Every finding on record at West Valley Hospice Inc

Upon observation, there was no evidence all patient records are retained for a minimum of six years from the date of the most recent discharge or the death of the patient, unless state law stipulates a longer period of time. The agency has been unable to obtain records from the previous owner. There are currently staying in ongoing communication with previous owner in order to obtain the records. The agency does have a current system in place to maintain records appropriately. All records since change in ownership are being maintained appropriately.

Condition of Participation: Patient’s Rights. L500

Upon patient record review there was not evidence that the hospice informed and provided written information to the patient concerning its policies on advance directives, including a description of applicable state law. Condition Level Deficiency cannot be abated as there have been no new admissions since last survey and/or compliance date.

Upon patient record review there was not 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. Condition Level Deficiency cannot be abated as there have been no new admissions since last survey and/or compliance date.

Upon patient record review there was not evidence that if a state court has not adjudged a patient incompetent, any legal representative designated by the patient in accordance with state law may exercise the patient's rights to the extent allowed by state law. Condition Level Deficiency cannot be abated as there have been no new admissions since last survey and/or compliance date.

Upon patient record review there was not evidence that the patient chooses a health care provider, including an attending physician. Condition Level Deficiency cannot be abated as there have been no new admissions since last survey and/or compliance date.

Upon patient record review there was not evidence of the appropriate documentation for release of confidential information. Condition Level Deficiency cannot be abated as there have been no new admissions since last survey and/or compliance date.

Upon observation, there was no evidence the patient has the right to be free of mistreatment, neglect, or verbal, mental, sexual and physical abuse, including injuries of unknown source, and misappropriation of patient property. Condition Level Deficiency cannot be abated as there have been no new admissions.

Upon patient record review there was not evidence that the patient received information about the services covered under the hospice benefit. Condition Level Deficiency cannot be abated as there have been no new admissions since last survey and/or compliance date.

Upon patient record review there was not evidence that the patient received information about the scope of services that the hospice will provide and specific limitations on those services. Condition Level Deficiency cannot be abated as there have been no new admissions since last survey and/or compliance date.

Condition of Participation: Initial and Comprehensive Assessment of the Patient.

Upon patient record review there was not 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. Condition Level Deficiency cannot be abated as there have been no new admissions since last survey and/or compliance date.

Upon patient record review there was not 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. Condition Level Deficiency cannot be abated as there have been no new admissions since last survey and/or compliance date.

Upon patient record review there was not 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 No deficiencies identified in clinical record review, but cannot abate deficiency as no visits available afternoon of survey.

Upon patient record review there was not 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. Condition Level Deficiency cannot be abated as there have been no new admissions since last survey and/or compliance date.

Condition of Participation: Interdisciplinary Group, Care Planning, and Coordination of Services. L536

Upon patient record review there was not 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. Condition Level Deficiency cannot be abated as there have been no new admissions since last survey and/or compliance date.

Upon patient record review, 3 of 5 (Patient #1, 2, 4) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1: RN 2/mo and 1/mo prn. SN frequency 1/wk and 2 prn visits/mo. Last documented SN visit 9/30/24. Patient #2: RN 2/mo and 1/mo prn. SN frequency 1/wk and 2 prn visits/mo. Last documented SN visit 9/26/24. Patient #4 RN 2/mo and 2/mo prn. SN frequency 1/wk and 3 prn visits/mo. Last documented SN visit 10/4/24.

Condition of Participation: Hospice Aide and Homemaker Services. L607

Upon patient record review there was not 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 Condition Level Deficiency cannot be abated as there have been no Hospice Aide services provided since last survey and/or compliance date

Upon patient record review there was not evidence 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 Condition Level Deficiency cannot be abated as there have been no Hospice Aide services provided since last survey and/or compliance date

Upon patient record review there was 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. Condition Level Deficiency cannot be abated as there have been no Hospice Aide services provided since last survey and/or compliance date.

Condition of Participation: Clinical Records.

Upon patient record review there was not 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 Condition Level Deficiency cannot be abated as there have been no new admissions since last survey and/or compliance date.

Deficiency cannot be abated, as initial survey records are still not available.

Condition of Participation: Drugs and Biologicals, Medical Supplies, and Durable Medical Equipment.

Upon observation, there was no evidence a copy is provided of the hospice written policies and procedures on the management and disposal of controlled drugs to the patient or patient representative and family. Condition Level Deficiency cannot be abated as there have been no new admissions since last survey and/or compliance date.

Upon observation, there was no evidence the hospice discussed the policies and procedures for managing the safe use and disposal of controlled drugs with the patient or representative and the family in a language and manner that they understand to ensure that these parties are educated regarding the safe use and disposal of controlled drugs. Condition Level Deficiency cannot be abated as there have been no new admissions since last survey and/or compliance date.

Upon patient record review there was not evidence that the written policies and procedures for managing controlled drugs was provided and discussed. Condition Level Deficiency cannot be abated as there have been no new admissions since last survey and/or compliance date.

Condition of Participation: Patient’s Rights. L500

Upon patient record review, 2 of 9 (Patient #1,5) did not have evidence that the hospice informed and provided written information to the patient concerning its policies on advance directives, including a description of applicable state law. Patient #1, Patient primary diagnosis is heart disease with secondary of Alzheimer disease. Plan of care and nursing assessment documents patient is anxious , awake, lethargic, confused. The patient was seen awake, lethargic at times and with confusion and disorientation. Patient is only oriented to place and person, reoriented patient as needed. Patient signed his own consents. Patient #5, Patient primary diagnosis is senile degeneration of brain, documenting primary disease as dementia. RN initial assessment documents alert and oriented x2 with forgetfulness and confusion. CTI documents patient is awake, mostly confused and disoriented.

Upon patient record review, 2 of 9 (Patient #1,5) 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. Patient #1, Patient primary diagnosis is heart disease with secondary of Alzheimer disease. Plan of care and nursing assessment documents patient is anxious , awake, lethargic, confused. The patient was seen awake, lethargic at times and with confusion and disorientation. Patient is only oriented to place and person, reoriented patient as needed. Patient signed his own consents. Patient #5, Patient primary diagnosis is senile degeneration of brain, documenting primary disease as dementia. RN initial assessment documents alert and oriented x2 with forgetfulness and confusion. CTI documents patient is awake, mostly confused and disoriented.

Upon patient record review, 2 of 9 (Patient #1,5) did not have evidence that if a state court has not adjudged a patient incompetent, any legal representative designated by the patient in accordance with state law may exercise the patient's rights to the extent allowed by state law. Patient #1, Patient primary diagnosis is heart disease with secondary of Alzheimer disease. Plan of care and nursing assessment documents patient is anxious , awake, lethargic, confused. The patient was seen awake, lethargic at times and with confusion and disorientation. Patient is only oriented to place and person, reoriented patient as needed. Patient signed his own consents. Patient #5, Patient primary diagnosis is senile degeneration of brain, documenting primary disease as dementia. RN initial assessment documents alert and oriented x2 with forgetfulness and confusion. CTI documents patient is awake, mostly confused and disoriented.

Upon patient record review, 2 of 9 (Patient #1,5) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient #1, Patient primary diagnosis is heart disease with secondary of Alzheimer disease. Plan of care and nursing assessment documents patient is anxious , awake, lethargic, confused. The patient was seen awake, lethargic at times and with confusion and disorientation. Patient is only oriented to place and person, reoriented patient as needed. Patient signed his own consents. Patient #5, Patient primary diagnosis is senile degeneration of brain, documenting primary disease as dementia. RN initial assessment documents alert and oriented x2 with forgetfulness and confusion. CTI documents patient is awake, mostly confused and disoriented.

Upon patient record review, 2 of 9 (Patient #1,5) did not have evidence of the appropriate documentation for release of confidential information. Patient #1, Patient primary diagnosis is heart disease with secondary of Alzheimer disease. Plan of care and nursing assessment documents patient is anxious , awake, lethargic, confused. The patient was seen awake, lethargic at times and with confusion and disorientation. Patient is only oriented to place and person, reoriented patient as needed. Patient signed his own consents. Patient #5, Patient primary diagnosis is senile degeneration of brain, documenting primary disease as dementia. RN initial assessment documents alert and oriented x2 with forgetfulness and confusion. CTI documents patient is awake, mostly confused and disoriented.

Upon patient record review, 2 of 9 (Patient #1,5) did not have evidence that the patient received information about the services covered under the hospice benefit. Patient #1, Patient primary diagnosis is heart disease with secondary of Alzheimer disease. Plan of care and nursing assessment documents patient is anxious , awake, lethargic, confused. The patient was seen awake, lethargic at times and with confusion and disorientation. Patient is only oriented to place and person, reoriented patient as needed. Patient signed his own consents. Patient #5, Patient primary diagnosis is senile degeneration of brain, documenting primary disease as dementia. RN initial assessment documents alert and oriented x2 with forgetfulness and confusion. CTI documents patient is awake, mostly confused and disoriented.

Upon patient record review, 2 of 9 (Patient #1,5) did not have evidence that the patient received information about the scope of services that the hospice will provide and specific limitations on those services. Patient #1, Patient primary diagnosis is heart disease with secondary of Alzheimer disease. Plan of care and nursing assessment documents patient is anxious , awake, lethargic, confused. The patient was seen awake, lethargic at times and with confusion and disorientation. Patient is only oriented to place and person, reoriented patient as needed. Patient signed his own consents. Patient #5, Patient primary diagnosis is senile degeneration of brain, documenting primary disease as dementia. RN initial assessment documents alert and oriented x2 with forgetfulness and confusion. CTI documents patient is awake, mostly confused and disoriented.

Condition of Participation: Initial and Comprehensive Assessment of the Patient.

Upon patient record review 1 of 9 (Patient #5) 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 #5, MSW completed initial assessment on 5/14, patient was admitted on 2/15. MSW documented on 2/16, patient declined MSW service.

Upon patient record review 2 of 9 (Patient #7,8) 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 #7,8, No evidence of psych social assessment completed. RN initial assessment documented need for visit due to lack of coping skills.

Upon patient record review, 4 of 9 (Patient #1,2,3,9) 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, Upon home visit, patient caregiver states patient is no longer taking Calcium. Calcium remain on medication profile. Patient #2, Upon home visit, patient takes Vitamin D3 every day. No evidence of Vitamin D3 on medication profile. Patient #3, Upon home visit, medication profile states Metoprolol 50mg 2x/day. Patient medication bottle reads Metoprolol 25mg 2x/day. Patient #9, Oxygen @2lpm via nasal cannula as needed shortness of breath. No evidence order was documented on medication profile. Order documented under treatment.

Upon patient record review, 6 of 9 (Patient #1,2,3,5,6,8) 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 #1,2,3,5,6,8, No evidence of bereavement assessment completed, MSW documents patient did not want MSW to talk with family.

Upon patient record review, 7 of 9 (Patient #3,4,5,6,7,8,9) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual's attending physician, if any) • Changes that have taken place since the initial assessment • Information on the patient's progress toward desired outcomes • Reassessment of the patient's response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days Patient #3,4,5,6,7,8,9, No evidence of discussion of home health aide during IDG. Patient #6, RN completed initial visit on 1.27.24. No evidence that RN made any additional visits. LVN completed visits on 2.10, 2.24, 3.9, 3.23, 4.6, 4.20, 5.4, 5.18, 6.1, 6.15, 6.29.

Condition of Participation: Interdisciplinary Group, Care Planning, and Coordination of Services. L536

Upon patient record review, 2 of 9 (Patient #1,4) 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, Patient has heart disease as primary diagnosis. No evidence of cardiac care plan. Patient is a full code, no evidence of full code status care plan. Patient #4, Spiritual care documents patient has loss of faith on initial assessment. No evidence of care plan identifying loss of faith. No evidence of care plan addressing 16 year old granddaughter who lives in home. No evidence of care plan for full code status.

Upon patient record review, 4 of 9 (Patient #1,2,3,4) 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 #1,2,3, No evidence of DME documented on plan of care. Patient has walker identified during home visit. Patient #4, No evidence of DME documented on plan of care. Patient has walker documented on initial assessment.

Upon client record review, 3 of 9 (Patient #4,6,7) did not have evidence that the IDG in collaboration with the attending physician reviewed, revised and documents the individualized plan as frequently as the patient's condition requires but no less frequently then every 15 calendar days. Patient #4, No evidence of MD review on IDG notes on 7/4/, 7/15, 7/29. Patient #6, No evidence of MD review on IDG notes on 1/29, 2/12, 2/26, 3/11, 3/25, 4/8, 4/22, 5/6, 5/20, 6/3, 6/17, 7/1. Patient #7, No evidence of MD review on IDG notes on 5/20.

Upon patient record review, 1 of 9 (Patient #5) 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 #5, No evidence of MSW documented progress toward goals on 8/12. No evidence of MSW or SC updating progress toward goals on 8/26.

Upon client record review, 8 of 9 (Patient #1,2,3,4,5,7,8,9) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1, LVN frequency 1x/week, 2 visits completed the first week on 7/14 and 7/19. MSW order for eval, no evidence of visit completed or documentation of missed visit or order to discontinue. SC order for eval, no evidence of initial assessment completed, missed visit or order to discontinue. Patient #2, LVN frequency 1x/week, visits missing week of 7/28, 8/4, 8/11, 8/18. MSW completed telephone visit on 7/6/24, no evidence of order for telephone visits. SC eval, no evidence of visit, missed visit or discontinued order. Patient #3, LVN frequency 1x/week, missed visit first week. B/p order to notify MD of b/p greater than 160, b/p 161/84, no evidence of b/p reported to MD. MSW eval, no evidence of visit, missed visit or discontinued order for visit. SC eval, no evidence of visit, missed visit or discontinued order for visit. Patient #4, SN 1x/week, no evidence of visit completed week of 7/14. Completed 2 visits within one week on 7/31 and 8/3. Patient #5, No evidence of order for 5/14 MSW visit. Patient #7, Frequency documented as RN every 14 days till 4/18/24, LVN 1x/week until 4/18/24. No evidence of order frequency after 4/18/24, patient was seen with continued frequency until 5/17/24. Patient #8,9, MSW and SC order for eval, no evidence of visit, missed visit or discontinued services.

Upon observation, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient #1,2,3, Upon observation of visits, all had clean area for b/p, thermometer, pulse ox. Upon using the first item, this item was returned to the clean area.

Condition of Participation: Hospice Aide and Homemaker Services. L607

Upon patient record review, 4 of 9 (Patient #3,5,6,7) 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 #3,5,7, Order for aide services. No evidence of care plan completed for aide service. Patient #6, Aide care plan instructs aide to report any change is condition. No evidence of documentation of what changes.

Upon patient record review 6 of 9 (Patient #3,5,6,7,8,9,) 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 #3,5,8, Order for Aide 2x/week, no evidence of any visits. Patient #6, Order for Aide 1x/week, no evidence of any visits. Patient #7, No evidence of bed bound/chair to bed, objects within reach on aide care plan. Aide documented completed. Patient #9, Aide frequency 2x/week, no evidence of visits the first week and only 1 visit the second and third week. No evidence of any additional visits or order to discontinue visits.

Upon patient record review 1 of 9 (Patient #7) did not have 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 #7, No evidence of aide supervisory visits completed on 4/27/24 and 5/11/24.

Upon personnel record review, 1 of 13 (Personnel #2 ) did not have evidence the alternate administrator's personnel record verifies that: • The employee has appropriate education and experience requirements • There is a signed job description for this role • The employee has been orientated to this role Personnel #2, Alt Administrator does not meet the job description requirements of RN or Business Administration.

Upon patient record review, 1 of 9 (Patient #8) did not have evidence that a hospice that provides hospice care to a Medicare or Medicaid beneficiary does not discontinue or reduce care because of the beneficiary's inability to pay. Patient #8, Patient had Medicaid California, discharge summary documents patient had not updated his Medicaid and the agency discharged patient for not having a payor source. Discharge summary states MSW instructed patient on importance to update their insurance. No evidence of MSW visit made to patient in record.

Upon patient record review, 2 of 9 (Patient #5,6) did not have evidence that the medical director or physician designee provides written certification that it is anticipated that the patient's life expectancy is 6 months or less if the illness runs its normal course. The physician must consider the following when making this determination: • The primary terminal condition • Related diagnosis • Current subjective and objective medical findings • Current medication and treatment orders • Information about the medical management of any of the patient's conditions unrelated to the terminal illness Patient #5, No evidence of MD narrative documented on CTI dated 8/13/24 for recertification. Patient #6, No evidence of MD narrative documented on CTI dated 1/27/24

Upon patient record review, 1 of 9 (Patient #6) did not have evidence that before the recertification period for each patient, the medical director or physician designee must review the patient's clinical information and provide written documentation that it is anticipated that the patient's life expectancy is 6 months or less. Patient #6, No evidence of MD narrative documented on CTI dated 4/26/24.

Condition of Participation: Clinical Records.

Upon patient client record review, 3 of 9 (Patient #1,5,6) 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 #1, Patient primary diagnosis is heart disease with secondary of Alzheimer disease. Plan of care and nursing assessment documents patient is anxious , awake, lethargic, confused. The patient was seen awake, lethargic at times and with confusion and disorientation. Patient is only oriented to place and person, reoriented patient as needed. Patient signed his own consents. Patient #5, Patient primary diagnosis is senile degeneration of brain, documenting primary disease as dementia. RN initial assessment documents alert and oriented x2 with forgetfulness and confusion. CTI documents patient is awake, mostly confused and disoriented. Patient #6, No election benefit date documented on the election benefit form.

Upon patient client record review, 1 of 9 (Patient #6) 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. Patient #6, IDG note on 7/1, missing MD, RN,SC signatures, 6/17, 6/3, 5/20, missing MD and SC signatures.

Upon observation,all patient records are retained for a minimum of six years from the date of the most recent discharge or the death of the patient Agency has 9 unduplicated for the last 3 years. Requested to review the discharges of agency active patients from initial survey. Agency was not able to produce these charts and state they have become lost.

Upon client record review, 4 of 9 (Patient #6,7,8,9) 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 Patient #6,7,8,9, No evidence of discharge summary sent to MD.

Upon client record review, 4 of 9 (Patient #6,7,8,9) did not have evidence that the discharge summary includes all required information. Patient #6,7,8,9, No evidence of brief description of services provided. Documentation was the first visit note and the last visit note.

Condition of Participation: Drugs and Biologicals, Medical Supplies, and Durable Medical Equipment.

Upon observation, there was no evidence a copy is provided of the hospice written policies and procedures on the management and disposal of controlled drugs to the patient or patient representative and family. Patient #1, Patient primary diagnosis is heart disease with secondary of Alzheimer disease. Plan of care and nursing assessment documents patient is anxious , awake, lethargic, confused. The patient was seen awake, lethargic at times and with confusion and disorientation. Patient is only oriented to place and person, reoriented patient as needed. Patient signed his own consents. Patient #5, Patient primary diagnosis is senile degeneration of brain, documenting primary disease as dementia. RN initial assessment documents alert and oriented x2 with forgetfulness and confusion. CTI documents patient is awake, mostly confused and disoriented.

Upon observation, there was no evidence the hospice discussed the policies and procedures for managing the safe use and disposal of controlled drugs with the patient or representative and the family in a language and manner that they understand to ensure that these parties are educated regarding the safe use and disposal of controlled drugs. Patient #1, Patient primary diagnosis is heart disease with secondary of Alzheimer disease. Plan of care and nursing assessment documents patient is anxious , awake, lethargic, confused. The patient was seen awake, lethargic at times and with confusion and disorientation. Patient is only oriented to place and person, reoriented patient as needed. Patient signed his own consents. Patient #5, Patient primary diagnosis is senile degeneration of brain, documenting primary disease as dementia. RN initial assessment documents alert and oriented x2 with forgetfulness and confusion. CTI documents patient is awake, mostly confused and disoriented.

Upon client record review, 2 of 9 (Patient #1,5) did not have evidence that the written policies and procedures for managing controlled drugs was provided and discussed. Patient #1, Patient primary diagnosis is heart disease with secondary of Alzheimer disease. Plan of care and nursing assessment documents patient is anxious , awake, lethargic, confused. The patient was seen awake, lethargic at times and with confusion and disorientation. Patient is only oriented to place and person, reoriented patient as needed. Patient signed his own consents. Patient #5, Patient primary diagnosis is senile degeneration of brain, documenting primary disease as dementia. RN initial assessment documents alert and oriented x2 with forgetfulness and confusion. CTI documents patient is awake, mostly confused and disoriented.