Every finding on record at Treasure Care Hospice Inc

Upon patient record review, 3 of 14 (Patient #1, 5, 7) did not have evidence that the patient chooses a health care provider, including an attending physician Patient #1: Patient choice of physician is blank. Patients #5 and 7: The space allocated for choice of physician, has patient information written in, with one line marked through and Medical Director information written in beside it. There is no clear evidence that patient aware of change when made.

Upon patient record review, 2 of 14 (Patient #4, 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 #4, 5: Problems, goals, interventions include Oxygen therapy, however oxygen is not listed on medication profile.

Upon patient record review, 3 of 14 (Patient #5, 6, 8) 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 #5,6,8: Initial bereavement assessment does not identify bereaved. Bereavement Assessment section of RN comprehensive assessment is blank.

Upon patient record review, 10 of 14 (Patient #1, 2, 3, 4, 5, 6, 7, 8, 9, 10) 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. Patients #1, 2. 3, 4, 5, 6, 7, 8, 9, 10 : Patients have orders for oxygen therapy however, the problems, goals and interventions do not include related safety precautions. Patient #7: Medications include Metformin, but there are no related problems, goals, interventions

Upon observation, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Visit #3: Nurse used stethoscope on patient and wrapped around her neck without cleaning.

Upon personnel record review, 1 of 14 (Personnel #7) 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 #7: The competency validates "shampoo" but not specifically sink, tub, shower.

Upon personnel record review, 2 of 14 (Personnel #1,2) did not have evidence that the administrator is a hospice employee and possesses the education and experience required by the governing body. Personnel #1: The administrator does not meet agency defined job qualifications required for Administrator/Designee which states A Bachelor's degree in Registered Nurse, social Work or related field, Master's Degree in health care or related field preferred OR three to five years experience in health care management. No such evidence is documented in application. Personnel #2: The alternate administrator does not meet agency defined job qualifications required for Administrator/Designee which states A Bachelor's degree in Registered Nurse, social Work or related filed, Master's Degree in health care or related field preferred OR three to five years experience in health care management. No such evidence is documented in application.

Upon personnel record review, 1 of 14 (Personnel #9) did not have evidence that the hospice employees have received orientation on their specific job requirements. Personnel #9: Although the personnel file has signed job description for bereavement coordinator, the employee denies accountability for this position and related responsibilities.

Upon personnel record review, 3 of 14 (Personnel #2, 9, 10) 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 #2, 9, 10: There is no documented competency for volunteer coordinator, personnel identified by administration as bereavement coordinator, or volunteer.

Upon patient record review, 1 of 14 (Patient #12) did not have evidence that the medical director or physician designee provides written certification that it is anticipated that the patient's life expectancy is 6 months or less if the illness runs its normal course. The physician must consider the following when making this determination: • The primary terminal condition • Related diagnosis • Current subjective and objective medical findings • Current medication and treatment orders • Information about the medical management of any of the patient's conditions unrelated to the terminal illness Patient #12: There is no narrative by hospice physician. The allocated space is blank.

Upon patient client record review, 10 of 14 (Patient #1, 2, 3, 4, 5, 6, 7, 8, 9, 10) 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 #1: Patient choice of physician is blank. Patients #5, 7: The space allocated for choice of physician, has patient information written in, with one line marked through and Medical Director information written in beside it. There is no clear evidence that patient made this change or aware of change when made. Patient #1, 2, 3, 4, 5, 6, 7, 8, 9, 10: The addendum requested and provided lacks required details including specific hospice diagnosis. Form only lists ICD Code, emergency room visit, PCP visit and medications, but as non-covered and reason for non-coverage is blank.

Upon patient client record review, 8 of 14 (Patient #1, 2, 3, 6, 9, 11, 12, 14) did not have evidence that each patient record contains Advance Directives. Status of patient's wishes regarding advanced directives is unclear as cited below: Patient #1: EMR code status to Attempt CPR/Full Code but paper admission/consent forms include POLST DNR dated 3/17/25, and signed by patient and physician. Patient #2: EMR code status is Undecided, but paper admission/consent forms include POLST DNR dated 3/15/25 and signed by patient and physician. Patient #3: EMR code status to Attempt CPR/Full Code but paper admission/consent forms include POLST DNR dated 3/14/25 and signed by patient and physician. Patient #6: EMR code status to Attempt CPR/Full Code but paper admission/consent forms include POLST DNR dated 12/2/24 and signed by patient and physician. Patient #9: EMR code status to Attempt CPR/Full Code but paper admission/consent forms include POLST DNR dated 2/4/24 and signed by patient and physician. Patient #11, 12, 14: EMR code status is DNR, but paper admission/consent forms include POLST forms with Section A: Attempt CPR/Full Code. dated 5/15/24, 5/10/24, 4/1/24 respectively and signed by patient and physician. No evidence of change/updated code status in EMR.

Upon patient client record review, 1 of 14 (Patient #8) did not evidence that each patient record contains physician orders. Patient #8: 3/30/24 order that says patient refused visit today, but no specified discipline therefore incomplete order.

Upon patient client record review, 4 of 14 (Patient #2, 5, 6, 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 #2: MSW frequency 1/recert period. 3/31/25 and 4/14/25 IDG psychosocial notes say will visit patient on a monthly and/or prn basis. Patient #5, 6, 8: Bereavement Assessment form is not authenticated with signature. (assigned to MSW)

Upon client record review, 1 of 14 (Patient #11) did not have evidence that if a patient revokes the election of hospice care or is discharged from hospice in accordance with §418.26, the hospice must forward to the patient's attending physician: • A copy of the hospice discharge summary • The patient's clinical record, if requested Patient #11: No indication that the discharge summary was shared with attending physician.