Luminere Hospice, Inc.

“Upon patient record review, 2 of 16 (Patient #3,6) 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 #3 Medication profile lists Clotrimazole Cream and Triamcinolone cream with instructions to “apply to affected area” no evidence of specific location. Patient #6 Medication profile lists CBD Roll on states to “apply to affected area” no evidence of specific location.”

“Upon patient record review, 4 of 16 (Patient #3,4,6,8) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual’s attending physician, if any) • Changes that have taken place since the initial assessment • Information on the patient’s progress toward desired outcomes • Reassessment of the patient’s response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days Patient #3 RN visit completed 4/8/24, 3/1/24 and 1/19/24, no evidence of assessment completed in 15 days following the visit dates. RN assessment visits were made 4/26/24, 3/25/24 and 3/2/24. Patient #4 RN comprehensive assessment due 7/30/23 and was not completed until 8/2/23. Patient #6 RN visit completed 4/8/24, no evidence of visit completed within 15 days by 4/22/24. Patient #8 RN visit completed 4/23/24 and 3/21/24, no evidence of assessment completed in 15 days following the visit dates. RN assessment visits were made 5/14/24 and 4/9/24.”

“Upon patient record review, 5 of 16 (Patient #4,5,6,8,12) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family’s needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient #4 SN visit on 7/23/24 states “Patient with pain to bilateral knees and back”, no evidence of any interventions completed. Patient #5 SN visits on 3/29/24, 4/5/24, 4/19/24 and 4/26/24 did not have a comprehensive pain assessment completed in full. Patient #6 SN visit on 7/26/24 states “Patient is still not satisfied with sleep”, no evidence of any interventions completed. Visits on 7/5/24, 7/12/24, 7/19/24 and 7/25/24 did not have a comprehensive pain assessment completed in full and no evidence of any pain interventions despite patient pain rated 6/10. Patient #8 SN visits on 5/28/24, 6/4/24 and 6/18/24 narrative states “Patient in pain”, no evidence of pain assessment or interventions completed. Patient #12 5/20/24 RN did not completed a comprehensive pain assessment.”

“Upon patient record review, 7 of 16 (Patient #3,4,5,6,8,11,12) 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 #3,4,5,6,8,11,12 Pain Goals/Interventions state “Patient will report pain is relieved/controlled in 2 weeks”, no evidence of a measurable outcome for pain.”

“Upon patient client record review, 3 of 14 (Patient #3,6,7) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient #3 Patient requested to receive the “Notification of Non-Covered Items”, no evidence the patient received the document. Patient #6 Consents dated for 11/28/23 and SOC date was 11/27/23. SOC date 11/27/23 was not filled out in the appropriate election of hospice date section of consents. Patient requested to receive the “Notification of Non-Covered Items”, no evidence the patient received the document. Patient #7 Patient requested to receive the “Notification of Non-Covered Items”, no evidence the patient received the document. This was COS and uploaded to patient EMR.”

“Upon patient client record review, 5 of 16 (Patient #4,5,9,11,13) 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 #4 RN Supervisory visits were completed on 8/27/23, 8/6/23, 7/16/23 and 7/2/23 as stated by RN in narrative “Supervisory Visit”, the supervisory visits on records are incomplete. The record only indicates the supervisory visit was done . There is no documentation to support assessment of the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient’s needs.(the specific check off information related to assessment of care is blank in the note) “. 9/17/24 Supervisory visit completed, however patient was discharged 9/5/24. Patient #5 D/C Summary for 4/28/24 has 2 different dates documented in summary to include 3/15/24 and 4/28/24. Visit on 4/8/24 as stated by RN in narrative “Supervisory Visit”, the supervisory visits on records are incomplete. The record only indicates the supervisory visit was done . There is no documentation to support assessment of the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient’s needs.(the specific check off information related to assessment of care is blank in the note) “ Patient #9 D/C Summary states discharge date of 2/4/25, however the d/c was completed 2/24/25. Patient #11 Patient discharged 4/19/24, however there are 2 incomplete SN visit notes in the EMR for 4/24/24 and 5/1/24. Patient #13 D/C summary stated discharge date effective 5/31/24, however discharge date was 3/31/24.”