Every finding on record at Trinity Hospice 2, LLC

Upon patient record review 2 of 19 (Patient #7,11) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient 7,11: There is no evidence of a comprehensive spiritual assessment within 5 days of admission. Patient 7: Patient was admitted on 08/06/2024. Initial comprehensive psychosocial assessment dated 08/12/2024, outside of initial 5 days of admission.

Upon patient record review, 5 of 19 (Patient #7,8,10,11,12) 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 7: Patient with physician’s order for continuous oxygen at 2LPM via nasal cannula on plan of care. There is no evidence of oxygen on the medication list. The following medications are on medication list without evidence of indication for medications: Vitamin D2 50,000 international units by mouth weekly. Sertraline 100mg by mouth daily. Topiramate 100mg by mouth twice daily. Pregabalin 100mg by mouth daily. Ezetimibe 10mg by mouth daily. Patient 8: Patient with physician’s order for PRN oxygen at 2LPM via nasal cannula on plan of care. There is no evidence of oxygen on the medication list. The following medications are on medication list without evidence of indication for medications: Baclofen 10mg by mouth three times daily. Senokot 8.6mg by mouth daily. Patient 10: The following medications are on medication list without evidence of indication for medications: Levothyroxine 25mcg by mouth daily. Acetaminophen 500mg/15mL; take 30mL by mouth three times daily. Prolia 6mg/mL; inject 1mL subcutaneously every six months. Patient 11: The following medication is on medication list without evidence of indication for medication: Gabapentin 100mg by mouth three times daily. Lactulose 10Gm/15mL is on medication list with conflicting order as reads: 15mL by mouth daily every three days. There is no evidence of indication for this medication. Patient 12: The following medication is on medication list without evidence of indication for medication: Melatonin 3mg by mouth daily at bedtime.

Upon patient record review, 1 of 19 (Patient #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 8: There is no evidence of comprehensive bereavement assessment within 5 days of admission.

Upon patient record review, 5 of 19 (Patient #2,3,7,11,14) 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 with active pain plan of care including problems, goals, and interventions. Patient’s documented pain goal in this plan of care is “-- /10.” There is no evidence of individualized pain goal in this plan of care. Patient 3: Patient with active pain plan of care including problems, goals, and interventions. Patient’s documented pain goal in this plan of care is “--/10.” There is no evidence of individualized pain goal in the pain plan of care. Patient with active integumentary plan of care including problems, goals, and interventions. This includes intervention: “Measures to prevent skin breakdown <SPECIFY>.” There is no evidence of individualized integumentary intervention in this plan of care. Patient 7: Patient has the following problems documented in the medical record during nursing visit dated 08/06/2024: edema, irregular heart rate, dyspnea. There is no evidence of plans of care including problems, goals, and interventions for these documented problems. Patient 11: Patient has active safety/falls plan of care including problems, goals, and interventions. One of the interventions included in this plan of care is, “Assist with transfers (specify).” There is no evidence of individualized transfer assist intervention in the safety plan of care. Patient 14: Patient’s fall risk was assessed as high during admission assessment and recertification assessment. There is no evidence of a safety/falls plan of care including problems, goals, and interventions.

Upon patient record review, 4 of 19 (Patient #3,6,11,14) 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:Patient has active wound plan of care with documented wound treatment on plan of care as, “wound care as prescribed <SPECIFY>.” There is no evidence of individualized prescribed wound care. Patient has active cardiac plan of care with included intervention is supplemental oxygen. This patient has no evidence of a physician’s order for oxygen. Patient 6: Patient has active cardiac plan of care with included intervention of supplemental oxygen. This patient has no evidence of a physician’s order for oxygen. Patient 11: Patient has active wound plan of care with documented wound treatment on plan of care as, “wound care as prescribed <SPECIFY>.” There is no evidence of individualized prescribed wound care. Patient 14: Patient has active cardiac plan of care with included intervention of supplemental oxygen. This patient has no evidence of a physician’s order for oxygen.

Upon patient record review, 2 of 19 (Patient #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 6: 08/02/2024 physician’s order states wheelchair as tolerated with max assist for transfers. There is no evidence of wheelchair DME order in the patient’s plan of care. Patient 7: 08/06/2024 physician’s order includes hospital bed and overbed table. There is no evidence of these DME orders in the patient’s plan of care.

Upon patient record review, 1 of 19 (Patient #3) 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 3: There is documentation in the medical record that patient’s wounds were healed as of nursing assessment dated 09/30/2024. There is no evidence of updated wound plans of care, reflecting these healed wounds.

Upon patient record review, 8 of 19 (Patient #2,3,4,7,9,10,12,13) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 2: Patient seen by massage therapist on dates: 07/30/2024, 08/13/2024, 09/19/2024. There is no evidence of a physician’s visit frequency order for this discipline in the plan of care. Patient 3: Patient was seen by massage therapist on 09/18/2024. There is no evidence of a physician’s visit frequency order for this discipline in the plan of care. Patient 4: Patient was seen by massage therapist on 09/18/2024. There is no evidence of a physician’s visit frequency order for this discipline in the plan of care. Patient admitted on 08/31/2024 with physician’s visit frequency order for SN of twice weekly. There is evidence of only one SN visit this week, dated 08/31/2024. Patient 7: There is an active Physician order 08/06/24 with visit frequency orders-once a month and 3 as needed. There is no evidence of any spiritual care visits made to this patient since admission. There is documentation on 08/22/2024 IDT that chaplain services have been declined. Patient 9: Physician’s order for visit frequencies as of 05/30/2024 for complementary therapies: Music therapy-4 times monthly. Massage therapy-4 times monthly. Documented music therapy visits: 08/07/2024, 08/20/2024, 08/29/2024, 09/11/2024, 09/18/2024, 09/25/2024. There is no evidence of fourth August or September music therapy visit. Documented massage therapy visits: 08/05/2024, 08/13,2024, 08/29/2024, 09/17/2024, 09/30/2024. There is no evidence of fourth August massage therapy visit. There is evidence of only two massage therapy visits in September. Physician’s order for volunteer visit frequency is twice monthly and 3 PRN. Documented volunteer visits: 07/11/2024, 09/17/2024. Documented volunteer coordinator visits: 08/14/2024, 08/30/2024. There is no evidence of second September volunteer visit. Patient 10: Physician’s order for visit frequency for massage therapy 07/15/2024 to 10/01/2024 is twice monthly. There is evidence of only one documented visit in August, dated 08/21/2024. Patient 12: Physician’s order for spiritual care visit frequency, dated 07/03/2024 is once monthly and 3 as needed. Documented September visits made 09/09/2024, and 09/23/2024. There is no evidence of documentation that either visit was PRN. Physician’s order for massage therapy visit frequency, dated 07/03/2024 is twice monthly. There is no evidence of massage therapy visits documented in patient’s medical record. Patient 13: Physician’s order for massage therapy visit frequency was discontinued on 08/14/2024. New order written 10/07/2024 for twice monthly. There is evidence of documented massage therapy visit made 09/11/2024.

Upon patient record review 2 of 19 (Patient #3,4) 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 3: Physician’s order for hospice aide visit frequency, dated 06/17/2024 is twice weekly. On 08/13/2024 and 08/20/2024, there are documented missed visits. There were also visits made on these dates. There is no evidence of second visits made these weeks. Patient 4: Patient was admitted 08/31/2024. Physician’s order for hospice aide visit frequency written on this date for twice weekly. There is no evidence of any documented hospice aide visits made until 09/10/2024. There are two documented missed visits, dated 09/03/2024 and 09/05/2024.

Upon patient record review 2 of 19 (Patient #3,8) 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 3: There is documentation of a hospice aide supervisory visit made on 08/27/2024 and 09/12/2024, which is 16 days apart. There is no evidence of a supervisory visit made within 14 days during this period. Patient 8: There is no evidence in the patient’s medical record of a documented hospice aide supervisory visit made since 09/23/2024.

Upon patient record review, 2 of 5 (Patient #1, 3) did not have evidence in the patient record that hospice aide assignments and duties are: • 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, 3 HA assignment includes "Shampoo every visit per patient/cg request".

Upon patient record review 2 of 5 applicable (Patient #2, 3) did not have evidence documentation in the patient record that a hospice aide provides services that are ordered by the interdisciplinary group and included in the plan of care Patient #2: HA assignment include task of shampoo every visit. HA did not document shampoo as done 10/21/21 or 10/26/21. HA Visit 10/19/21 tasks assigned but not checked as completed included chair, elimination, inc care, bed bath every visit, perineal care soap and water every visit and shampoo each visit. HA Visit 11/1/21 tasks assigned but not checked as completed included chair, barrier protective inc cream, bed bath every visit, clothes assistance, perineal care, shampoo every visit. Patient #3: HA frequency per initial POC was 3xweek. Only 2 visits documented the weeks of 10/17, 10/25, 10/31 and 11/7/21. Only 1 visit documented week of 11/14, 11/21 and 11/28/21. No change order identified.

Upon patient record review, 1 of 5 (Patient #3) did not have evidence that each patient record contains: • Signed election statement in accordance with 418.24 Patient #3: Effective Date for Hospice Election Statement was blank on the election form.