Every finding on record at Tranquility Sands Hospice, Inc.

Upon patient record review, 2 of 14 (Patient #1 & 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 1: Miralax present on medication record with no complete instructions present related to the use of a diluent. Patient 2: Morphine Sulfate Concentrate and Norco are present on the medication record as needed for "pain". There is no further instruction present for the appropriate time to administer different medications based upon pain intensity or severity.

Upon patient record review, 1 of 14 (Patient #2) 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 2: Patient has documented history of seizure disorder. No evidence of seizure precautions found on plan of care.

Upon patient record review, 2 of 14 (Patient #1 & 2) 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 • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient 1: Frequency "NP as needed" found on plan of care update 5/18/24. No evidence of a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs. Patient 2: Frequency "NP as needed" & "MD as needed and recert" found on plan of care update. No evidence of a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs.

Upon patient record review, 3 of 14 (Patient #1, 2, & 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 medications and treatments. Patient 1: Miralax present on plan of care with no complete instructions present related to the use of a diluent. Patient 2: Morphine Sulfate Concentrate and Norco are present on the plan of care as needed for "pain". There is no further instruction present for the appropriate time to administer different medications based upon pain intensity or severity. Patient 7: Foley catheter initiated on 5/23/24. Plan of care does not include specified balloon size per MD. Further, nephrostomy site care initiated 5/10/23 does not include a frequency for dressing change or who is to perform. Per nursing documentation, this is changed once weekly by the caregiver.

Upon patient record review, 4 of 14 (Patient #3, 4, 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. Patients 3, 4, 6 & 7: No evidence found of provision of emergency Oxygen tanks to patient.

Upon client record review, 1 of 14 (Patient #1) 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 of once weekly. There is no visit documented or evidence found of patient refusal of a visit the week of 5/12/24. Visit frequency for the week was not met. In addition, Spiritual Care visit 2/10/24 and MSW visit 4/20/24 both conducted via telephone. No evidence found on plan of care of telephonic/virtual visits acceptable or indicated per MD.

Upon personnel record review, 1 of 14 (Personnel #2) 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 Record #2: The Initial Competency Assessment Skills Checklist for the Hospice Aide indicates the evaluation method on all the above required tasks as "V". Surveyor verified with staff that this indicates a verbal explanation of the skill to be performed. No evidence that the assessment was completed while the aide is performing the tasks with a patient or pseudo-patient.

Upon patient record review, 2 of 14 (Patient #2 & 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 2: Patient has documented history of seizure disorder. No evidence of seizure precautions found on aide instructions. Patient 6: New wound care orders 5/20/24 and 5/26/24 to separate wound locations. Hospice aide instructions show no evidence of update to include instructions for dressings in place r/t bathing.

Upon personnel record review, 3 of 14 (Personnel # 9, 10, & 11) did not have evidence the hospice employees and contract employees have received orientation on the hospice philosophy. Personnel records 9, 10, & 11 for contracted therapy services contained no evidence contracted staff have received orientation on the hospice philosophy.

Upon personnel record review, 3 of 14 (Personnel #9, 10, & 11) did not have evidence that the hospice employees have received orientation on their specific job requirements. Personnel records 9, 10, & 11 for contracted therapy services contained no evidence of orientation on their specific job requirements.

Upon personnel record review, 3 of 14 (Personnel #9, 10, & 11) did not have evidence that a skills competency assessment, specific to each discipline had been conducted for all personnel including volunteers initially during orientation. Personnel records 9, 10, & 11 for contracted therapy services had skills competency assessments completed by self-assessment only.

Upon patient client record review, 1 of 14 (Patient #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 9: There is a revocation form present in the medical record. However, the date in the body of the revocation statement has been incorrectly corrected with a write over. The date of revocation is unclear. The signature line has a date line present beside it, no date was filled in here to signify the date the form was signed. No evidence found of effective date of revocation.

Upon observation, there was no evidence the hospice provides orientation to personnel of a SNF/NF or ICF/IID regarding the policies and procedures of the provision of care/service including all required content.