Every finding on record at Tranquility Care Hospice Inc

Upon patient record review, 1 of 14 (Patient #5) 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#5: Levaquin 500 mg PO daily x 7 days ordered for URI on 4/10/23. There is no stop date on medication profile to date.

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: The Initial Bereavement Risk Assessment was not completed.

Upon patient record review, 1 of 14 (Patient #1) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs Patient Spiritual Counselor (SC) visit frequency of, 1 PRN visit monthly for spiritual needs (Effective 09/01/21). This frequency did not include a baseline visit frequency for the SC.

Upon patient record review, 1 of 14 (Patient #1) 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: This patient had a oxygen tanks and shower chair. These were not included on the Plan of Care.

Upon client record review, 1 of 14 (Patient #6) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #6: The initial and current plan of care indicated the MSW and SC to complete initial assessment within 5 days of SOC. These initial visits were completed. However, both MSW and SC visited patient the second benefit month without an order. The MSW visited on 4/10/23 and the SC visited on 4/14/23.

Upon personnel record review, 1 of 13 (Personnel #9 ) 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.) The CHHA competency for the following tasks were verbally assessed and not observed/demonstrated with patient or pseudo patient: · Nail care · Toileting and elimination

Upon patient record review 6 of 14 (Patients #2, 3, 4, 6, 7 and 14) 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 Patient #2: The POC listed Aide visit frequency of, 2 X's per week. For 1st Benefit Week 1 there were no visits made. Patient #3: The POC listed Aide visit frequency of, 2 X's per week. For 1st and 2nd Benefit Weeks, the Aide made only one visit each of these weeks on 1/26/23 (1st week) and 2/2/23 (2nd week). Patient #4: The POC listed Aide visit frequency of, 2 X's per week as ordered on 3/17/23. The Aide made visits prior to order date of 3/17/23. The Aide visited patient without order on the following dates- 12/19, 12/23, 12/26, 12/30, 1/2, 1/6, 1/9, 1/13, 1/16, 1/20, 1/23, 1/27, 1/30, 2/3, 2/6, 2/10, 2/13, 2/17, 2/20, 2/22, 2/24, 2/27, 3/3, 3/6, 3/10 and 3/13. Patient #6: The POC listed Aide visit frequency of, 1 X per week. For 1st Benefit Week there were no visits made. Patient #7: The POC listed Aide visit frequency of, 2 X's per week. For 1st Benefit Week, there was only 1 visit on 1/20/23 only. Patient #14: The POC listed Aide visit frequency of, 2 X's per week. For 1st Benefit Week 1 there were no visits made.

Upon patient client record review, 2 of 14 (Patients #6 and #9) 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 #6: The Medical Director/Attending indicated patient was 62 years old in the CTI narrative. Per clinical record this patient is 83 years old. Patient #9: The Medical Director/Attending indicated patient was 61 years old in the CTI narrative. Per clinical record this patient is 67 years old.