Every finding on record at Wetherby Hospice Care Inc.

Upon patient record review 3 of 14 (Patient #2, 3, 8) 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 2: The patient was admitted for hospice services on 09.16.2023. The comprehensive assessment related to psychosocial needs was not completed by the MSW until 10.01.2023, which exceeds the 5 day requirement. Patient 3: The patient was admitted for hospice services on 10.14.2024. The comprehensive assessment related to psychosocial needs was not completed by the MSW until 10.24.2024, which exceeds the 5 day requirement. Patient 8: The patient was admitted for hospice services on 10.18.2023. The comprehensive assessment related to psychosocial needs was not completed by the MSW until 10.24.2023, which exceeds the 5 day requirement.

Upon patient record review, 5 of 14 (Patient #1, 2, 4, 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. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy Patient 1: The medication list indicates diclofenac gel 3% topical bid PRN joint pain. This fails to specify a quantity or location for application of this topical medication. (corrected onsite) Patient 2: The medication list indicates diclofenac gel 1% apply a thin layer topical bid PRN joint pain. This fails to specify a location for application of this topical medication. (corrected onsite) Patient 4: The medication list indicates triamcinolone cream 0.1% apply a thin layer bid redness/itching. This fails to specify a location for application of this topical medication. (corrected onsite) Patient 9: The medication list indicates diclofenac gel 1% apply a thin layer topical bid PRN pain. This fails to specify a location for application of this topical medication. (corrected onsite) Patient 10: The medication list indicates carboxymethylcellulose sodium eye drops 0.5% 1 gtt ophthalmic daily. This fails to specify the location for insertion of this ophthalmic medication. (corrected onsite)

Upon patient record review, 5 of 14 (Patient #2, 4, 7, 9, 10) 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 2: The RN visited the patient and completed a comprehensive assessment on 09.26.2024; the next RN visit and comprehensive assessment was completed on 10.18.2024, which exceeds the 15 day requirement; The LVN saw the patient according to the SN frequency specified via the plan of care. Patient 4: The RN visited the patient and completed a comprehensive assessment on 09.18.2024; the next RN visit and comprehensive assessment was completed on 10.05.2024, which exceeds the 15 day requirement; The LVN saw the patient according to the SN frequency specified via the plan of care. Patient 7: The RN visited the patient and completed a comprehensive assessment on 09.26.2024; the next RN visit and comprehensive assessment was completed on 10.16.2024, which exceeds the 15 day requirement; The LVN saw the patient according to the SN frequency specified via the plan of care. Patient 9: The RN visited the patient and completed a comprehensive assessment on 09.09.2024; the next RN visit and comprehensive assessment was completed on 10.04.2024, which exceeds the 15 day requirement; The LVN saw the patient according to the SN frequency specified via the plan of care. Patient 10: The RN visited the patient and completed a comprehensive assessment on 09.06.2024; the next RN visit and comprehensive assessment was completed on 10.04.2024, which exceeds the 15 day requirement; The LVN saw the patient according to the SN frequency specified via the plan of care.

Upon patient record review, 5 of 14 (Patient #1, 2, 4, 9, 10) 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 patient utilizes diclofenac gel for management of the terminal illness; however, the plan of care does not indicate a quantity or location for application of this topical medication. (corrected onsite) Patient 2: The patient utilizes diclofenac gel for management of the terminal illness; however, the plan of care does not indicate a location for application of this topical medication. (corrected onsite) Patient 4: The patient utilizes triamcinolone cream for management of the terminal illness; however, the plan of care does not indicate a location for application of this topical medication. (corrected onsite) Patient 9: The patient utilizes diclofenac gel for management of the terminal illness; however, the plan of care does not indicate a location for application of this topical medication. (corrected onsite) Patient 10: The patient utilizes carboxymethylcellulose sodium eye drops for management of the terminal illness; however, the plan of care does not indicate the location for insertion of this ophthalmic medication. (corrected onsite)

Upon patient record review, 4 of 14 (Patient #4, 9, 10, 14) did not have evidence that each patient record contains: • Signed election statement in accordance with 418.24 Patient 4, 14: The patient/representative requested Notification of Noncovered Items, Services, and Drugs at the time of hospice admission; however, there was no evidence that this notification was provided within the required 5 days, or at any subsequent time. Patient 9, 10: The election form failed to indicate the date hospice services were initiated. Additionally, the patient/representative requested Notification of Noncovered Items, Services, and Drugs at the time of hospice admission; however, there was no evidence that this notification was provided within the required 5 days, or at any subsequent time.

Upon patient record review, 1 of 14 (Patient #12) did not have evidence that the hospice forwarded a summary and a copy of the patient record, if requested, to a facility when transferring the patient to that facility. Patient 12: There was no evidence that the hospice forwarded the current plan of care, certification of terminal illness, or other related documents to the receiving agency.