Every finding on record at Unitypoint at Home

Upon patient record review 1 of 19 (Patient #3) 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 3: The medical record contained an initial comprehensive spiritual assessment 6/2/23 with start of care 5/23/23.

Upon patient record review 2 of 19 (Patients #2,#8) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient 2: There was no evidence of a comprehensive spiritual assessment. Patient 8: There was no evidence of a comprehensive spiritual assessment.

Upon patient record review, 9 of 19 (Patients #1,#2,#3,#4,#5,#6,#7,#12,#13) 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 1,3: The medication profiles contained miralax oral powder with no instructions for a diluent. Corrected on site. Patient 2: The medical record contained nursing documentation upon admission identifying patient use of oxygen. There was no evidence of oxygen listed on the medication profile. Corrected on site. Patient 4: The medication profile contained bisacodyl suppository PRN with no indication, oxygen with no delivery method and miralax and metamucil oral powders with no instructions for a diluent. Corrected on site. Patient 5: The medication profile contained oxygen with no delivery method, triamcinolone topical with no area defined for administration. Delivery method for oxygen corrected on site. Patient 6: The medication profile contained oxygen with no delivery method. Patient 7:The medication profile contained melatonin PRN with no indication, and miralax oral powder with no instructions for a diluent. Corrected on site. Patient 12: The medication profile contained nystatin topical powder with no area defined for administration, and miralax oral powder with no instructions for a diluent. Miralax instructions corrected on site. Patient 13: The medication profile contained lidocaine and zinc oxide topical ointments with no area defined for administration.

Upon patient record review, 2 of 19 (Patients #1,#3) 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 1: The medical record contained an initial bereavement assessment completed 1/6/23 with start of care 12/6/22. Patient 3: There was no evidence of a bereavement assessment.

Condition of Participation: Interdisciplinary Group, Care Planning, and Coordination of Services. L536

Upon patient record review, 2 of 19 (Patients #11,#14) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient 11: The medical record contained nursing documentation upon recertification 7/21/23 identifying patient wounds stage 3 to right ankle, stage 4 to sacrum and diabetic wound to right pretibial. There was only one assessment of wounds in the medical record. Patient 14: The medical record contained orders for wound care to buttocks. There was no evidence of wound assessments between 6/14/23 and 6/28/23.

Upon patient record review, 6 of 19 (Patients #1,#3,#9,#11,#12,#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 1: The medical record contained nursing documentation 7/21/23 identifying patient dyspnea with transfers. There was no evidence of problems, goals, and interventions related to respiratory dysfunction included in the plan of care. Corrected on site. Patient 3: The Certification of Terminal Illness identified patient had primary diagnosis of Alzheimer's Disease with agitation requiring lorazepam. There was no evidence of problems, goals, and interventions related to neurological dysfunction or behaviors included in the plan of care. Corrected on site. Patient 9: The medical record contained nursing documentation upon admission identifying patient had dyspnea at rest and with exertion. There was no evidence of problems, goals, and interventions related to respiratory dysfunction included in the plan of care. Corrected on site. Patient 11: The medical record contained nursing documentation upon recertification visit 7/21/23 identifying patient agitation requiring ativan and haldol medication management. There was no evidence of problems, goals, and interventions related to agitation included in the plan of care. Patient 12: The medical record contained nursing documentation upon admission identifying patient history of falls and issues with dyspnea. There was no evidence of problems, goals, and interventions related to fall safety and respiratory dysfunction included in the plan of care. Corrected on site. Patient 14: Upon observation and interview during home visit, the patient was dependent of oxygen and identified as using indwelling catheter. There was no evidence of problems, goals, and interventions related to respiratory dysfunction and urinary dysfunction requiring catheter included in the plan of care.

Upon patient record review, 1 of 19 (Patient #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 2: The medical record contained an order for Social Work to visit PRN only. Corrected on site.

Upon patient record review, 9 of 19 (Patients #1,#3,#4,#5,#6,#7,#11,#12,#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 1: The medical record contained an order for miralax oral powder with no instructions for a diluent. Corrected on site. Patient 3: The medical record contained an order for miralax oral powder with no instructions for a diluent. Corrected on site. Patient 4: The medical record contained orders for a bisacodyl suppository PRN with no indication, oxygen with no delivery method, and miralax and metamucil oral powders with no instructions for a diluent. Patient 5: The medical record contained orders for oxygen with no delivery method, and triamcinolone topical ointment with no area defined for administration. Oxygen order corrected on site. Patient 6: The medical record contained an order for oxygen with no delivery method. Patient 7: The medical record contained orders for melatonin PRN with no indication, and miralax oral powder with no instructions for a diluent. Corrected on site. Patient 11: The medical record contained a wound order 5/4/23 with no dressing type. The record also contained catheter care on the aide care plan. There was no evidence of an order for an indwelling catheter. Patient 12: The medical record contained orders for nystatin topical powder with no area defined for administration, and miralax oral powder with no instructions for a diluent. Patient 14: The medical record contained a wound care order 3/31/23 with no frequency for dressing changes. Upon interview during home visit, patient was identified as requiring an indwelling catheter. There was no evidence of an order for an indwelling catheter.

Upon patient record review, 5 of 19 (Patients #3,#5,#6,#9,#11) 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 3: The medical record contained nursing documentation upon recertification visit 7/7/23 identifying patient use of a walker. There was no evidence of the walker included as DME in the plan of care. Corrected on site. Patient 5: During home visit interview, patient identified use of a nebulizer, shower chair, and commode. There was no evidence of the nebulizer, shower chair, and commode included as DME in the plan of care. Corrected on site. Patient 6: During home visit observation, the patient was witnessed using oxygen and identified use of shower chair during the interview. There was no evidence of the oxygen and shower chair included as DME in the plan of care. Patient 9: The medical record contained nursing documentation upon admission identifying patient use of a walker. There was no evidence of the walker included as DME in the plan of care. Corrected on site. Patient 11: The aide care plan contained instructions for the aide to complete catheter care. There was no evidence of catheter supplies included in the plan of care.

Upon client record review, 3 of 19 (Patients #5,#7,#10) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 5: The medical record contained an order for nursing visit frequency of twice weekly. There was evidence of three scheduled nursing visits completed the week of 7/23/23. Patient 7: The medical record contained an order for spiritual care visit frequency of once monthly. There was no evidence of a visit completed in June. Patient 10: The medical record contained an order for nursing visit frequency of three times weekly. There was evidence of four scheduled nursing visits completed the week of 7/16/23.

Upon personnel record review, 1 of 13 (Personnel # 7) did not have evidence that all bereavement services are provided by a qualified counselor in accordance with applicable laws and regulations, professional practice standards, the hospice's policies and procedures and/or job descriptions which includes experience or education in grief or loss counseling.

Upon patient record review, 1 of 19 (Patient #7) 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 7: The aide care plan contained tasks for shower and shampoo PRN. There was no evidence of instructions that patient was cognitively able to make the decision and functionally able to complete the task.

Upon patient record review 1 of 19 (Patient #5) 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 5: During home visit, the patient and hospice aide discussed plan to complete a sponge bath and explained the process they complete. The aide care plan bathing task was for shower.

Upon patient record review 2 of 19 (Patients #3,#11) 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 was no evidence of supervisory visits completed between 6/8/23 and 6/27/23. Patient 11: There was no evidence of supervisory visits completed between 6/20/23 and 7/13/23.

Upon observation, there was no evidence the hospice maintains, documents and provides volunteer orientation and training that is consistent with hospice industry standards.

Upon personnel record review, 1 of 13 (Personnel #9) did not have evidence that a skills competency assessment, specific to each discipline had been conducted for all personnel including volunteers initially during orientation.

Upon patient client record review, 1 of 19 (Patient # 11) 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 11:The medical record contained an election form with unanswered section regarding patient choice to elect or decline to receive notification of non-covered items.

Upon patient client record review, 1 of 19 (Patient # 14) did not have evidence that each patient record contains Physician certification and recertification of terminal illness. Patient 14: The medical record contained an election of benefit form indicating the patient chose a community physician as their attending physician. There was no evidence the agency received a Certification of Terminal Illness from the attending physician.

Upon patient client record review, 3 of 19 (Patients #1,#10,#11) 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 1: The medical record contained documentation identifying a missed nursing visit 7/28/23. The template for the missed visit did not contain a reason to explain why the visit was unable to be completed. Corrected on site. Patient 10: The medical record contained documentation identifying a missed nursing visit 7/4/23. The template for the missed visit did not contain a reason to explain why the visit was unable to be completed. Corrected on site. Patient 11: The medical record contained documentation identifying a missed nursing visit 7/4/23. The template for the missed visit did not contain a reason to explain why the visit was unable to be completed.

Upon client record review, 1 of 19 (Patient #18) 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 18: There was no evidence the agency forwarded the discharge summary to the attending physician for continuity of care after revocation.

Upon client record review, 2 of 19 (Patient #11,#13) did not have evidence that a written hospice plan of care is established and maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided is in accordance with this hospice plan of care. Patient 11: The medical record contained an order for nursing visit frequency of once weekly. There was evidence of two scheduled nursing visits completed the week of 7/23/23. Patient 13: The medical record contained an order for nursing visit frequency of once weekly. There was no evidence of a nursing visit completed the week of 7/9/23, and two scheduled nursing visits completed the week of 7/16/23.

Upon client record review, 1 of 19 (Patient # 11) 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 11-There was documentation that the patient had a foley. There was no evidence of whether facility or hospice was managing catheter changes.