Every finding on record at Trinity Hospice 3, LLC

Upon patient record review 1 of 8 (Patient #1) 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 1: The Chaplain comprehensive assessment visit was made on 10/25/24 with assessment visit not documented until 11/6/24. The MSW comprehensive assessment visit was made on 10/24/24 with assessment visit not documented until 11/13/24.

Upon patient record review, 1 of 8 (Patient #7) 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: Medication list with order: erythromycin ophthalmic 5mg/gm/inch. Apply 0.25 inch to upper and lower lid margin twice daily. There is no evidence of application site on the medication list. Medication list with order: zinc oxide 20 percent ointment. 1 ointment topical twice daily. Cleanse with wound cleanser, dry area, apply zinc oxide twice daily by caregiver. Hospice nurse to evaluate weekly. There is no evidence of application site on medication list.

Upon patient record review, 4 of 8 (Patient #1,2,5,7) 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 1: Identified needs: high risk for falls, neuro, nutrition, constipation, pain, mobility, high risk for skin breakdown. No evidence of problems, goals, interventions on the plan of care: falls, pain. COS Patient 2: Identified needs: neuro, cardiac, falls, nutrition/dysphagia, mobility, bleeding precautions, UTI. No evidence of problems, goals, interventions on the plan of care: bleeding precautions. COS Patient 5: Identified needs: mobility, falls, anxiety, respiratory with dyspnea and oxygen, constipation, high risk for skin breakdown, pain. No evidence of problems, goals or interventions on the plan of care: pain, falls. Patient 7: Identified needs: mobility, pain, dyspnea, edema, neuro with confusion, respiratory with oxygen, falls, high risk for skin breakdown. No evidence of problems, goals or interventions on the plan of care: pain.

Upon patient record review, 1 of 8 (Patient #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 7: Plan of care with order: erythromycin ophthalmic 5mg/gm/inch. Apply 0.25 inch to upper and lower lid margin twice daily. There is no evidence of application site on the plan of care. Plan of care with order: zinc oxide 20 percent ointment. 1 ointment topical twice daily. Cleanse with wound cleanser, dry area, apply zinc oxide twice daily by caregiver. Hospice nurse to evaluate weekly. There is no evidence of application site on plan of care.

Upon patient record review, 2 of 8 (Patient #1,6) 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: Identified DME needs: reclining high back wheelchair, pommel cushion, chair alarm, hospital bed, alternating pressure pad, bed alarm, fall mat. No evidence of DME on the plan of care: pommel cushion, chair alarm, bed alarm, fall mat. Patient 6: Identified DME needs: wheelchair, oxygen, hospital bed. No evidence of DME on the plan of care: oxygen.

Upon observation, there was no evidence a written plan of correction is developed in response to any QAPI activity that does not meet an acceptable threshold. According to the agency identifying and establishing a PIP, agency submission of documentation is not submitted within 48 hours and continues with no evidence of timely submission through January 2025. Patient 1: All represent late documentation. RN: 10/24/24 visit documented 10/29/24. 10/30/24 visit documented 11/3/24. 11/5/24 visit documented 11/17/24. 11/11/24 visit documented 11/14/24. 11/20/24 visit documented 12/3/24. 11/29/24 visit documented 12/4/24. 12/5/24 visit documented 12/12/24. 12/13/24 visit documented 12/16/24. 12/24/24 visit documented 12/28/24. 1/3/25 visit documented 1/6/25. Face to Face visits: 10/23/24 face to face visit documented 10/30/24. Aide: 12/2/24 visit documented 12/6/24. 12/9/24 visit documented 12/12/24. Patient 2: Late aide documentation: 12/9/24 visit documented 12/12/24. Patient 3: Late RN documentation: 1/16/25 visit documented 1/23/25.

Upon patient record review 1 of 8 (Patient #6) 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 6: Aide visit frequency order is twice weekly. The week of 11/17/24-11/23/24 only evidence of one aide visit, documented on 11/21/24.