Every finding on record at Top Quality Hospice & Palliative Care Inc

Upon patient client record review, 1 of 14 (Patient #6) did not have evidence that the hospice informed and provided written information to the patient concerning its policies on advance directives, including a description of applicable state law. Patient #6-Patient with a primary diagnosis of stroke. RN documented confusion, FAST of 6E, and lethargy on initial comprehensive assessment. Spiritual Care documented on initial assessment “due to patient’s disorientation, lethargy, and limited ability to communicate”. MSW documented on initial assessment for documentation question-"patient’s response to illness" MSW selected "cannot respond". MSW documented in their narrative “patient disoriented and confused, which limited communication”. According to documentation, there is not evidence the patient was able to comprehend the election of the hospice benefit.

Upon patient client record review, 1 of 14 (Patient #6) did not have evidence that the hospice obtained the patient's or representative's signature confirming that they received a copy of the Patient's Rights and Responsibilities. Patient #6-Patient with a primary diagnosis of stroke. RN documented confusion, FAST of 6E, and lethargy on initial comprehensive assessment. Spiritual Care documented on initial assessment “due to patient’s disorientation, lethargy, and limited ability to communicate”. MSW documented on initial assessment for documentation question-"patient’s response to illness" MSW selected "cannot respond". MSW documented in their narrative “patient disoriented and confused, which limited communication”. According to documentation, there is not evidence the patient was able to comprehend the election of the hospice benefit, including Patient's Rights and Responsibilities.

Upon patient client record review, 1 of 14 (Patient #6) did not have evidence that if a state court has not adjudged a patient incompetent, any legal representative designated by the patient in accordance with state law may exercise the patient's rights to the extent allowed by state law. Patient #6-Patient with a primary diagnosis of stroke. RN documented confusion, FAST of 6E, and lethargy on initial comprehensive assessment. Spiritual Care documented on initial assessment “due to patient’s disorientation, lethargy, and limited ability to communicate”. MSW documented on initial assessment for documentation question-"patient’s response to illness" MSW selected "cannot respond". MSW documented in their narrative “patient disoriented and confused, which limited communication”.According to documentation, there is not evidence the patient was able to comprehend the election of the hospice benefit.

Upon patient client record review, 1 of 14 (Patient #6) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient #6-Patient with a primary diagnosis of stroke. RN documented confusion, FAST of 6E, and lethargy on initial comprehensive assessment. Spiritual Care documented on initial assessment “due to patient’s disorientation, lethargy, and limited ability to communicate”. MSW documented on initial assessment for documentation question-"patient’s response to illness" MSW selected "cannot respond". MSW documented in their narrative “patient disoriented and confused, which limited communication”. According to documentation, there is not evidence the patient was able to comprehend the election of the hospice benefit, including evidence that the patient chooses a health care provider, including an attending physician.

Upon patient client record review, 1 of 14 (Patient #6) did not have evidence of the appropriate documentation for release of confidential information. Patient #6-Patient with a primary diagnosis of stroke. RN documented confusion, FAST of 6E, and lethargy on initial comprehensive assessment. Spiritual Care documented on initial assessment “due to patient’s disorientation, lethargy, and limited ability to communicate”. MSW documented on initial assessment for documentation question-"patient’s response to illness" MSW selected "cannot respond". MSW documented in their narrative “patient disoriented and confused, which limited communication”. According to documentation, there is not evidence the patient was able to comprehend the election of the hospice benefit, including release of confidential information.

Upon patient client record review, 1 of 14 (Patient #6) did not have evidence that the patient received information about the services covered under the hospice benefit. Patient #6- Consents signed by patient with a primary diagnosis of stroke. RN documented confusion, FAST of 6E, and lethargy on initial comprehensive assessment. Spiritual Care documented on initial assessment “due to patient’s disorientation, lethargy, and limited ability to communicate”. MSW documented on initial assessment for documentation question-"patient’s response to illness" MSW selected "cannot respond". MSW documented in their narrative “patient disoriented and confused, which limited communication”. According to documentation, there is not evidence the patient was able to comprehend the election of the hospice benefit.

Upon patient client record review, 1 of 14 (Patient #6) did not have evidence that the patient received information about the scope of services that the hospice will provide and specific limitations on those services. Patient #6-Patient with a primary diagnosis of stroke. RN documented confusion, FAST of 6E, and lethargy on initial comprehensive assessment. Spiritual Care documented on initial assessment “due to patient’s disorientation, lethargy, and limited ability to communicate”. MSW documented on initial assessment for documentation question-"patient’s response to illness" MSW selected "cannot respond". MSW documented in their narrative “patient disoriented and confused, which limited communication”. According to documentation, there is not evidence the patient was able to comprehend the election of the hospice benefit, including scope of services that the hospice will provide and specific limitations on those services.

Upon patient record review, 3 of 14 (Patient #4, 5, 9) 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- Medications, A&D and Calmoseptine orders were not defined. The location of application was not listed on the medication profile. Corrected on site Patient #5- Medications, A&D and Calmoseptine orders were not defined. The location of application was not listed on the medication profile. Corrected on site Patient #9- Polyethylene Glycol order on medication profile did not contain ordered instructions for a dilutant.

Upon patient record review, 2 of 14 (Patient #8, 9) 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 #8- Change in condition was not assessed by RN. Communication note on 11/2/24 stating a phone call was received for symptoms of a urinary track infection. MD treatment orders were entered on 11/2/24. Change in condition was not assessed in-person by an RN until 11/5/24. Communication note on 9/15/24 stating a phone call was received for uncontrolled pain. MD treatment orders were entered. Change in condition was not assessed in-person by an RN until 9/17/24. Wound care specialist consult order 11/12/24 of skin impairment by LVN with no follow up by RN. Patient #9- On 3/17/24 an MD order was entered for continuous care based on LVN's assessment findings during an in-person visit. Continuous care was initiated by LVN on 3/17/24. RN assessment was not completed until 3/18/24. Last RN visit prior to initiation of continuous care was completed on 3/13/24.

Upon patient record review, 2 of 14 (Patient # 6, 8) 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-Integumentary- high risk of skin break down was documented within the RN initial assessment. Skin precaution management was not present on the integumentary plan of care. Corrected on site Patient #8-Oxygen therapy was noted on the plan of care to be administered at 5L/min via nasal cannula. A physician's order and the patient's medication list stated that oxygen was to be administered at 2L/min via nasal cannula. Corrected on site

Upon patient record review, 4 of 14 (Patient #4, 5, 8, 9) 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 #4- Medications, A&D and Calmoseptine orders were not defined. The location of application was not ordered. Corrected on site Patient #5- Medications, A&D and Calmoseptine orders were not defined. The location of application was not ordered. Corrected on site Patient #8- Urinary catheter orders did not include maintenance of catheter and change frequency. Corrected on site Patient #9- Polyethylene Glycol order did not contain ordered instructions for a dilutant.

Upon client record review, 1 of 14 (Patient #4) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #4- MSW/SC recertifications visits were completed without a physician's order.

Upon home visit observation, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Nurse did not perform hand hygiene between glove changes when completing assessment of patient.

Upon patient record review, 1 of 14 (Patient #2) 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 #2-The hospice aide plan of care contained “assist with oral medications, per RN instructions” and the hospice aide documented that this was completed with each visit. The plan of care did not specify "to provide reminders" or give any additional defined instructions of acceptable actions to be completed within the scope of practice of the hospice aide.

Upon patient record review 1 of 14 (Patient #6) 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 #6- There was no evidence of hospice aide supervisory completed every 14 days. No hospice aide supervisory was completed between visit dates 10/9/24 and 11/6/24. RN visit on 11/23/24 RN did not supervise the hospice aide. Corrected on site per late entry documentation.

Upon patient client record review, 1 of 14 (Patient #6) 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 #6-Patient with a primary diagnosis of stroke. RN documented confusion, FAST of 6E, and lethargy on initial comprehensive assessment. Spiritual Care documented on initial assessment “due to patient’s disorientation, lethargy, and limited ability to communicate”. MSW documented on initial assessment for documentation question-"patient’s response to illness" MSW selected "cannot respond". MSW documented in their narrative “patient disoriented and confused, which limited communication”. According to documentation, there is not evidence the patient was able to comprehend the election of the hospice benefit.

Upon patient client record review, 1 of 14 (Patient #8) did not have evidence that each patient record contains responses to medications, symptom management, treatments, and services. Patient #8- Communication note on 11/2/24 stating a phone call was received for symptoms of a urinary track infection. MD treatment orders were entered on 11/2/24. RN visit 11/5/24 and no noted verbal follow up on medication efficacy or patient response to treatment. Communication note on 9/15/24 stating a phone call was received for uncontrolled pain. MD treatment orders were entered on 9/15/24. RN visit 9/17/24 and no noted verbal follow up on medication efficacy or patient response to treatment.

Upon patient client record review, 1 of 14 (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 was no MD order or plan of care for hospice aide services and a hospice aide supervisory visit was completed by the RN on 11/5/24.

Upon personnel record review, 1 of 13 (Personnel #6) did not have evidence that all Medical Social Services are provided by a qualified Medical Social Worker in accordance with the state's Social Work Practice Act, the hospice's policies and procedures and/or job descriptions. Personnel 6: The file contained evidence the social worker achieved a Master's Degree in Sociology. There was no evidence of supervision by an social worker with a Master of Social Work.

Upon patient client record review, 2 of 5 (Patient #1, #2) 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 #1 record had white out correction to EOB document. Patient #2: Physician CTI had incorrect Benefit Period (BP) dates listed as 10/1/21 to 1/3/22. The dates for BP-1 would be 910/1/21 to 12/29/21 to equal 90 days.