Every finding on record at Welby Way Home LLC

Upon patient record review, 2 of 14 records reviewed (Patient #2,3) 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 #2: The record indicated the following medication was ordered: Acetaminophen ES 500mg po 2 tabs as needed for mild/moderate pain every 4 hours. There was no evidence in the record not exceed 4 grams in a 24 hour period. COS. Patient #3: The medication profile had Oxygen 2-5 lpm via NC continuous, there was no evidence this matched the physician order. COS.

Upon patient record review, 2 of 14 records reviewed (Patient #2, #3) 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 #2: The record indicated the following medication was ordered: Acetaminophen ES 500mg po 2 tabs as needed for mild/moderate pain every 4 hours. There was no evidence in the order to not exceed 4 grams in a 24 hour period. COS. Patient #3: The record indicated a physician order on 12/07/24 for Oxygen 2LPM as needed for shortness of breath, there was no route of administration on the physician order. COS

Upon patient record review, 3 of 14 records reviewed (Patient #1, #2, #3) 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 #1: The plan of care summary indicated the patient had a CADD Pump in the home and the medication profile had no medication listed for the CADD Pump. The Administrator confirmed there was no CADD Pump in the home. COS. In addition, the record indicated the patient had the following DME and medical supplies ordered on 12/02/24: ensure, wipes, incontinent pads, diapers, sterile gloves, oxygen regulator, wheel chair, foot rest, suction machine, bed rails, oxygen cart, nebulizer and oxygen concentrator. There was no evidence of these items in the care plan. COS. Patient #2: The record indicated the patient had oxygen, oxygen tank, nebulizer, bariatric bed and air pressure mattress ordered on 12/06/24. There was no evidence of these items in the care plan. COS. Patient #3: The record indicated the patient had the following DME ordered on 9/9/24: wheel chair, breathing tubing, suction machine, overbed table, oxygen cannula, humidifiers, oxygen, oxygen concentrator, mattress, electric hospital bed, bed side rails. There was no evidence of these items in the care plan. COS.

Upon patient record review, 7 of 14 (Patient #1,2,3,4,6,8,9) 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 record indicated the IDG was scheduled on 11/20/24 and 12/04/24. There was no evidence of notes and or signatures from the Nurse, MD, Social Worker and/or Chaplain on these IDG dates and no evidence the IDG POC was updated with progress towards goals being met. COS. Patient #2: The record indicated the patient was admitted on 12/06/24. There was no evidence of an IDG meeting at the time of the survey. COS. Patient #3: The record indicated the IDG was scheduled on 11/06/24, 11/20/24 and 12/04/24. There was no evidence of notes and or signatures from the Nurse, MD, Social Worker and/or Chaplain on these IDG dates and no evidence the IDG POC was updated with progress towards goals being met. COS. Patient #4: The record indicated the IDG was scheduled on 08/21/24. There was no evidence of participation by the Social Worker and/or Chaplain and no evidence the IDG POC was updated with progress towards goals being met. COS. Patient #6: The record indicated the IDG was scheduled on 11/20/24. There was no evidence of participation by the MD, Nurse, Chaplain and/or Social Worker. In addition the attending physician was not updated and no evidence the IDG POC was updated with progress towards goals being met. COS. Patient #8: The record indicated the IDG was scheduled on 11/20/24. There was no evidence of participation by the Social Worker and/or Chaplain and no evidence the IDG POC was updated with progress towards goals being met. COS. Patient #9: The record indicated the IDG was scheduled on 11/20/24. There was no evidence of participation by the Social Worker and/or Chaplain and no evidence the IDG POC was updated with progress towards goals being met. COS.

Upon patient record review, 1 of 14 records reviewed (Patient #8) 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 #8: The start of care was on 11/18/24. There was no evidence the patient was informed or allowed to request a copy of the Notice of Noncovered Items.

Upon patient record review, 1 of 5 (Patient #5) 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 5: The narrative portion of the comprehensive nursing assessment indicates that the SN provided the patient with multiple doses of liquid morphine sulfate 0.25mL sublingually to relieve end of life symptoms that included SOB and discomfort; however, liquid morphine sulfate did not appear on the patient's medication list. Additionally, the narrative note indicates the DME company delivered oxygen to the patient's home and it was administered at 2L/minute via nasal canula continuously until the time of the patient's death; however, the oxygen does not appear on the patient's medication list.

Upon patient record review, 1 of 5 (Patient #3) 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 a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs. Patient 3: On 12.29.2021, the aide orders were updated indicating the aide is to see the patient 1 x weekly and PRN for ADL assistance; the number of PRN visits allowable must be specified in the order. (corrected on site)

Upon patient record review and direct observation, 4 of 5 (Patient #1, 3, 4, 5) 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 1: The narrative portion of the comprehensive initial assessment, dated 09.20.2021, indicated the patient utilizes both a walker and a wheelchair for management of the terminal illness. However, the plan of care does not include the equipment the patient utilizes. (corrected on site) Patient 3: The narrative portion of the comprehensive initial assessment, dated 09.24.2021, indicated the patient utilizes a walker for management of the terminal illness. However, the plan of care does not include the equipment the patient utilizes. (corrected on site) Patient 4: The narrative portion of the comprehensive initial assessment, dated 09.01.2021, indicated the patient utilizes a walker for management of the terminal illness. However, the plan of care does not include the equipment the patient utilizes. Patient 5: The narrative portion of the comprehensive initial assessment, dated 08.05.2021, indicated oxygen was delivered by the DME company for management of the terminal illness. However, the plan of care does not include the equipment the patient utilizes.

Upon client record review, 3 of 5 (Patient #1, 2, 3) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 1: There is an order for the MSW and chaplain to make initial assessment visits, then there is no further orders for ongoing visits by the MSW or chaplain. The MSW and chaplain both make monthly visits to the patient. Patient 1,2,3: Nursing orders were written for the RN to visit 1 x every 2 weeks for supervisory visits and the LVN to visit 1 x weekly; the RN sees the patient 1 x weekly and no LVN visits have ever been made.

Upon patient record review 1 of 3 applicable (Patient #1) did not have evidence documentation in the patient record that a hospice aide provides services that are ordered by the IDG. Patient 1: The aide has seen the patient 1 x weekly since admission; the initial order indicates the aide should visit the patient 1 x weekly. On recertification, the aide order frequency states the aide is to visit the patient 2 x weekly; this was confirmed by the RN to be an error. (corrected on site)

Upon patient client record review, 1 of 5 (Patient #5) did not have evidence that each patient record contains a signed election statement in accordance with 418.24. Patient 5: The signed election statement did not contain an effective date for the election of hospice benefits.