Every finding on record at Unitypoint at Home

Upon patient record review, 1 of 21 (Patient #4) 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 04: The medication profile includes duplicate orders for Hydrocodone 5-325mg, take 1-2 tablets by mouth every 4 hours as needed for pain, may also take 1-2 tablets every 4 hrs PRN for pain. The medication profile includes duplicate orders for Lorazepam 0.5mg, take 1 tablet by mouth 2 times daily and 2 tablets nightly, and may have additional 1 tablet every hour as needed for anxiety/restlessness. (Corrected on site.)

Upon patient record review, 1 of 21 (Patient 6) 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 06: The patient was admitted on 7/11/23, the bereavement assessment was completed on 9/25/23.

Upon patient record review, 2 of 21 (Patient #1, 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. Patient 01: The patient was admitted on 8/26/23 with a primary diagnosis of Alzheimer's and a secondary condition of Type II Diabetes Mellitus, the patient takes Lispro three times daily with meals, the plan of care does not include a problem statement with interventions and goals that address the management of the diabetes. The admit assessment includes evidence that the patient has 2+ edema, dysphagia and weight loss, the plan of care does not include a problem statement with interventions and goals to address these issues. Patient 10: The patient was admitted on 4/6/24 and reports frequent bouts of diarrhea, the patient uses Immodium, as needed to control the symptom, the POC does not include interventions and goals for the management of the diarrhea.

Upon patient record review, 1 of 21 (Patient #3) 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 03: Volunteer services are ordered for this patient and indicated as PRN with no quantity indicated.

Upon patient record review, 1 of 21 (Patient #10) 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 10: The medication profile includes orders for Duoneb respiratory treatments, the POC does not include a nebulizer.

Upon patient record review, 2 of 21 (Patient #1,14) 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 01: The patient recertification visit assessment and updated comprehensive assessment includes information that the patient continues with swallowing difficulties and edema, the plan of care has not been updated to include a problem statement with interventions and goals for the management of the issues. Patient 14: The patient medication orders include Eliquis 2.5mg BID effective 2/22/24, the plan of care was not updated to include bleeding precautions.

Upon patient record review, 2 of 21 (Patient #3, 8) 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 03: The following hospice aide task assignments are indicated as PRN; assist with feeding, assist with ambulation, nail care & filing. (Corrected on site) Patient 08: The following hospice aide task assignments are indicated as PRN; assist with feeding, assist with ambulation. (Corrected on site.)

Upon patient record review 2 of 21 (Patient #7, 8) 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 07: The hospice aide visit order is indicated for 2 x per week, there was only 1 visit performed for the week of 3/17/24 - 3/23/24, the documentation indicated "due to agency staffing issues." Patient 08: The patient hospice aide task assignment includes assistance with feeding, the documentation for 4/18/24 does not indicate if the task was performed or declined.

Upon client record review, 1 of 21 (Patient #2) did not have evidence that the hospice plan of care identifies the care and services that are needed and specifically identify which provider (nursing facility or hospice) is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care. Patient 02: The plan of care includes wound care orders for a wound to the right buttock, cleanse with warm soapy water, pat dry apply zinc oxide paste BID and PRN. The order does not include which provider is responsible for performing the care and does not include an indicator for PRN.

Upon observation, there was no evidence the hospice inpatient facility tests their power systems in accordance with NFPA 99 and NFPA 110 including the maintenance and testing of alternate power sources and transfer inspection and testing and maintenance and testing of circuitry. NFPA 110 Part 8.3.7: A fuel quality test shall be performed at least annually using appropriate ASTM standards. The agency is unable to provide evidence of annual fuel quality testing reports for the generator located at the Paula Baber Hospice House.

Upon observation, there is no evidence the corridor walls and doors of a facility is provided consistent with the 2012 editions of the LSC of the National Fire Protection Association and NFPA 99. Hospices are exempt from chapter 19.3.6.3.5 "exception number 1 and 2 and 19.3.6.3.6 number 2". If recommended by state survey agency, CMS may waive for periods deemed appropriate, specific provisions of the LSC which, if rigidly applied, would result in unreasonable hardship to the hospice, but only if the waiver would not adversely affect the health and safety of patients. The provisions of the adopted edition of the Life Safety Code do not apply in a State if CMS finds that a fire and safety code imposed by State law adequately protects patients in hospices. Existing Construction During the walk through inspection it was identified that the cross corridor fire rated doors within the smoke compartment located in the west corridor do not prevent the passage of smoke. Upon release of the doors, it was noted that the outward swinging door towards the path of egress became stuck at the top and center of the frame leaving a gap and preventing the door from closing properly. A gasket would also be required where the doors should properly meet, to prevent the passage of smoke.