the wound. The same patient has orders for Triamcinoline acetonide external cream 0.1% effective 6/30/20, but the orders do not specify where to apply the medication.

Upon patient record review, 4 of 11 (Patient #1, 2, 3, 4) 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. Patients #1 had oxygen in the home. The POC does not include orders for the DME. Corrected on site. Patient #2 had oxygen, hospital bed, and bedside table in the home. The POC does not include orders for the DME. Corrected on site. Patient #3 had hospital bed, hoyer lift, walker, and wheelchair in the home. The POC does not include orders for the DME. Corrected on site. Patient #4 had oxygen, walker, and a bedside table in the home. The POC does not include orders for the DME. Corrected on site.

Upon patient record review, 6 of 11 (Patient #2, 3, 5, 6, 7, 8) 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 #2 The patient record indicated that upon admit on 2/22/22, the patient was to be re-evaluated for effectiveness of pain control and report a comfortable level within 24 hours. The POC is not updated to reflect the patients progress toward the outcome and goals for pain control. Patient #3 The patient POC effective 2/14/22 indicated that the patient had SOB that the patient would report a comfortable breathing level within 1 week, the POC is not updated to reflect the patients progress toward the outcome and goals for SOB. Patient #5 The POC initiated on 6/7/21 states "pain level will be at goal of 2 within 0-24 hrs", the POC has not been updated to reflect the progress towards this goal. There is evidence in the record that patient had complaints of difficulty sleeping and was prescribed Trazodone, this was not updated in the POC to include desired outcomes, or reassessment of the patient's response to care. The patient tested positive for COVID 19 on 1/19/22, but this was not updated in the patient POC. The patients medication profile reflects orders for Tylenol Severe Cold/Flu for the treatment of COVID-19 effective 1/19/22 although the patient no longer presents with symptoms and is no longer using the medication. Patient #6 There is evidence in the record that the patient was treated with an antibiotic on 2/17/22 for a skin infection but this was not added to the POC. Patient #7 The patient was admitted on 3/7/22 with an expected goal of improvement in physical discomfort within 24-48 hours, the POC has not been updated to assess the progress towards the patients goals. Patient #8 There is no update in the POC for patients progress for goal/outcomes for agitation that was initiated on 11/29/21 (the goal was written for 1wk) poor intake written on 9/2/21 (written for 1 week) and edema written on 9/2/21 (written for 1 week) confusion initiated on 9/2/21 (written for 1 wk.)

Upon patient record review, 1 of 9 applicable (Patient #6) 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 #6 The CNA plan of care has not been updated since 6/25/21 but shows an end date of 8/23/2020. The plan assigns complete shower 1 x week, but the patient is bedbound and aide reports that she does not take her to the shower.

Upon patient client record review, 1 of 11 (Patient #8) 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 #8 There are orders in the record to discontinue the aide services effective 11/22/21, but the POC continued to list aide services 2x week until 2/15/22.

Upon patient record review, 1 of 2 applicable (Patient #8) did not have evidence that the hospice provided the following information: • The most recent hospice plan of care specific to each patient • Hospice election form and any Advance Directives specific to each patient • Physician certification and recertification of the terminal illness specific to each patient • Names and contact information for hospice personnel involved in hospice care of each patient • Instructions on how to access the hospice's 24-hour on-call system • Hospice medication information specific to each patient • Hospice physician and attending physician (if any) orders specific to each patient Patient #8 During home visit with this patient, there is no evidence of the patients certificate of terminal illness, updated POC, or updated medication profile on record at the NF.