Every finding on record at Wesley Hospice, LLC

Upon personnel record review, 2 of 13 (Personnel #4,6) did not have evidence Emergency Preparedness training including: Personnel 4 and 6: The personnel files did not contain evidence of: • Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles • Demonstrate staff knowledge of emergency procedures • Provide emergency preparedness training at least annually • Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others • Maintain documentation of all emergency preparedness training Corrected on site. The agency performed the education during survey via Zoom.

Upon patient record review, 14 of 14 (Patient #1,2,3,4,5,6,7,8,9,10,11,12,13,14) did not have evidence that the hospice obtained the patient's or representative's SIGNATURE confirming that they received a copy of the Patient's Rights and Responsibilities. The nurse Initial Assessment documents that the information was provided to the patient/family prior to SOC, however: no signature was obtained.

Upon patient record review, 3 of 14 (#4,6,12) 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 limit Patients 4,6,12: The medication profiles contain incomplete orders for 'MiraLAX oral powder for reconstitution; administer 17gm orally once daily for constipation" with no evidence of directions for reconstitution. Corrected on site.

Upon patient record review, 2 of 14 (#4,13) 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 #4,13: oral anticoagulation medication ordered on POC with no Nursing Care Plan with problems, goals and interventions for of risk for bleeding/anticoagulation therapy measures. Corrected on site. Patient #13: Pt has a diagnosis of Aspiration and Dysphagia, no aspiration risk problems goals or intervention on nursing care plan.

Upon patient record review, 3 of 14 (Patient #4,6,12) 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. Patients 4,6,12: The POC's contain incomplete orders for 'MiraLAX oral powder for reconstitution; administer 17gm orally once daily for constipation" without evidence of directions for reconstitution. Corrected on site.

Upon personnel record review, 1 of 13 (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.) Personnel 5: The aide competency did not contain evidence of the following tasks: Normal range of motion and positioning, Appropriate and safe techniques in personal hygiene and grooming that include--Sponge and tub bath, and Shampoo, sink, tub, and bed.

Upon patient record review 13 of 14 (Patient #1,2,3,4,6,7,8,9,10,11,12,13,14) did not have evidence documentation in the patient record that a hospice aide provides services that are: Patient #1,2,3,4,6,7,8,9,10,11,12,13,14: There were no aide frequencies on the aide written instructions or frequencies on each individual task. Corrected on site.

Upon personnel record review, 2 of 13 (Personnel #4,6) did not have evidence that a skills competency assessment, specific to each discipline had been conducted for all personnel including volunteers initially during orientation. Personnel 4,6: The personnel files did not contain a skills competency.

Upon patient client record review, 14 of 14 (#1,2,3,4,5,6,7,8,9,10,11,12,13,14) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patients 1,2,3,4,5,6,7,8,9,10,11,12,13,14: The CTI's written by the medical director were all hand written and illegible. Patient 9: The SN documented 7/15/24 "Wound care performed by: Clinician" and "Care performed: Independently". There is no evidence the nurse followed the POC as the nurse did not document details of wound care provided. The SN documented on 7/12/24 Wound care: completed and performed wound care/dressing change: completed. There is no evidence the nurse followed the POC as the nurse did not document details of wound care provided.