Every finding on record at Tina Healthcare

Upon patient record review 1 of 14 (Patient #1) 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#1: Patient was admitted on 09/20/24. There is no evidence of a spiritual assessment until 09/28/24.

Upon patient record review 1 of 14 (Patient #9) 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#9: There is no evidence of a spiritual or psychosocial assessment being completed on this patient.

Upon patient record review, 1 of 14 (Patient #9) 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#9: There is no evidence of an initial bereavement assessment being completed.

Upon patient record review, 1 of 14 (Patient #6) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual's attending physician, if any) • Changes that have taken place since the initial assessment • Information on the patient's progress toward desired outcomes • Reassessment of the patient's response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days Patient#6: There is no evidence of an RN visit made between 09/23/24- 10/21/24.

Upon patient record review, 1 of 14 (Patient #6) 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#6: There is no evidence of assessment or measurements of wound by RN between 9/23/24-10/21/24.

Upon patient record review, 5 of 14 (Patient #1,#2,#3,#4,#7) 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: The RN documents patient has ongoing issues with vascular dementia a co morbidity, is on oxygen and requires daily meds for constipation as well as take diarrhea medication twice a week. There is no evidence of problems with goals and interventions related to these issues. Corrected on site. Patient#2: The record indicates patient is receiving spiritual services. There are no problems, goals, or interventions on plan of care for these services. Corrected on site. Patient#3: The record indicates patient take Eliquis daily. There is no evidence of bleeding precaution on plan of care. Also, this patient is receiving spiritual and psychosocial services. There is no evidence of problems, goals, or interventions related to these services on plan of care. Corrected on site. Patient#4: The record indicates patient is receiving spiritual and psychosocial services. There is no evidence of problems, goals, or interventions related to these services on plan of care. Corrected on site. Patient#7: Documentation on IDG 12/17/24 states a glucometer, lancets, and strips were ordered for patient who is NIDDM. The same IDG note also states patient has an unstageable wound to right heel. There is no evidence of problems, goals, or interventions related to these issues on plan of care.

Upon patient record review, 2 of 14 (Patient #1,#5) 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 record indicates patients terminal diagnosis was changed to protein mal-nutrition on 3/18/25. There is no evidence of an order for change in diagnosis in record. Corrected on site. Patient#5: The record indicates that patient has an order for wound care. However, the order does not specify who is responsible for wound care. Patient resides in board and care home. Corrected on site.

Upon client record review, 5 of 14 (Patient #1,#2,#3,#4,#5) did not have evidence that the IDG in collaboration with the attending physician reviewed, revised and documents the individualized plan as frequently as the patient's condition requires but no less frequently then every 15 calendar days. Patient#1,#2,#3,#4,#5: The record indicates IDG was held in 5/6/25. There is no evidence of narrative or documentation on progress toward goals from MSW or from SC for this IDG.

Upon patient record review, 1 of 14 (Patient #1) 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#1: The record indicates patients terminal diagnosis was changed to protein mal-nutrition on 3/18/25. There is no evidence of problems goals or interventions related to this diagnosis on plan of care. Corrected on site.

Upon client record review, 2 of 14 (Patient #1,#9) 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 record indicates patient was out of town 04/11/25-04/14/25 on travel contract. There is no evidence of an order to discontinue visits this week. There is no documentation of any visit completed by this agency or travel agency for this week. Patient#9: The record indicates SN frequency is ordered at one time per week. There is no evidence of SN visit for week of 6/30, 7/14, and week of 7/27/24.

Upon patient record review, 1 of 14 (Patient #5) did not have evidence that the IDG shares information on a on-going basis with non-hospice healthcare providers furnishing services unrelated to the terminal illness and related conditions. Patient#5: There is no evidence that IDG documents coordination or collaboration with contracted wound agency who is assisting with patient wound care debridement.

Upon patient record review, 1 of 14 (Patient #9) did not have evidence that Social work services are based on the patient's psychosocial assessment and the patient/family's needs and acceptance of these services. Patient#9: The RN documented on the initial IDG on 6/14/24 that she would refer to MSW for assistance with poor living conditions. She documents that the living environment smells like trash or vomit. There are small children in the home, with a young girl laying on the couch in the room with a bad, harsh, cough. There is no evidence of documentation of any follow up on the situation by MSW or other team member.

Upon patient record review, 2 of 14 (Patient #1,#3) 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: RN admit documentation indicates patient requires aspiration precautions, bleeding precautions, and is legally blind. There is no indication of aspiration precautions, bleeding precautions, or patient being legally blind on the aide plan of care. Corrected on site. Patient#3: The record indicates the patient takes Eliquis daily. There is no evidence of bleeding precautions on the aide plan of care. Corrected on site.

Upon patient record review 3 of 14 (Patient #1,#2,#4) 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: The record indicates the aide frequency is ordered at 2 times per week. The week of 4/13/25 there is only one documented visit. There is no evidence of an order for missed visit or to reduce visit frequency for this week. Patient#2: The record indicates an order was entered on 4/24/25 to increase aide frequency to 3 times per week. However, the aide continued to be scheduled 2 times per week until 5/5/25. Patient#4: On the aide visit for 5/2/25 the aide documented completing task that are no assigned on the aide plan of care. Unassigned task completed include colostomy care, turn and position, toileting, catheter care, and measure urinary output. On aide visit 4/18/25 the aide documents not completing the following task that were assigned for every visit: fall precautions, peri care, encourage fluids, mental status, oxygen precautions, and housekeeping including change linens, tidy room empty trash.

Upon patient record review, 1 of 5 records (Patient #1) did not have evidence that the patient has received effective pain management and symptom control from the hospice for conditions related to the terminal illness. Patient 1: The comprehensive assessment contains documentation by the RN that patient is uncomfortable because of pain. There is no evidence of the patient receiving effective pain management and symptom control in the plan of care.

Upon patient record review, 3 of 5 records (Patient #1,#3,#4) 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 1: The medication profile contains furosemide 40mg 1 tab, 1 or 2 times daily for weight gain or increased swelling. There is no evidence of a frequency or if it is PRN. Corrected on site. Patient 3: The medication profile contains atorvastatin calcium 10mg 1 tab at bedtime. Upon home visit finding patient has atorvastatin 40mg 1 tab daily that patient is currently taking. Corrected on site. Patient 4: The medication profile contains lorazepam 1mg tab as needed for severe anxiety. No evidence of a frequency.

Upon patient record review, 3 of 5 (Patient #1,#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 medications and treatments. Patient 1: The plan of care contains an order for furosemide 40mg 1 tab, 1 or 2 times daily for weight gain or increased swelling. There is no evidence of a frequency or if it is PRN. Corrected on site. Patient 3: The plan of care contains atorvastatin calcium 10mg 1 tab at bedtime. Upon home visit finding patient has atorvastatin 40mg 1 tab daily that patient is currently taking. Corrected on site Patient 4: The plan of care contains an order for lorazepam 1mg tab as needed for severe anxiety. No evidence of a frequency. Corrected on site.

Upon patient record review, 4 of 5 records (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. Patient 1: The comprehensive assessment contains documentation of patient having hospital bed, air mattress and shower chair. There is no evidence of these items being included on the plan of care. Patient 2: The comprehensive assessment contains documentation of patient having hospital bed and air mattress. There is no evidence of these items being included in the plan of care. Patient 3: The comprehensive assessment contains documentation of patient having a hospital bed. There is no evidence of this item being included in the plan of care. Patient 4: The comprehensive assessment contains documentation of patient having an air mattress, over bed table, and a bedpan. There is no evidence of these items being included in the plan of care.

Upon client record review, 3 of 5 (Patient #1,#2,#3) 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 plan of care contains orders for SN two times per week. There is no evidence of a second visit being made the week of 3-6-22 through 3-12-22. Patient 2: The plan of care contains orders for SN two times per week. There is no evidence of a second visit being made the week of 3-6-22 through 3-12-22. Patient 3: The plan of care contains orders for SN two times per week. There is no evidence of a second visit being made the week of 3-6-22 through 3-12-22.

Upon patient client record review, 1 of 5 (Patient #5) 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 5: The medical record contains a Certification of terminal illness for the patient being certified from 1-4-22--3-2-22. There is no evidence that patient had been admitted to hospice in the past. Dates should have been for 90 day certification period.

Upon client record review, 1 of 5 records (Patient #3) did not have evidence that all drugs and biologicals are labeled in accordance with currently accepted professional practice and include appropriate usage and cautionary instructions, as well as an expiration date, if applicable. Patient 3: Upon home visit findings, Patient had a bottle of Janumet and Jardiance with no evidence of being labeled in accordance with currently accepted professional practice and did not include appropriate usage and cautionary instructions.