Every finding on record at Tidewater Hospice, Inc.

Upon patient record review 1 of 19 (Patient #13) 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 13 admitted on 6/6/24, initial spiritual assessment completed on 6/14.

Upon patient record review 1 of 19 (Patient #14) 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 14 no evidence of an initial spiritual assessment.

Upon patient record review, 4 of 19 (Patient #1, 5, 6, 10) 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 nursing visits on 7/29/24, 8/5, 8/12 document use of prn Tylenol, no evidence of Tylenol on the medication profile. Patient 5 Tylenol 500mg 1-2tabs Q4-6h prn fever/pain, no evidence of a max dose on the medication profile. Patient 6 nursing visits on 7/18/24, 7/25, 8/1, 8/13 document Nystatin use to left breast, no evidence of Nystatin on medication profile. Patient 10 Tylenol 500mg 2 tab BID and Tylenol ER 650 mg 2 tabs BID both active on medication profile, no evidence of maximum dose not to exceed 4000mg daily.

Upon patient record review, 1 of 19 (Patient #7) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient 7 sacral wound assessed by the RN on 7/25/24 and the next documented wound assessment was completed on 8/15/24.

Upon patient record review, 1 of 19 (Patient #14) 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 14 declined chaplain support, care plan included an active care plan for the chaplain.

Upon patient record review, 4 of 19 (Patient #1, 5, 6, 10) 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 nursing visits on 7/29/24, 8/5, 8/12 document use of prn Tylenol, no evidence of an order for Tylenol. Patient 5 Tylenol 500mg 1-2tabs Q4-6h prn fever/pain, no evidence of an order for max dose. Patient 6 nursing visits on 7/18/24, 7/25, 8/1, 8/13 document Nystatin use to left breast, no evidence of an order for Nystatin. Patient 10 Tylenol 500mg 2 tab BID and Tylenol ER 650 mg 2 tabs BID both active orders, no evidence of a max dose.

Upon patient record review, 2 of 19 (Patient #3, 8) 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 3 nursing visits on 7/24/24, 7/29, 8/10, 8/12 document the use of a wheelchair, no DME order for the wheelchair. Patient 8 nursing visits 1/30/24, 8/21/24 document the use of a nebulizer and has active nebulized medications, no evidence of a DME order for the nebulizer.

Upon patient record review, 2 of 19 (Patient #10, 12) 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 10 aide care plan includes provide pivot assist with transfers to wheelchair, no evidence of a frequency. Patient 12 aide care plan included 2 active tasks for shower: one entered 7/9/24 for shower every visit and one entered 8/13/24 shower 1x week.

Upon patient record review 5 of 19 (Patient #1, 2, 6, 8, 11) 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 Patient 1 aide care plan included offer sips of liquid every visit, 8/14/24 visit documented NV-not required this visit. Aide care plan included brush teeth every visit, documented NV-not required this visit on 8/1/24 and 8/8. Patient 2 aide care plan included clean and file nails 1x week, clean and file nails documented as completed on 8/14/24 and 8/16. Patient 6 aide care plan included apply lotion every visit after bathing, the following visits documented NV-not required this visit: 7/23/24, 7/25, 8/8, 8/13, 8/15, 8/20, 8/22. Patient 8 aide care plan included apply lotion every visit, the following visits documented NV- not required this visit: 7/23/24, 7/24, 7/29, 8/1, 8/2. The aide care plan included keep patient area and bathroom clean and tidy every visit, the 8/2 visit documented NV-not required this visit. Patient 11 aide care plan included shower every visit, the following visits documented NV-not required this visit: 7/11/24, 8/1, 8/6, 8/13.

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. Volunteer percentage for 2023 was Q1-zero, Q2-zero, Q3-2.56%, Q4-2.63%, below the 5%.

Upon patient client record review, 3 of 19 (Patient #7, 10, 13) 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 7 wound care provided throughout June, July and August documented provided per orders, no evidence of the detail of the wound care provided. Visits 6/11/24, 6/19, 7/3, 7/11, 7/25, 8/15. Patient 10 wound care to left and right heels documented as per orders on the 7/9/24 and 7/16 visits, no evidence of the detail of the wound care provided. Patient 13 wound care to sacrum/left buttocks documented as per orders on the 7/18/24, 7/25, 8/5, 8/12, 8/20 visits, no evidence of the detail of the wound care provided.

Upon patient record review, 5 of 19 (Patient #3, 4, 8, 9, 13) 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 3, 4, 8, 9, 13 the agency has a process to provide documents to the SNF but this is not documented within the EMR for these patients.