Libra Hospice Care, Inc.

“Upon patient record review, 2 of 4 (Patient #1,#2) 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 patient has a physician order for a mechanical soft diet. There was no evidence of this physician order as part of the plan of care. There is no evidence of a mechanical soft diet in the plan of care. Corrected on site. Patient#2: The patient has a physician order for no added sodium and low fat diet. There was no evidence of this physician order as part of the plan of care. There is no evidence of a no added sodium and low fat diet on the plan of care. Corrected on site.”

“Upon patient record review, 10 of 14 (Patient #1,2,3,4,5,6,7,8,9,10) 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 • Drug therapy currently associated with laboratory monitoring Patient 1: Lidocaine patch 4 percent ordered 12/19/23. There is no evidence of application site or on/off directions. Ciclopirox 8 percent nail lacquer ordered 12/19/23. There is no evidence of application site re: which nails for application on medication profile. Patient 2: Lidocaine patch 5 percent ordered 7/2/24. There is no evidence of application site or application directions for a transdermal patch in plan of care. Praluent prefilled pen, There is no evidence of type of injection, site of injection, or rotation of injection sites on medication profile. Patient 3: Diclofenac 1 percent topical ordered 4/11/24. There is no evidence of application site in the plan of care. Patient has order for Basaglar, Repatha, and Ozempic. None of these orders have evidence of instructions to rotate injection sites in plan of care.on medication profile. Patient 4: Calmoseptine 0.44 percent topical ordered 3/29/24. Instructions for medication read Apply 2-4 times every incontinence care. There is no evidence of further instruction provided in the patient’s plan of care. Bisacodyl 10mg suppository ordered 3/29/24. There is no evidence of a frequency on medication profile. Clonidine 0.2mg transdermal patch ordered 3/29/24. There is no evidence of on/off instructions and no evidence of site rotation instructions on medication profile. Diclofenac 1 percent ordered 3/29/24. There is no evidence of application site on medication profile. Patient has order for Basaglar, Admelog, and Freestyle Libra Sensor. None of these orders have evidence of instructions to rotate injection sites on medication profile. Patient 5: Patient has duplicative orders for Azelastine hydrochloride 1 percent (137mch/spray) nasal solution written on 2/29/24. There is no evidence of application site on medication profile. Order 2 There is no evidence of dose quantity or site (which nare/nares) for this medication on medication profile. Diclofenac 1 percent duplicative order 2/9/24. Order 1: There is no evidence of application site on medication profile. Order 2: There is no evidence of an appropriate dosage or application site for this medication on medication profile. Restasis 0.05 percent with duplicative orders 2/29/24. There is no evidence of an application route for this medication. Patient 6: Patient has order for diclofenac 1 percent. here is no evidence of application site specified on medication profile. Patient has order for morphine sulfate 100mg/ml 0.25mg sl every 2 hours as needed for pain/dyspnea. There is no evidence of effective dose on medication profile. Patient 7: Patient has order 7/19/23 for hydrocortisone There is no evidence of application site on medication profile. Patient has orders insulin with no evidence of instructions to rotate injection sites. Patient has order written 7/19/23 for miralax. There is no evidence of instructions of how to measure or reconstitute this medication for administration. Patient has order for Benadryl written 7/20/23 cream that reads: Benadryl cream, 1 tube once a day for allergy, incomplete order. Patient has order for hydrocortisone with no specific area. Patient 8: Patient has order written 8/28/23 for calmoseptine 0.44 percent w/out specific area of application. Patient 9: Patient has order written 12/15/23 for diclofenac. There is no evidence of application site on medication profile. Patient 10: Patient has order written 6/2/23 for calmosetine to affected area. There is no evidence of application site on medication profile. Patient has order written 6/2/23 for clotrimazole to affected area. There is no evidence of application site on medication profile.”

“Upon patient record review, 9 of 14 (Patient #1,2,3,4,5,7,8,9,10) 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 physician’s order for bleeding precautions in the medical record. There is no evidence of bleeding precautions in the care plans. Patient 2: Patient has physician’s order for contact precautions in the medical record. There is no evidence of contact precautions in the care plans. Patient 3: Patient has physician’s order for fall, bleeding, and skin precautions in the medical record. There is no evidence of fall, bleeding, or skin precautions in the care plans. Patient 4: Patient has physician’s order for seizure, bleeding, and aspiration precautions in the medical record. There is no evidence of seizure, bleeding, or aspiration precautions in the care plans. Patient 5: Patient has physician’s order for fall, skin, contact, bleeding, aspiration precautions. Additionally, there is a documented chronic pain diagnosis. There is also documentation of decreased mobility. There is no evidence of care planning for any of the above-named issues. Patient 7: Patient has physician’s order for bleeding, fall, aspiration, oxygen precautions in the medical record. There is no evidence of any of the above-named precautions in the care plans. Patient 8: Patient has physician’s order for aspiration and bleeding precautions in the medical record. There is no evidence of care planning for these precautions in the medical record. Patient 9: Patient has physician’s order for contact and bleeding precautions in the medical record. The medical record does not include evidence of care planning for these precautions. Additionally, there is documentation of a diagnosis of depression and documentation of decreased mobility. The medical record does not contain evidence of care planning for these issues. Patient 10: Patient has documentation related to a wound. There is no evidence of care planning for this problem.”

“Upon patient record review, 10 of 14 (Patient #1,2,3,4,5,6,7,8,9,10) 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: Lidocaine patch 4 percent ordered 12/19/23. There is no evidence of application site or on/off directions. Ciclopirox 8 percent nail lacquer ordered 12/19/23. There is no evidence of application site re: which nails for application in the plan of care. Patient 2: Lidocaine patch 5 percent ordered 7/2/24. There is no evidence of application site or application directions for a transdermal patch in plan of care. Praluent prefilled pen, There is no evidence of type of injection, site of injection, or rotation of injection sites in the plan of care. Patient 3: Diclofenac 1 percent topical ordered 4/11/24. There is no evidence of application site in the plan of care. Patient has order for Basaglar, Repatha, and Ozempic. None of these orders have evidence of instructions to rotate injection sites in plan of care. Patient 4: Calmoseptine 0.44 percent topical ordered 3/29/24. Instructions for medication read Apply 2-4 times every incontinence care. There is no evidence of further instruction provided in the patient’s plan of care. Bisacodyl 10mg suppository ordered 3/29/24. There is no evidence of a frequency in the patient’s plan of care. Clonidine 0.2mg transdermal patch ordered 3/29/24. There is no evidence of on/off instructions in the plan of care. There is no evidence of site rotation instructions in the plan of care. Diclofenac 1 percent ordered 3/29/24. There is no evidence of application site in the plan of care. Patient has order for Basaglar, Admelog, and Freestyle Libra Sensor. None of these orders have evidence of instructions to rotate injection sites in plan of care. Patient 5: Patient has duplicative orders for Azelastine hydrochloride 1 percent (137mch/spray) nasal solution written on 2/29/24. There is no evidence of application site in the patient’s plan of care. Order 2 There is no evidence of dose quantity or site (which nare/nares) for this medication in the patient’s plan of care. Diclofenac 1 percent duplicative order 2/9/24. Order 1: There is no evidence of application site for this medication in the patient’s plan of care. Order 2: There is no evidence of an appropriate dosage or application site for this medication in the patient’s plan of care. Restasis 0.05 percent with duplicative orders 2/29/24. There is no evidence of an application route for this medication. Patient 6: Patient has order for diclofenac 1 percent. here is no evidence of application site specified in this plan of care. Patient has order for morphine sulfate 100mg/ml 0.25mg sl every 2 hours as needed for pain/dyspnea. There is no evidence of effective dose in this plan of care. Patient 7: Patient has plan of care written 7/19/23 for hydrocortisone There is no evidence of application site for this plan of care. Patient has orders insulin with no evidence of instructions to rotate injection sites. Patient has order written 7/19/23 for miralax. There is no evidence of instructions of how to measure or reconstitute this medication for administration. Patient has order for Benadryl written 7/20/23 cream that reads: Benadryl cream, 1 tube once a day for allergy, incomplete order. Patient has order for hydrocortisone with no specific area. Patient 8: Patient has order written 8/28/23 for calmoseptine 0.44 percent w/out specific area of application. Patient 9: Patient has order written 12/15/23 for diclofenac. There is no evidence of application site in the plan of care. Patient 10: Patient has order written 6/2/23 for calmosetine to affected area. There is no evidence of application site in the plan of care. Patient has order written 6/2/23 for clotrimazole to affected area. There is no evidence of application site in the plan of care.”

“Upon patient record review, 7 of 14 (Patient #2,3,4,5,6,8,10) 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 equipment and supply needs. Patients 2,3,5,6,8: There is documentation in the medical record that patient has cane, walker, and shower chair in home. There is no evidence of a physician’s order for these DME items in the patient’s plan of care. Patient 4: There is documentation in the medical record that patient has alternating pressure pad, wheelchair, bedside commode, and shower chair in home. There is no evidence of a physician’s order for these DME items in the patient’s plan of care. Patient 10: There is documentation in the medical record that patient has alternating pressure pad, wheelchair, and shower chair in home. There is no evidence of a physician’s order for these DME items in the patient’s plan of care.”

“Upon patient record review, 2 of 14 (Patient #6,11) 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 6: Patient’s level of care was changed to continuous care on 7/23/23. There is no evidence that patient’s care plans were updated to include this level of care change. Physician’s order for oxygen noted on 7/24/23. There is no evidence of a respiratory or oxygen care plan in this patient’s medical record. Patient 11: Patient’s level of care was changed to continuous care on 5/6/24. There is no evidence of an updated care plan that reflects this change.”

“Upon client record review, 6 of 14 (Patient #1,4,5,7,8,10) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 1: Physician’s order for SN visits is weekly. There is no evidence of SN visit made since 6/28/24. Patient 4: Physician’s order for spiritual care visits is monthly. There is no evidence of a spiritual care visit made in June 2024. Patient 5: Initial spiritual care visit note states that spiritual care is declined by patient and family. Chaplain goes on to document that they will follow up with patient/family every recertification period to continue to offer spiritual support. There is evidence in the medical record that that the physician’s order was not updated to reflect the above change. Spiritual care visits remain ordered monthly as per physician’s order. There is no evidence of spiritual care visits made in March 2024, April 2024, or June 2024. Patients 7,8,10: Patient has physician’s order for volunteer coordinator to evaluate for volunteer needs of patient/family. There is no evidence of a volunteer needs assessment in the medical record. Patient 8: Physician’s order for spiritual care states “spiritual care evaluation within 5 days of admission.” Spiritual care visits were made on 9/29/23 and 10/25/23. There is no evidence of a physician’s order for these visits in the plan of care. Physician’s order for psychosocial care states “psychosocial care evaluation within 5 days of admission.” Psychosocial care visits were made on 10/20/23 and 11/7/23. There is no evidence of a physician’s order for these visits in the plan of care.”

“Upon patient record review, 2 of 14 (Patient #4,8) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • 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 4: The following HHA tasks have no evidence of a frequency in the HHA care plan: turn/reposition; record BM; transfer X1; dressing in pajamas or gown; meal prep-snack; feeding assistance; all housekeeping tasks. In addition, both bedbound status and ambulatory ad lib are documented in HHA care plan. Patient 8: The following HHA tasks have no evidence of a frequency in the HHA care plan: record BM; transfer X1; diet; meal prep; feeding assistance; dentures.”

“Upon patient record review 2 of 14 (Patient #4,8) 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 Patients 4 and 8: There is evidence that the HHA is documenting in the narrative section of their documentation, “vital signs checked and reported” with each HHA visit. Vital signs are not an assigned task on the HHA care plan. Patient 4: Physician’s order for HHA visit is twice weekly. There is no evidence of HHA visit since 6/29/24. Patient 8: There is no physician’s order for HHA visits. HHA visited patient twice weekly since admission.”