Every finding on record at Vistacare USA, LLC

Upon patient record review 2 of 19 (Patients #3,#13) 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 was no evidence of a comprehensive spiritual assessment. The mini spiritual assessment completed 7/13/23 was blank and stated patient declined chaplain services. Corrected on site. Patient 13: There was no evidence of a comprehensive spiritual assessment. Corrected on site.

Upon patient record review, 3 of 19 (Patients #1,#2,#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 1: The plan of care identified oxygen equipment needed by the patient. There was no evidence of oxygen listed on the medication profile. Corrected on site. Patient 2: The medical record contained nursing documentation 7/12/23 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 duplicative senna plus listed for administration of one tablet daily and one tablet at bedtime. There was no evidence of instructions to clarify if dosages were the same order or intended for administration twice daily. Corrected on site.

Upon patient record review, 1 of 19 (Patient #4) 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 4: The medical record contained a wound care order 7/7/23 stating hospice nurse to measure and assess wound weekly. There was no evidence of an assessment completed after 7/11/23 and wound was inactivated without assessment 7/25/23. Nurse documentation 7/8/23 and 7/21/23 stated patient refused assessment and documentation 7/13/23 and 7/18/23 stated facility completed wound assessment.

Upon patient record review, 4 of 19 (Patients #2,#4,#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 2: The medical record contained nursing documentation 7/21/23 identifying patient is a high risk for aspiration. There was no evidence of problems, goals, and interventions related to dysphagia. Corrected on site. Patient 4: The medical record contained nursing documentation upon admission identifying patient issue with dysphagia requiring pureed diet. There was no evidence of problems, goals, and interventions related to dysphagia or fall safety. Corrected on site. Patient 10: The medical record contained nursing documentation upon admission identifying patient was NPO with tube feedings due to dysphagia. There was no evidence of problems, goals, and interventions related to dysphagia. Corrected on site. Patient 11: The plan of care included an active aide care plan. There was no evidence of the patient receiving aide services. The medical record contained spiritual care documentation 7/14/23 identifying patient declined further spiritual care visits. There was no evidence the plan of care was updated with discontinuation of services. Corrected on site. Corrected on site.

Upon patient record review, 2 of 19 (Patients #1,#2) 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 plan of care identified oxygen equipment needed by the patient. There was no evidence of an order for oxygen dose, frequency, and delivery method. Corrected on site. Patient 2: The medical record contained nursing documentation 7/12/23 identifying patient use of oxygen. There was no evidence of an order. Corrected on site.

Upon patient record review, 5 of 19 (Patients #2,#3,#6,#12,#13) 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 2: The medical record contained nursing documentation 7/12/23 identifying patient use of oxygen. There was no evidence of oxygen included as DME in the plan of care. Corrected on site. Patient 3: The medical record contained nursing documentation upon admission identifying patient use of a walker and wheelchair. The medication profile identified patient use of a nebulizer. There was no evidence of the walker, wheelchair, and nebulizer included as DME in the plan of care. Corrected on site. Patient 6: The medical record contained nursing documentation upon admission identifying patient use of a nebulizer. There was no evidence of the nebulizer included as DME in the plan of care. Corrected on site. Patient 12: The medical record contained nursing documentation upon admission identifying patient use of a commode. There was no evidence of the commode included as DME in the plan of care. Corrected on site. Patient 13: The plan of care included an oxygen concentrator as DME in the plan of care. Upon interview of patient during home visit, the patient was witnessed smoking upon arrival, therefore was asked if they had oxygen in the home and the patient stated they did not have any oxygen equipment. Corrected on site.

Upon client record review, 4 of 19 (Patients #5,#8, #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: The medical record contained an ordered social work frequency of once monthly. There was no evidence of a June social work visit. Corrected on site with late documentation for missed visit. Patient 8: The medical record contained an ordered nursing frequency of three times weekly. There was no evidence of a third visit the week of 8/6/23. Patient 13: The medical record contained an ordered social work frequency effective 6/1/23 for two visits month one and one visit month one. There was no evidence of social work visits completed in June and July.

Upon patient record review 2 of 19 (Patient # 9, 13) 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 9: The medical record contained ordered frequencies for aide visits twice weekly. There was no evidence of a second aide visit the week of 7/16/23. Patient 13: During home visit to the patient, the patient explained to a substitute aide that she did not receive showers and that they give sponge baths instead due to inability to get into the tub. Upon record review, the aide documented 7/26/23, 8/2/23, and 8/9/23 that the tasked shower was completed. The patient's daughter also verified during interview that the regular aide was giving sponge baths during visits.

Upon client record review, 2 of 19 (Patients #4,#6,#14) 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 4: The medical record contained a wound care order 7/7/23 stating hospice nurse to measure and assess wound weekly. There was no evidence of an assessment completed after 7/7/23 and wound was inactivated without assessment 7/25/23. There was no evidence of an assessment completed after 7/11/23 and wound was inactivated without assessment 7/25/23. Nurse documentation 7/8/23 and 7/21/23 stated patient refused assessment and documentation 7/13/23 and 7/18/23 stated facility completed wound assessment. Patient 6: The medical record contained an order for social work visit frequency of twice monthly. There was no evidence of second visits or missed visit documentation completed in June and July. Patient 14: The medical record contained ordered frequencies for nursing twice weekly and social work twice for the month of July. There was no evidence of a second nursing visit the week of 7/2/23 and a second social work visit completed in July.