Every finding on record at Urgent Help Hospice, Inc.

Upon patient record review 3 of 14 (Patient #3, 7, 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 3: There is no evidence of a comprehensive spiritual assessment; furthermore, the initial SN comprehensive assessment indicates that the patient/family requires assessment by the chaplain to determine spiritual needs. Patient 7: There is no evidence of a comprehensive psychosocial or spiritual assessment; furthermore, the initial SN comprehensive assessment indicates that the patient/family requires assessment by both the MSW & chaplain to determine needs. Patient 8: There is no evidence of a comprehensive spiritual assessment; furthermore, the initial SN comprehensive assessment indicates that the patient/family requires assessment by the chaplain to determine spiritual needs.

Upon patient record review, 3 of 14 (Patient #1, 4, 10) 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 Patient 1: The medication list contains a duplicate order for the patient's oxygen therapy. Both the initial PRN oxygen order that was entered at the time of admission on 08.22.2023 is present, as well as the subsequent continuous oxygen order that was obtained on 08.30.2023 due to the patient's decline. (corrected onsite) Patient 4: The medication list contains Miralax, but does not include instructions for the reconstitution of this powdered medication. (corrected onsite) Patient 10: The medication list contains Miralax, but does not include instructions for the reconstitution of this powdered medication. Additionally, there is a duplicate order for the patient's docusate 100mg. (corrected onsite)

Upon patient record review, 3 of 14 (Patient #3, 7, 10) 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 3: There is no evidence of an initial bereavement risk assessment. Patient 7: There is no evidence of an initial bereavement risk assessment. Patient 10: The patient was admitted for hospice services on 03.13.2023; however the initial bereavement risk assessment was not completed until 03.20.2023, which exceeds the 5 day allowance.

Upon client record review, 1 of 14 (Patient #5) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 5: Orders are present for the MSW to visit the patient 1 x monthly; however, during the month of July, there is evidence that the MSW made two visits to the patient on 07.22.2023 and 07.27.2023.

Upon patient record review, 9 of 14 (Patient #2, 3, 4, 5, 6, 10, 12, 13, 14) 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 2: The hospice aide care plan indicates that the patient requires a bed bath and brush & shampoo the hair, but does not specify the frequency for the performance of the tasks. (corrected onsite) Patient 3: The hospice aide care plan indicates that the patient requires a bath using the shower chair and brush & shampoo the hair, but does not specify the frequency for the performance of the tasks. (corrected onsite) Patient 4: The hospice aide care plan indicates that the patient requires a bed bath, brush & shampoo the hair, and brush the teeth, but does not specify the frequency for the performance of the tasks. (corrected onsite) Patient 5: The hospice aide care plan indicates that the patient requires a bath using the shower chair, brush & shampoo the hair, and brush the teeth, but does not specify the frequency for the performance of the tasks. (corrected onsite) Patient 6: The hospice aide care plan indicates that the patient requires a bed bath, brush & shampoo the hair, and brush the teeth, but does not specify the frequency for the performance of the tasks. (corrected onsite) Patient 10: The hospice aide care plan indicates that the patient requires a bed bath and brush & shampoo the hair, but does not specify the frequency for the performance of the tasks. (corrected onsite) Patient 12: The hospice aide care plan indicates that the patient requires a shower, brush & shampoo the hair, and brush the teeth, but does not specify the frequency for the performance of the tasks. Patient 13: The hospice aide care plan indicates that the patient requires a bed bath, brush & shampoo the hair, and brush the teeth, but does not specify the frequency for the performance of the tasks. Patient 14: The hospice aide care plan indicates that the patient requires a bed bath and brush & shampoo the hair, but does not specify the frequency for the performance of the tasks.

Upon patient client record review, 5 of 14 (Patient #1, 2, 5, 6, 10) did not have evidence that each patient record contains: • Signed election statement in accordance with 418.24 Patient 1, 2, 5, 6, 10: These patients were admitted using an out of date version of the hospice election form which did not contain the Notification of Noncovered Services and designation of the BFCC-QIO.