Grace Hospice Care, Inc.

“Upon patient record review, 2 of 4 (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 wound care to right and left buttocks, however there are no problems/goals/intervention for wound care in care plan . In addition, patient has Cardio care plan with goal patient will verbalize and or express decrease episodes of chest pain. Patient will maintain optimum peripheral circulation. No evidence documented of chest pain, no evidence of any heart medications or nitro. Patient primary diagnosis is Atrial fibrillation. #4, No initial care plans as the import button was not selected/hit. Corrected on site”

“Upon patient record review, 6 of 14 (Patient #1,2,4,6,13,14) 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: Patient 1: The comprehensive assessment has documented pt has a Midline IV requiring heparin and NS flushes. These medications are not included on the medication profile. The medication profile does not contains the thickening agent for fluids the pt is using. Corrected on site. Patient 2: Upon home visit pt is taking Vit D2 since 4/15/24. The POC has Vitamin D3. Corrected on site. Patient 4: The medication profile contains an order for Metamucil with no dose. Corrected on site. Patient 6: The medication profile contains an order for Miralax with no diluent. Corrected on site. Patient 13: The medication profile contains an order for Miralax with no diluent. Patient 14: The medication profile contains an order for Miralax with no diluent and Comfort Cain 1% with no frequency.”

“Upon patient record review, 3 of 14 (Patient #1,2,3) 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: The POC contains orders for a foley, Midline IV. The comprehensive assessment indicates pt is bedbound with a hoyer lift. There is no evidence of goals or interventions related to these problems. Pt has orders for thickened liquids, though no risk of aspiration care plan. SN added goals/interventions for skin integrity and aspiration risk during survey. Patient 2: Pt has orders for thickened liquids though has no care plan for high risk of aspiration. Corrected on site. Patient 3: The POC contains orders for a biliary drain. There are no goals or interventions related to this problem on the care plan. The patient’s hospice diagnosis is Paroxysmal Afib, there are not goals or interventions for cardiac on the care plan. Corrected on site.”

“Upon patient record review, 4 of 14 (Patient #1, 2, 4, 5) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient’s plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient 1: The Plan of care contains Spiritual care PRN with no quantifier. Corrected on site. Patient 2: The POC 12/29/23 contains an order for MSW within 5 days of admission, 1 time per month and PRN. There is no quantifier for the PRN. Patient 4: The POC contains an order for MSW once a month and PRN with no quantifier. Corrected on site. Patient 5: The POC contains an orders for MSW 1 time a month and PRN with no quantifier. Corrected on site.”

“Upon patient record review, 6 of 14 (Patient #1,2,3,4,6,12) 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 POC has no diet order. Corrected on site. Upon home visit finding the pt has Thickening agent that the patient is using there is no order for this. Corrected on site. The comprehensive assessment 2/21/24 indicates pt has a Midline IV for Ertapenum and requires NS and Heparin flushes. There are no orders on the POC for the Midline site care, dressing changes, saline or heparin flushes. Patient 2: Upon home visit pt is taking Vit D2 since 4/15/24. The POC has Vitamin D3. Corrected on site. Patient 3: The POC contains orders for wound care to a skin tear on 3/9/24 and a biliary drain site on 2/26/24 but does not state who will perform the wound care. Corrected on site. Patient 4: The POC contains an order for Metamucil with no dose. Patient 6: The POC contains an order for Miralax with no diluent. Corrected on site. Patient 12: The POC contains an order for Miralax with no diluent.”

“Upon patient record review, 2 of 14 (Patient #4,6) 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 4: The medical record contains a note by the physician that pt is c/o feeling cold and he was going to check their thyroid, the MD changed the thyroid medication on 10/6/23. There is no evidence of any goals or interventions in the care plan related to endocrine. Pt is also on a Fentanyl patch and there are no pain goals or interventions in the care plan. Corrected on site. Patient 6: The SN documented on 4/16/24 “open wound from scab to lower leg, pt applying Neosporin and leaving open to air.” There is no evidence the POC was updated. Corrected on site.”

“Upon client record review, 5 of 14 (Patient #1,2,5,6,8) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 1: The SN documented 2/23/24 “Pt and family allowed me to flush the IV line”. There are no orders for IV flushes on the POC. Patient 2: The POC contains an order for the SN to visit every 3 days to change the patient’s Fentanyl patch due to pt having no available caregiver to perform the task. The nurse performed a visit on 3/19/24, there is evidence the patch was due to be changed. There is no evidence the nurse changed the patch. SN addended note to say she did change the Fentanyl patch that visit and corrected the documentation for the lab draw. Patient 5: The medical record contains orders for SN twice weekly. The agency has a routing sheet that contains evidence the patient was seen for a second visit the week of 4/21-4/27 on 4/22/24 but the documentation has not been completed. Patient 6: The week of 4/7-4/13 there is missing visit documentation from 4/9/24. The SN wrote a communication note with visit findings that is not signed or dated and has not completed the nursing note. Patient 8: The SN documented 3/21/24 “Skin tear to right hand, cleansed with water and applied bandage”. There is no evidence of an order for this wound care.”

“Upon patient client record review, 4 of 13 (Patient #2, 3, 9, 13) 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 2: The nurse documented on 12/29/23 “Blood drawn for labs per order”. There is no evidence of specific care that was performed. Patient 3: The SN documented on 3/6/24 “ Dressing change done to biliary drain site”. There is no evidence of the specific care that was performed. SN addended the documentation to support the POC was followed. Patient 9: The SN documented on 12/19/23 “Wound care done per order”. On 12/17/23 the SN documented “16F/cath replaced today”. There is no evidence of specific care that was performed. Patient 13: The SN documented on 12/30/23 “Pox”. This is not an approved abbreviation.”