Every finding on record at Tone Hospice and Palliative Care Inc

Upon patient record review, 1 of 5 (Patient #2) 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 #2: Patient was prescribed Miralax, however, the order did not include directions for reconstitution.

Upon patient record review, 2 of 5 (Patient #1, 3) 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: Patient is on hospice with a primary diagnosis of Parkinson's disease. There are no interventions or goals for the primary diagnosis. The patient has been prescribed a bowel management program but has no interventions or goals for GI/Constipation. Patient #3: The patient is on Eliquis. There are no interventions or goals for use of anti coagulants or for bleeding precautions. There are no interventions or goals for pain, despite patient being on Cymbalta, Tegretol, Lidocaine, and Norco for neuropathic pain.

Upon client record review, 3 of 5 (Patient #1,2,3) 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. Patients 1, 2, and 3 did not have signatures from the chaplain on any IDG notes so no evidence of collaboration by a discipline actively seeing patient to evidence their involvement to update/revision of POC.

Upon personnel record review, 1 of 14 (Personnel #10) did not have evidence that Hospice Aide Services are provided by a qualified individual in accordance with the appropriate state's regulations, the hospice's policies and procedures and/or job descriptions and the ACHC Glossary of Personnel Qualifications as defined by the Medicare Conditions of Participation. Personnel #10: The Hospice Aide did not have evidence in the personnel record of qualifications in accordance with state regulations for CHHA's.

Upon personnel record review, 1 of 14 (Personnel #10) 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 #10: The competency skill checklist specified that the aide was observed doing a sponge, tub, OR shower bath and also observed shampooing in a sink, tub OR bed. The requirement is that each example is reviewed

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. For the last 12 months reporting, as well as for the year 2024, the volunteer percentage reached 4.3%.

Upon patient record review 2 of 10 (Patient #1, 4) 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 #1 - did not have evidence in the patient record that the comprehensive assessment identifies the spiritual needs related to the terminal. The spiritual component completed by the RN did not include a history of any religious affiliation and support, spiritual beliefs or traditions. Patient #4 - did not have evidence in the patient record that the comprehensive assessment identifies the spiritual needs related to the terminal. The spiritual component completed by the RN did not include a history of any religious affiliation and support, spiritual beliefs or traditions.

Upon patient record review, 3 of 10 (Patient #3, 4, 6) 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 #3 - Medication profile contained O2 at 3-6L/M per nasal cannula continuous did not include titration instructions for oxygen. Nystatin cream 2 x day for burning sensation - did not contain site, Calmosepline 1 x day for wound care - did not contain site. Patient #4 - Medication profile contained Cosopt solution 2 times a day - did not contain number of drops or if applied to one or both eye(s). Patient #6 - Medication profile contained Degludec 10 solution 1 x day subcutaneous - did not contain units/ml or dosage to give (10 solution unsure if that is 10U). SN initial comprehensive assessment documentation has patient on oxygen but not on medication profile.

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

Upon patient record review, 5 of 10 (Patient #1, 2, 3, 6, 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 medical record includes documentation on admission that the patient is at risk for falls, is incontinent of bowel and bladder and needs assistance with ADL. There is no evidence that the plan of care includes problems, goals and interventions for the management of the risk of falls, assistance with ADL's or the potential for skin breakdown. Patient #2 - The medical record includes documentation that the patient is at risk for skin breakdown due to inability to reposition self and incontinence of bowel and bladder. There is no evidence that the plan of care includes problems, goals and interventions to maintain skin integrity. Patient #3 - The medical record includes documentation on admission that the patient is at risk for falls, is incontinent of bowel and bladder and needs assistance with ADL. There is no evidence that the plan of care includes problems, goals and interventions for the management of the risk of falls, assistance with ADL's or the potential for skin breakdown. Patient #6 - The medical record includes documentation on admission that the patient is at risk for falls, is incontinent of bowel and bladder and needs assistance with ADL. Patient has a Foley catheter. There is no evidence that the plan of care includes problems, goals and interventions for the management of the risk of falls, assistance with ADL's, management of Foley or the potential for skin breakdown. Patient #7 - The medical record includes documentation on admission that the patient is at risk for falls, is incontinent of bowel and bladder and in bed most of the day. There is no evidence that the plan of care includes problems, goals and interventions for the management of the risk of falls or the potential for skin breakdown.

Upon patient record review, 3 of 10 (Patient #3, 4, 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 #3 - Orders for O2 at 3-6L/M per nasal cannula continuous did not have parameters for 3-6L i.e. titrate to keep O2 saturations above 90%. Nystatin cream 2 x day for burning sensation - did not contain site, Calmosepline 1 x day for wound care - did not contain site. Patient #4 - Orders for Cosopt solution 2 times a day - did not contain number of drops or if applied to one or both eye(s). Patient #6 -Orders for Degludec 10 solution 1 x day subcutaneous - did not contain units/ml or dosage to give (10 solution unsure if that is 10U). SN initial comprehensive assessment states patient on oxygen but on POC.

Upon patient record review, 3 of 10 (Patient #1, 6, 7) 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 includes SN documentation that the patient requires a hospital bed and walker. There is no evidence that a hospital bed is included on the plan of care as DME. Patient #6 - The medical record includes SN documentation that the patient requires a Foley catheter. There is no evidence that Foley supplies is included on the plan of care as medical supplies. Patient #7 - The medical record includes SN documentation that the patient requires a hospital bed and walker. There is no evidence that a hospital bed is included on the plan of care as DME.

Upon patient record review, 1 of 10 (Patient #7) 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 #7 - IDG on 01/03/25 and 01/16/25 did not include changes that have taken place since the initial assessment, information on the patient's progress toward desired outcomes or reassessment of the patient's response to care. IDG form blank.

Upon client record review, 4 of 10 (Patient #1, 2, 4, 5) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1 - SN visit frequency 2xwk 1 PRN/wk - week 7 SN made 5 visits. SN visit frequency 03/31/24 2wk3, 1wk1 - wk 8 - 4 visits documented. Patient #2 - SN visit frequency effective 05/16/24 1wk + 1 PRN/wk - SN made 3 visits week 2 and 4. MSW visit frequency 1wk - 2 visit made wk 2, no visits made wk 3. Patient #4 - effective 05/26/24 SN visit frequency 1wk +1 PRN/wk - 3 visit made wk 4. Patient #5 - effective 12/16/24 SN visit frequency 2wk - only 1 visit completed wk 3. MSW visit frequency 1wk - no visit made wk 3 or 6.

Condition of Participation: Hospice Aide and Homemaker Services. L607

Upon patient record review, 5 of 10 (Patient #1, 2, 3, 4, 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 #1 - No tasks on aide care plan contained frequency of tasks. Aide care plan contained both shower and Bed bath but no documentation that patient was cognitively or functionally able to make decision. Patient #2 - Aide frequency effective 06/02/24 1-2 times week. No tasks on aide care plan contained frequency of tasks. Patient #3 - Aide frequency 1 x week and 2 PRN. No tasks on aide care plan contained frequency of tasks. Patient #4 - Aide frequency 1 x week and 2 PRN. No tasks on aide care plan contained frequency of tasks. Patient #6 - Aide frequency 1 x week and 2 PRN. No tasks on aide care plan contained frequency of tasks. Aide care plan contained both shower and Bed bath but no documentation that patient was cognitively or functionally able to make decision.

Upon patient record review 5 of 10 (Patient #1, 2,3 4, 6) 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 visit frequency 03/11/24 2 x week. Only 1 visit made week of 03/17/24 and 04/01/24, no visits made week of 03/24/24 - no documentation of reason for missed visits. Aide documented bed bath on 04/03/24 and shower on 03/18/24 - no other tasks addressed. Visit date 03/11/24 and 03/14/24 Aide documented visit time in home but aide visit note blank. Patient #2 - Aide visit note 06/04/24 and 06/07/24 Aide documented visit time in home but aide visit note blank. Patient #3 - Aide visit note on 09/11/24 contained provided bed bath but bed bath not ordered on care plan - no other task addressed on visit note. Visit notes blank for 09/14/24, 09/18/24 and 09/21/24. Patient #4 - Aide visit frequency 1 x week and 2 PRN but no visit made week of 07/07/24 - no documentation of reason for missed visit. Patient #6 - Aide visit note on 05/30/24 only addressed bed bath completed - no other tasks addressed.

Upon patient record review 2 of 10 (Patient #1, 4) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs. Patient #1 - No Aide Supervisory visits documented from 02/22/24 through 04/03/24. Patient #4 - No Aide Supervisory visits documented from 06/26/24 through 07/13/24.