Every finding on record at 1st Response Hospice, Inc.

Upon patient record review, 3 of 14 (Patient #8,11,12) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient #8: The Hospice Election form has options in form of check boxes, for patient to mark "I acknowledge that my choice for an attending physician is ............ " or "I do not wish to choose my attending physician." The box choosing attending is checked but there is no name/information identifying the patient's choice of physician. Patient #11, 12: The Hospice Election form has options in form of check boxes, for patient to mark "I acknowledge that my choice for an attending physician is ............ " or "I do not wish to choose my attending physician." Both boxes are unchecked.

Upon patient record review, 3 of 14 (Patient #1,5,7) 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: Upon interview/observation during home visit, patient daughter stated that Advair Diskus, Cetirizine HCl, and Sucralfate have been discontinued however, these remain on the medication profile. The patient is using bowel regimen consisting of Docusate Sodium and Lactulose and daughter reports to be effective. These 2 meds are not on the current hospice medication profile. Patient #5: There was no evidence of effective case management/coordination of care with The Wound Pro clinicians regarding wound treatment. There is a 6/7/24 note by Wound Pro, to Cleanse the wound with Dakin’s solution and pat dry with gauze. Apply skin prep to the peri-wound. Apply Mupirocin ointment to the wound bed, followed by oil emulsion gauze and alginate AG. Cover with foam with silicone bordered dressing 3x/week and prn for soiled or loose dressing. Use bordered gauze between scheduled dressing change and prn for soiled or loose dressing. Start Levaquin 750 mg once a day by mouth for 14 days . Mupirocin 22g of 2%. Apply to affected area during changes. During patient visit, there was no evidence that the above wound treatment or medications were available in home, and also there was no evidence of these orders on medication profile and affected area is not specified. Patient #7: PCG call 3/27/24 to report lower back pain. 3/29/24 SN notes that Lidocaine patch was ordered by MD 3/27/24. This is not on med profile.

Upon patient record review, 2 of 14 (Patient #1, 5) 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: There is a buttock wound however, no evidence of related problems, goals interventions included in initial IDG POC. Patient #5: Patient admitted with multiple wounds. Plan of Care does not include problems/interventions/goals related to wounds and only addresses integumentary as skin is clear dry and intact with no cuts, wounds, lacerations, bruises, s/s of infection, risk for skin integrity, breakdown related to disease process, decreased activity, mobility, circulation, poor nutritional intake, urinary and bowel incontinence.

Upon patient record review, 3 of 14 (Patient #1,5,7) 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: There is evidence of specific wound care orders from Wound Pro recommendation however, orders do not state who is to perform care. Patient #5: There was no evidence of effective case management/coordination of care with The Wound Pro clinicians regarding wound treatment. There is a 6/7/24 note by Wound Pro, to Cleanse the wound with Dakin’s solution and pat dry with gauze. Apply skin prep to the peri-wound. Apply Mupirocin ointment to the wound bed, followed by oil emulsion gauze and alginate AG. Cover with foam with silicone bordered dressing 3x/week and prn for soiled or loose dressing. Use bordered gauze between scheduled dressing change and prn for soiled or loose dressing. Start Levaquin 750 mg once a day by mouth for 14 days . Mupirocin 22g of 2%. Apply to affected area during changes. During patient visit, there was no evidence that the above wound treatment or medications were available in home, and also there was no evidence of these orders on plan of care and affected area is not specified. Patient #7: PCG call 3/27/24 to report lower back pain. 3/29/24 SN notes that Lidocaine patch was ordered by MD 3/27/24. No order and not on med profile.

Upon contract review, 1 of 4 (Wound Pros) did not have evidence the agreement to furnish any services under arrangement included that the hospice must retain administrative and financial management, and oversight of staff and services for all arranged services, to ensure the provision of quality care. Arranged care/services are supported by written contract/agreement that requires all care/services are: • Authorized by the hospice • Furnished in a safe and effective manner by qualified personnel • Delivered in accordance with the patient's plan of care There is evidence in Patient records #1, 5, 13, that a non-hospice provider is performing specialized wound assessment and treatment to patients, with no documented evidence that the treatment is unrelated to the primary hospice diagnosis of each patient. There is no evidence of a contractual arrangement at all between The Wound Pros and the hospice agency.

Upon patient client record review, 8 of 14 (Patient #1, 5, 7. 8. 10, 11, 12, 13, ) 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 #1, 5, 13: Patients are receiving wound assessment/treatment from The Wound Pros. apparently billed to Medicare Part B. The patients requested notice of non covered items addendum, however the wound provider services are not included on hospice addendum provided to patients. Patient #7: The patient's signature on Hospice Election form is not dated. The space allocated for signature date is blank. The other admission forms are signed with signature date of 11/17/23, but the 2 page Election statement has no date for patient signature. Patient #8: The Hospice Election form has options in form of check boxes, for patient to mark "I acknowledge that my choice for an attending physician is ............ " or "I do not wish to choose my attending physician." The box choosing attending is checked but there is no name/information identifying the patient's choice of physician. Patient #10. Election Statement effective date is blank. Patient #11, 12: The Hospice Election form has options in form of check boxes, for patient to mark "I acknowledge that my choice for an attending physician is ............ " or "I do not wish to choose my attending physician." Both boxes are unchecked. Also the effective date is blank. Also, for Patient #12, the effective date is blank.

Upon patient client record review, 2 of 14 (Patient #5, 9) did not have evidence that each patient record contains Physician certification and recertification of terminal illness. Patient #5, 9: Election statement shows that patient chose attending MD separate from hospice physician. There is no documented CTI by the attending for the initial hospice benefit period.

Upon patient client record review, 2 of 14 (Patient #1, 5) 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 #1: Admitted 6/8/24. Initial comprehensive assessment reports skin intact, with no documented evidence of skin breakdown. No skin impairment noted at this time. Initial IDG Care Plan includes problem only for high risk skin breakdown. However, there is a wound pro referral 6/9/24 and subsequent 6/12/24 SN visit - nurse noted no issues noted. 6/12 SN visit noted skin is clear, dry and intact. no cuts, wounds, lacerations, bruises. Yet, there is a 6/12/24 "updated" wound pro referral for left hip stage 2 and left buttock stage 1. There is a June 12 progress note (page 2 of referral) from Wound Pros with picture of right posterior buttock wound identified as Stage 3 along with treatment/orders for wound care. Patient #5: Physician order for 4/23/24 to recertify patient to Good Faith Hospice with terminal dx of ALZ for benefit period 4/24/24-7/22/24 which is not the correct hospice agency.