Every finding on record at Vistacare USA, LLC

Upon patient record review, 4 of 19 (Patient #1, #2, #3, #11) 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 patient was admitted on 10/26/23 and a spiritual assessment is not on record until 11/10/23. Patient #2-The patient was admitted on 10/12/23 and a spiritual assessment is not on record until 11/07/23. Patient #3-The patient was admitted on 09/29/23 and a spiritual assessment is not on record until 10/09/23. Patient #11-The patient was admitted 10/03/23 and a spiritual assessment is not on record until 10/10/23.

Upon patient record review, 3 of 19 (Patient #6, #9, #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. Patient #6-The patient declined Spiritual Care Services. A Spiritual assessment was not performed by the RN or Social Worker. A spiritual assessment is not on record. (corrected on site) Patient #9-A spiritual assessment is not on record. Patient #12-A spiritual assessment is not on record.

Upon patient record review, 6 of 19 (Patient #1, #4, #6, #8, #9, #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. Patient #1-The medication profile includes FIASP Flextouch U-100 insulin 100u/ml three times daily per sliding scale with meals. The orders do not specify the sliding scale for dosing. (corrected on site) Patient #4-The medication profile includes 2 medications ordered for pain without parameters/differentiation for administration: Tylenol 325 mg 2 q6h prn pain and Morphine 20mg/ml .25 ml q2h prn pain. On 10/25/23 the IDG documents the patient is on continuous Oxygen. Oxygen is not listed on the medication profile. (corrected on site) Patient #6- The patient was admitted on Oxygen. Oxygen is not listed on the medication profile. (corrected on site) Patient #8-On 10/16/23 the nurse documents instructing the patient on the use of the Oxygen concentrator/Oxygen. Oxygen is not listed on the medication profile. (corrected on site) Patient #9-Orders were received to Discontinue Seroquel on 10/16/23. Seroquel is an active medication on the medication profile. Patient #10-Orders were received 10/09/23 for Nitroglycerin .4mg SL prn chest pain. The medication profile does not include Nitroglycerin.

Upon patient record review, 3 of 19 (Patient #1, #9, #11) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component completed within the 5 days 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. Patient #1-A Bereavement Risk assessment is not on record. (corrected on site) Patient #9-The patient was admitted 10/03/23 and the bereavement assessment was not performed until 10/09/23. Patient #11-The patient was admitted 10/03/23 and a bereavement assessment was not performed until 10/10/23.

Upon patient record review, 2 of 19 (Patient #2, #11) 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). Patient #2- The patient has a sacral wound. The wound was measured on 10/17/23 and 11/01/23. Between 11/07/23 and 11/20/23 the wound was not measured. The patient is also receiving care for a left lateral thigh iliac crest wound. There is only one wound measurement on record on 10/12/23. Patient #11-On 11/18/23 Triage documented the patient called with a question about eye drops she is using ("Cistane"). She has used them 2 days in a row for dry eyes and they haven't bothered her. Her family is concerned because there have been a lot of eye drops pulled from the market recently and they want to know if it is ok to use them. Triage documents advising caller that "Cistane" is not on her list of medications(caller states she just bought them). and a message will be forwarded to the on call nurse for follow up. There is no documentation on record that a follow up call was made to the patient to address the concerns. Subsequent visits on record also do not address the eye drops concern.

Upon patient record review, 2 of 19 (Patient #9, #13) did not have evidence that each patient and family received education and training provided as appropriate to their responsibilities for the care and services identified in the plan of care. Patient #9-The medication profile contains Testosterone Cypionate 200mg/ml IM Oil. Inject 200mg (1 cc) in buttock every 2 weeks for low testosterone. The record indicates the family administers medications. The documentation does not specify that the patient and family had been educated and were able to administer the injections. Patient#13-The record documents the patient was admitted on 10/30/23 following a hospital stay for heart failure, MRSA, LLE cellulitis, lymphedema, and sepsis. Upon admission there were orders for the patient to have dressing changes to the Left Lower Extremity as follows: Perform wound care to left lower extremity every 3rd day or as dressing becomes soiled. Cleanse with wound cleanser, apply Zinc barrier and cover with gauze. On admission the nurse documented a dressing was on the lower extremity, clean, dry and intact and supplies were not available to change the wound. On 11/02/23 the nurse documents the wound is open and a dog was observed licking the patients left lower extremity. The visit note does not document the patient was instructed on infection control and/or the wound was dressed. The record documents wound care was not ordered and not provided. The record indicates the patient has a moderate to large amount of exudate. The next follow up visit was 11/07/23. On 11/07/23 the nurse documents the LLE is weeping and the family is using Triamcinolone cream (not the ordered treatment). The nurse documents the family agreed to have the leg wrapped in Optilock and Kerlix and supplies would be ordered for the treatment. On 11/10/23 the nurse documents the LLE was cleansed and Optilock was applied and the leg was wrapped in Kerlix. The family was advised Unna boots would be performed when supplies come in. On 11/10/23 the family also asked if an ace bandage could also be applied because the dogs would lick the dressing off. The record documents the family stated the dog can smell infection and wants to lick the wound. The documentation did not address the family's concern/ace bandage. Between 10/30/23 and 11/09/23 documentation does not evidence the nurse had supplies and/or performed wound care. Wound care supplies were not procured timely, infection control education is not documented, and dressing changes were not provided as ordered which put the patient at risk for increasing infection and the family's concerns to secure the dressing in the most effective manner was not addressed.

Upon patient record review, 2 of 19 (Patient #1, #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-The plan of care includes a goal that the patients PAC will remain patent and free from infection throughout therapy. This goal is not applicable to the plan of care. Upon interview, the PAC is to remain unaccessed and there are no orders to flush the catheter or maintain patency. Patient #11- The patient has a goal that the Facility staff is knowledgeable, aware and involved in the hospice plan of care. This goal is not applicable as the patient does not reside in a facility.

Upon patient record review, 2 of 19 (Patient #4, #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 #4- 11/06/23 orders for Social Worker are for 2 prn as the sole frequency (corrected on site) Patient #11-The Chaplain frequency on record is listed as 4 prn as the sole frequency effective 10/03/23

Upon patient record review, 6 of 19 (Patient #1, #3, #4, #6, #7, #8) did not have evidence the plan of care includes all services necessary for the palliation and management of the terminal illness and related conditions, including specific orders for all medications and treatments. Patient #1-The 10/26/23 plan of care includes FIASP Flextouch U-100 insulin 100u/ml three times daily per sliding scale with meals. The orders do not specify the sliding scale for dosing.(corrected on site) Patient #3-The 09/29/23 plan of care includes orders for the SN to instruct the facility staff on hospice responsibilities, and facility staff responsibilities. The orders are not applicable to the plan of care as the patient does not reside in a facility. (corrected on site) Patient #4- The plan of care 11/06/23 includes 2 medications ordered for pain without parameters/differentiation for administration: Tylenol 325 mg 2 q6h prn pain and Morphine 20mg/ml .25 ml q2h prn pain. On 10/25/23 the IDG documents the patient is on continuous Oxygen. Oxygen liter flow, delivery method and frequency is not listed on the plan of care. (corrected on site) Patient #6-The plan of care includes orders for a Fleets enema prn constipation. Fleets enema is not listed on the medication profile. Upon interview, a Fleets Enema was not ordered and this is an error on the plan of care (corrected on site) Patient #7-On 10/25/23 the plan of care includes orders for the SN to discuss need for Adult Protective Service referral with IDG and initiate referral if indicated. The orders were not applicable to the plan of care as assessments did not identify risk factors to warrant an APS referral. (corrected on site) Patient #8-On 10/16/23 the nurse documents instructing the patient on the use of the Oxygen concentrator/Oxygen. Oxygen is not listed on the plan of care.

Upon patient record review, 6 of 19 (Patient #1, #2, #3, #6, #10, #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 #1-The Chaplain visited the patient and developed a plan of care on 11/10/23 to visit the patient 1m3. The 11/15/23 revised plan of care/IDG documentation did not document the Chaplain findings from the initial comprehensive assessment. The Chaplain documented the patient is closed for spiritual services. Patient #2- The Social Worker visited the patient and developed a plan of care on 10/19/23 to visit the patient. The 10/25/23 revised plan of care/IDG documentation did not document the Social Worker findings from the initial comprehensive assessment. The Chaplain visited the patient and developed a plan of care on 11/08/23 to visit the patient monthly. The 11/22/23 revised plan of care/IDG documentation did not document the Chaplain findings from the initial comprehensive assessment. The spiritual findings were not documented. Patient #3-The 11/08/23 and 11/22/23 revised plan of care/IDG documentation did not document Chaplain findings and progress towards goals. On 11/08/23 the Chaplain documented the patient received a one time visit per care plan. The patient had a care plan for monthly spiritual visits effective 10/01/23. On 11/22/23 the only Chaplain documentation includes the patient has minimal progress towards goals. The IDG documentation does not include the patients religious preferences, spiritual support, and identified needs from spiritual visits. Patient#6-The Social Worker visited the patient and developed a plan of care on 10/18/23 to visit the patient. The 10/25/23 revised plan of care/IDG documentation did not document the Social Worker findings from the initial comprehensive assessment. The Social Work section of the IDG documented the patient will be evaluated on 10/18/23. The 11/08/23 revised plan of care/IDG documentation does not address the psychosocial findings/needs or progress towards goals. The Social Worker only documented the RN put the patient on regular pain meds. Patient #10-The Chaplain visited the patient and developed a plan of care on 10/10/23 to visit the patient 1q2m2. The revised plans of care/IDG documentation 10/18/23-11/29/23 are blank in the Spiritual section. Patient #14-The Chaplain visited the patient and developed a plan of care on 11/14/23 to visit the patient 1m1, 2m2. The 11/15/23 or 11/25/23 revised plan of care/IDG documentation did not document the Chaplain findings from the initial comprehensive assessment. The sections for religious preference of patient and family and spiritual support for patient and family are blank.

Upon patient record review, 8 of 19 (Patient #1, #2, #6, #7, #9, #11, #12, #13) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1- Effective 11/01/23 the Social Worker is ordered to visit the patient monthly. Two routine visits were made in November on 11/01/23 and 11/09/23. Patient #2-Effective 10/12/23 the Social Worker is ordered to visit 1q2m2 (once every 2 months). The social worker visited monthly on 10/19/23 and 11/10/23. (Late entry orders corrected on site) Patient #6-Effective 10/12/23 the Social Worker is ordered to visit 1q2m2 (once every 2 months). The social worker visited monthly on 10/18/23 and 11/09/23. (Late entry orders corrected on site) Patient #7- Effective 10/25/23 the Social Worker is ordered to visit 2q2m2 (twice every 2 months). The social worker visited 10/27/23, 11/13/23 and 11/27/23. (Late entry orders corrected on site) Patient #9-On 10/03/23 orders were on the initial plan of care for PT to eval and treat for immobility. A PT evaluation is not on record. Effective 10/03/23 the Social Worker is ordered to visit the patient monthly. Two routine visits were made in October on 10/09/23 and 10/25/23. On 10/03/23 the Chaplain was ordered to visit within 5 days. The record indicates the Chaplain attempted to visit on 10/05/23 and the family requested the visit to be rescheduled for 10/09/23. A visit is not on record for 10/09/23 and a Chaplain evaluation has not been performed. Patient #11-Effective 10/03/23 the Social Worker is ordered to visit the patient monthly. Two routine visits were made in October on 10/10/23 and 10/26/23. Patient #12-Effective 11/01/23 the Social Worker is ordered to visit the patient monthly. Two routine visits were made in November on 11/02/23 and 11/21/23.The patient has a left breast wound with orders for nursing to measure the wound weekly. The week of 11/12/23-11/18/23 wound measurements are not on record. The patient has orders to receive a Chaplain evaluation effective 10/31/23. The record does not include a Chaplain evaluation and/or documentation of attempts to visit the patient. Patient #13-The patient was admitted 10/30/23 with orders to perform wound care to the patients left lower extremity every 3rd day or as needed when the dressing becomes soiled. The wound was to be cleansed with wound cleanser , apply zinc barrier cream and cover with gauze. On admission the nurse documents the dressing is clean dry and intact and wound supplies were unavailable. On 11/2/23 the nurse documents wound care was not provided and not ordered. On 11/7/23 the nurse also documents wound care was not performed. The record indicates the first dressing change occurred on 11/10/23.

Upon patient record review, 2 of 19 (Patient #8, #11) did not have evidence in the patient record that hospice aide assignments and duties are: • Complete written patient care instructions for a hospice aide prepared by the Registered Nurse. Patient #8-The Aide care plan includes a bed bath assigned every visit and a shower assigned every visit. (corrected on site) Patient #11- The Aide care plan does not include Oxygen precautions which are applicable to the patients care.

Upon patient record review 1 of 19 (Patient # 4) did not 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 #4-Between 11/06/23 and 11/27/23 an aide supervisory visit is not on record.

Upon patient record review, 4 of 19 (Patient #1, #9, #10, #11) did not have evidence that all entries are clear, complete, and accurate. Patient #1- On 11/22/23 the nurse documented the patient has bilateral wounds to bilateral lower extremities. Dressing to lower extremities changed. The documentation is not specific for the wound assessment/description and the actual dressing changes performed. (corrected on site) Patient #9-On 11/10/23 the nurse documented the patient appears to have the "absense" of the top right back teeth MD contacted and order given, the record should have read abcess. On 11/21/23 the nursing note reads "care if you're a nerd to call and then you need your concerns". Patient #10-The patient was admitted 10/07/23 with orders for nebulizer treatments : Ipratropium .5mg-Albuterol 3mg (2.5 mg base)/3ml. Administer 3 ml q4h prn shortness of breath. On 11/16/23 the nurse documented providing instruction for the breathing treatments which she does not have the machine for. Upon interview, the documentation is incomplete as the patient did have a machine which was not working at the time of the visit and the hospice ordered a replacement nebulizer which was not documented. Patient #11-The Certification of Terminal illness on record documents the patients intake has gone from 100% to 625%.

Upon patient record review, 1 of 19 (Patient #18) did not have evidence that the discharge summary includes all required information. Patient #18- The discharge summary does not include a summary of the patient's stay, including treatments, symptoms and pain management. The discharge summary only states the patient revoked the election and no longer wants hospice.