Nevaeh Hospice Inc.

“Upon patient record review, 3 of 14 (Patient #2, 5, 6) did not have evidence that the hospice obtained the patient’s or representative’s signature confirming that they received a copy of the Patient’s Rights and Responsibilities. Patient #2, 5: There is no documented signature confirming the patient received copy of Patient Rights and Responsibilities. There is an outdated consent form utilized on these patients according to interview. There is evidence of updated form including signature for validation. Patient #6: Boxes are not manually checked on manual form that contains signature to confirm patient received copy of Patient Rights and Responsibilities.”

“Upon patient record review, 1 of 14 (Patient #6) 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. Patient #6: No documented evidence of initial bereavement assessment was completed within 5 days of election.”

“Upon patient record review, 2 of 14 (Patient #3, 10) 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 #3: Documented 5/18/24 PRN SN visit note related to coccyx wound. SN initiated Optifoam dressing. There was no update to IDG POC related to new findings/treatment. Patient #10: MD order for 3/15/24 ear wax removal and 3/19/24 order for Cephalexin PO for ear infection. There was no update to IDG POC.”

“Upon client record review, 1 of 14 (Patient #3) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #3: There was a documented PRN SN Visit 6/7/24 for leaking Foley reported by ALF staff. “16 Fr Foley replaced with an 18 Fr. Foley catheter...10 cc balloon”. Still there was no order documented for catheter maintenance or changes. The catheter change was performed without physician order. There was a 5/18/24 SN PRN Visit Note r/t coccyx/mid/lower back pressure injury. Nurse initiated Optifoam. There was no documented order for the treatment. 5/28/24 IDG Meeting note references need for suture removal from Rt BKA amputation site. Although there was documentation of planned suture removal for 5/30/24, there was no follow up documentation that plan/intervention was completed. Upon interview, it was confirmed that the sutures removed by nurse 5/30/24. However, the nurse received verbal order, but failed to document the order in medical record, prior to performing suture removal.”

“Upon patient record review 2 of 14 (Patient #1, 6) 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: Missed Visit Report documenting hospice aide out sick 5/23/24. . There is no evidence that replacement aide or a different date for visit was offered. Patient #6: Missed Visit Report related to HA had sick time 5/24/24. There is no evidence that replacement aide or a different date for visit was offered.”

“Upon patient client record review, 10 of 14 (Patient #2, 3, 4, 5, 7, 8, 9, 10, 11, 12) 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 #2, 3, 4, 7, 8, 10, 11: The name of agency is not written in allocated space to identify agency. Patient #5,12: Medical Director and Medical Director alternate names written in space for hospice care provider name, rather than agency name. Patient #9, 10, 11: MD choice not clear. Form has blank for “my choice is...” and it is not checked or completed. There is not space for “I do not choose.””

“Upon patient client record review, 1 of 14 (Patient #7) 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 #7: Patient Visit Date 5/29/24 by SC. The electronic signature date for SC, however is 5/13/24 1:13 pm. Upon interview, the staff states a drop down box is utilized to choose date and SC inadvertently chose wrong date.”

“Upon observation, there was no evidence the hospice discussed the policies and procedures for managing the safe use and disposal of controlled drugs with the patient or representative and the family in a language and manner that they understand to ensure that these parties are educated regarding the safe use and disposal of controlled drugs. Patient #6: The agency patient admission handbook includes a copy of the policies, but there is no documented evidence that discussion occurred. This was an outdated form that did not include acknowledgement of discussion and the form has since been updated.”