Every finding on record at Windsor Hospice and Palliative Care Services

Upon patient record review, 3 of 14 (Patient #1, #2, #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 therapy currently associated with laboratory monitoring Patient #1: Hyoscamine was documented on the medication profile without a dosage or route indicated. In addition, the plan of care dated 08/03/23 and the MD certification indicated the patient was using Oxygen 2L NC, but oxygen was not listed on the medication profile. Patient #2: Hyoscamine was added to the medication profile without a dosage or route indicated. Patient #8: Hyoscamine was added to the medication profile without a dosage or route indicated.

Upon patient record review, 13 of 14 (Patient#1,#2,#3,#4,#5,#6,#7,#8,#10,#11,#12,#13,#14) 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. Patients #1, #2, #3, #4, #5, #6, #7, #8, #10, #11, #12, #13, #14: Each client had a partial bereavement assessment completed which identified the bereaved persons and the needed IDT interventions. However, the actual document for bereavement assessment was not completed within 5 days of the admission.

Upon observation, there was no evidence of involvement of the governing body and organizational leaders in the Quality Assessment/Performance Improvement (QAPI) program. There was no evidence of an annual QAPI evaluation.

Upon patient record review, 2 of 14 (Patient #1, #11) did not have evidence in the patient record that hospice aide assignments and duties are: • 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 #1:The aide care plan dated 01/02/24 indicated Bed Bath, Partial Bath and Shower were all ordered "as directed' by the RN. Patient #11: The aide care plan dated 05/19/23 indicated both Bed Bath and Shower were ordered by the RN.

Upon patient record review 1 of 14 (Patient #1) 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 #1: On 02/13/24, 02/15/24 and 02/20/24, the aide documented "Yes" to providing Bed Bath, Partial Bath and Shower.

Upon client record review, 1 of 14 (Patient #11) 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 #11: There was no evidence of a discharge summary for this patient that revoked hospice services.