Every finding on record at Your Family Hospice, Inc.

Upon patient record review 4 of 11 (Patient #1, 5, 8 and 10) 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 #1, 5, 8, and 10: Comprehensive spiritual care assessment not completed.

Upon client record review, 6 of 11 (Patient #1, #2, #3, #4, #5, #10) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1: SW ordered one time per month on the plan of care. SW saw the patient twice in December on 12/2 and 12/18. No evidence to support a PRN visit or ordered frequency change. RN ordered once every 14 days on the plan of care. RN saw patient weekly 10/15 and 10/20, 15 days between RN visits on 6/1 and 6/16, weekly on 6/16 and 6/21 and weekly on 8/16 and 8/20. No evidence to support a PRN visit or ordered frequency change. Patient #2: RN ordered one time every 14 days on the plan of care. RN saw the patient weekly on 2/16 and 2/23. No evidence to support a PRN visit or ordered frequency change. Patient #3: LVN ordered to see patient 1 time a week on initial plan of care. LVN saw patient twice the week on 11/1 on 11/1 and 11/4. No evidence to support a PRN visit or ordered frequency change. RN ordered to see patient once every 14 days on the plan of care. RN with visits on 1/10 and 1/21 and then visits on 3/17 and 4/1 (15 days). No evidence to support a PRN visit or ordered frequency change. Patient #4: SC ordered on the plan of care to see patient one time monthly. No evidence to support a visit was conducted in March, refusal of visit or an ordered frequency change. Patient #5: RN ordered on the plan of care to see patient once every 14 days. 16 days between visits on 3/26 and 4/11. Patient #10: SC ordered once every month on the plan of care. No evidence to support a visit was made in December or an ordered change in frequency. SW ordered once every month on the plan of care. No evidence to support a visit was made in December or an ordered change in frequency.

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: LVN didn't use a barrier under her bag and placed in directly on a bed in the patients room. The nurse proceeded to place box of gloves and equipment directly on the patients bed. Nurse was also observed to put on gloves to apply calmoseptine cream to patients left foot. She didn't remove her gloves or change them prior to cleaning the patients left eye. After cleaning the patients eye, the nurse took off her dirty gloves and laid them on top of the opened box of clean gloves.

Upon patient record review 2 of 6 applicable (Patient #6, #8) 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 #6: Aide ordered twice a week on the plan of care. Week of 2/8 only 1 visit performed. No evidence to support a declined visit or change in ordered frequency. Patient #8: Aide ordered twice a week on the plan of care. Week of 3/21 and 3/28 only one visit completed. No evidence to support a declined visit or change in ordered frequency.