Every finding on record at Vista Community Hospice, Inc

Upon observation, there was no evidence the Emergency Plan communication plan must includes a primary and alternate means for communicating with hospice's employees and Federal, state, tribal, regional, and local emergency management agencies. Corrected on site.

Upon patient record review 7 of 14 (Patient #2,#3,#6,#7,#8,#10,#12) 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. Patients #2,#3, #6,#7,#8,#10,#12: No evidence of a spiritual needs assessment, by SC or SN.

Upon patient record review, 1 of 14 (Patient #6) 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 #6: Medication profile dated 6/8/2023 included Polyethylene Glycol 17GM PO Q 3 days PRN constipation. No evidence of a diluent. Dated 11/16/2024 Triamcinolone 0.1% topical BID PRN for skin itchiness. No evidence of an area to apply.

Upon patient record review, 1 of 14 (Patient #6) 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 #6: SOC date 6/8/2023, initial bereavement assessment occurred 6/14/2023.

Upon patient record review, 8 of 14 (Patient #1,#2,#3,#4,#7,#8,#10,#11) 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: On SN SOC assess identified fall risk of 18-high, no evidence in the POC of problem/intervention/goals for safety/fall risk. Corrected on site. Patient #2: On SN SOC assess identified O2 use, no evidence in the POC of problem/intervention/goals for O2. Corrected on site. Patient #3: On SN SOC assess identified O2 use, no evidence in the POC of problem/intervention/goals for O2. Corrected on site. Patient #4: On SN SOC assess identified fall risk of 21-high, dysphagia, and is taking Eliquis. No evidence in the POC of problem/intervention/goals for safety/fall risk, risk of aspiration and risk of bleeding. Corrected on site. Patient #7: On SN SOC assess identified fall risk of 9-moderate and is taking Pradaxa. No evidence in the POC of problem/intervention/goals for safety/fall risk and risk of bleeding. Patient #8: On SN SOC assess identified Braden score of 14-moderate and need for aspiration precautions, no evidence in the POC of problem/intervention/goals for skin integrity and aspiration precautions. Patient #10: On SN SOC assess identified O2 use and 2+ pitting edema, mild SOB; client just discharged from hospital with 3rd documented MI. No evidence in the POC of problem/intervention/goals for O2 and cardio-respiratory related to edema, SOB. Patient #11:On SN SOC assess identified use of Plavix and terminal diagnosis of Acute respiratory failure with hypoxia, SOB with speech, 10L continuous O2 use. No evidence in the POC of problem/intervention/goals for cardio-respiratory related to respiratory dysfunction and bleeding precautions..

Upon patient record review, 1 of 14 (Patient #11) 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 #11: Order dated 6/28/2023 included MSW as needed and at recert. No evidence of specificity for PRN order.

Upon patient record review, 2 of 14 (Patient #6,#12) 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 #6: Order dated 6/8/2023 included Polyethylene Glycol 17GM PO Q 3 days PRN constipation. No evidence of a diluent. Dated 11/16/2024 Triamcinolone 0.1% topical BID PRN for skin itchiness. No evidence of an area to apply. Patient #12: Orders dated 11/16/2023 included Unasyn Q12 hr. via PICC line for 2 weeks, and Ceftriaxone 2Gm Q 12Hrs. via PICC line for 2 weeks. No evidence of who was to administer medications.

Upon patient record review, 3 of 14 (Patient #5,#11,#13) 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 dated 8/1/2024, 8/29/2024, 9/12/2024 and 10/10/2024 included SC 1x month. No evidence of SC visits months of August, September, and October 2024. Patient #11: SC ordered x1 dated 6/26/2023. SC visit 6/23/2023. Visits also occurred on 8/20/2024 and 9/24/2024 without an order. Patient #13: SOC orders did not include visit frequency for MSW. Visits made 1/25/2024 and 2/6/2024 without an order.

Upon personnel record review, 1 of 14 (Personnel # 5) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) ·Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff. ·Reading and recording temperature, pulse, and respiration ·Safe transfer techniques and ambulation. ·Normal range of motion and positioning ·Appropriate and safe techniques in personal hygiene and grooming that include-- ·(A) Bed bath ·(B) Sponge, tub, and shower bath ·(C) Shampoo, sink, tub, and bed ·(D) Nail and skin care ·(E) Oral hygiene ·(F) Toileting and elimination The other subject areas in this section may be evaluated through written examination, oral examination or after observation of a Hospice Aide with a patient. Personnel #5: No evidence in personnel file of observed competencies with a patient or pseudo-patient

Upon patient record review, 9 of 14 (Patient #1,#2,#3,#4,#5,#7,#8,#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 #1: SN SOC identified use of O2, no evidence on aide assignment sheet of O2 precautions. Corrected on site. Patient #2: SN SOC identified use of O2, no evidence on aide assignment sheet of O2 precautions. Corrected on site. Patient #3: SN SOC identified use of O2, no evidence on aide assignment sheet of O2 precautions. Corrected on site. Patient #4: SN SOC identified use of O2, on Eliquis, and has dysphagia. No evidence on aide assignment sheet of O2 precautions, bleeding or aspiration precautions. Corrected on site. Patient #5: SN SOC identified use of O2 and has dysphagia. No evidence on aide assignment sheet of O2 or aspiration precautions. Corrected on site. Patient #7: SN SOC identified use of O2, use of Pradaxa and seizures. No evidence on aide assignment sheet of O2, bleeding or seizure precautions. Patient #8: SN SOC identified use of O2 and at risk for aspiration. No evidence on aide assignment sheet of O2 or aspiration precautions. Patient #13: SN SOC identified use of O2 and has dysphagia. No evidence on aide assignment sheet of O2 or aspiration precautions. Patient #14: SN SOC identified use of O2 . No evidence on aide assignment sheet of O2 precautions.

Upon client record review, 2 of 14 (Patient #9,#10) did not have evidence that the hospice forwarded a summary and a copy of the patient record, if requested, to a facility when transferring the patient to that facility. Patient #9,#10: No evidence of a transfer summary sent to the hospital in which patient was transferred.

Upon patient record review, 5 of 14 (Patient #6,#7,#8,#9,#10) 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 Patients #6,#7,#8,#9,#10: No evidence of required records sent to attending physician.

Upon patient record review, 3 of 14 (Patient #6,#8,#10) did not have evidence that the discharge summary includes all required information. Patient #6: No evidence of a complete discharge summary. Patient #8: No evidence of a complete discharge summary. Patient #10: No evidence of a complete discharge summary.

Upon patient record review, 1 of 5 (Patient #1) 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: SN note dated 11.15.2021 indicates the patient's O2 was discontinued; there is a signed order indicating this. However, the medication list was not updated to demonstrate the discontinuation of oxygen therapy. (corrected on site)

Upon patient record review, 1 of 1 applicable (Patient #5) 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 5: The hospice aide care plan, dated 05.20.2021, indicates the patient requires shower, shampoo, and oral care, but does not specify the frequency of these tasks.