Every finding on record at Wind Breeze Hospice Inc

Upon observation, there was no evidence the Emergency Plan communication plan includes all of the following: • Names and contact information for the following: • Hospice employees • Entities providing services under arrangement • Patients' physicians • Other hospices Upon review of the Emergency Plan, the communication plan did not include updated names and contact information for staff.

Upon observation, there was no evidence the Emergency Plan communication plan must includes a primary and alternate means for communicating with hospice's employees and Federal, state, tribal, regional, and local emergency management agencies.

Upon patient record review, 1 of 12 (Patient #8) 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 #8: Upon review of the medication profile, it was noted that a nebulizer was listed with the instructions "may nebulize 1 vial over 15 minutes." There was no evidence of dosage, frequency or medication to be nebulized listed.

Upon patient record review, 4 of 12 (Patient #2,4,5,7) 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 nursing comprehensive dated 04/05/25, assessed patient to be at high risk for skin breakdown on the Braden Scale (8). There was no evidence of problems, goals or interventions related to potential skin issues. Patient #4: The medication profile showed documented evidence of patient's use of a nebulizer treatment. There was no evidence of problems, goals or interventions listed related to the use of the nebulizer. Patient # 5: The nursing comprehensive dated 08/09/24, documented that shortly before the nurse arrived, the patient had received a dose of morphine for severe pain related to diagnosis of lung cancer with bone metastasis. The documentation noted the patient stated "this is the first time I have been pain-free in weeks." There was no evidence of pain problems, goals or interventions listed related to this pain. Patient # 7: The nursing comprehensive showed documented evidence that the patient was using a nebulizer for relief of shortness of breath. The nebulizer was also listed on the supply list. There was no evidence of problems, goals or interventions related to the use of this nebulizer.

Upon patient record review 1 of 12 (Patient #1) did not have evidence that the IDG ensures that the care and services provided are based on all assessments of the patient and family needs. Patient #1: Upon record review, noted the RN had assessed the patient and according to that note, the daughter of the patient had requested a visit from the social worker to get some additional information on available community resources. The RN also noted that contact was made with the social worker to make contact with the daughter. The IDG note on 04/10/25 stated that the social worker had provided education to the patient's daughter regarding end-of-life care, however there was no evidence of contact with the daughter. There was also no evidence that a visit/phone call was conducted with the daughter since 01/06/25.