Every finding on record at A & B Hospice Services, LLC

Upon patient record review, 1 of 15 (Patient #14) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient #14: The record did not contain evidence the patient chose an attending physician.

Upon patient record review, 4 of 15 (Patient #5,#11,#12,#14) did not have evidence in the patient record that the comprehensive assessment takes into consideration the imminence of death. Patients #5,#11,#12,#14: The medical record did not contain evidence the imminence of death was assessed at the time the comprehensive assessment was completed.

Upon patient record review, 2 of 15 (Patient #2, #3) 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 #2: The medication profile indicated the patient was taking Metoprolol and Cipro; the medications were discontinued 7/19/23. There was no evidence the medication profile was updated to reflect the discontinuation of medications. Patient #3: The medical record contained documentation the patient was taking polyethylene glycol 17 gm/scoop1x daily as needed for constipation. There was no diluent included in the instructions on the medication profile. In addition, the patient was administered fleets enemas for constipation. There was no evidence of fleets enema on the medication profile.

Upon patient record review, 2 of 15 (Patient #1,#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. Patients #1: The comprehensive assessment by the RN indicated the patient had weight loss and eating less than 25% of meals. There was no evidence of problems, goals, or interventions addressing this on the plan of care. In addition the, the spiritual and psychosocial assessments identified patient needs. There was no evidence of problems, goals or interventions addressing these on the plan of care. Patients #3: The comprehensive assessment by the RN indicated the patient was having constipation. There was no evidence of problems, goals, or interventions addressing this on the plan of care. In addition the psychosocial assessment identified patient needs. There was no evidence of problems, goals, or interventions addressing this on the plan of care.

Upon patient record review, 1 of 15 (Patient #3) 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 #3: The medical record contained documentation the patient was taking polyethylene glycol 17 gm/scoop1x daily as needed for constipation. There was no diluent included in the order. In addition, the patient was administered fleets enemas for constipation. There was no evidence of an order.

Upon patient record review, 2 of 15 (Patient #2,#6) 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. Patient #2: The medical record contained documentation the patient had a nebulizer, over bed table, and walker. There was no evidence these items were included on the plan of care. Patient#6: The medical record contained documentation the patient was using CPAP. There was no evidence CPAP was included on the plan of care.

Upon observation, there was no evidence the hospice measures, analyzes, and tracks quality indicators, including adverse patient events and other aspects of performance that enable the hospice to assess processes of care, hospice services, and operations. The agency hired a consultant to conduct QAPI activities with data collection but no evidence of any tracking, trending or analyzation of the data of follow up with a plan to correct issues identified by the agency.

Upon observation, there was no evidence of involvement of the governing body and organizational leaders in the Quality Assessment/Performance Improvement (QAPI) program.

Upon patient record review, 2 of 15 (Patient #8,#9) did not have evidence the hospice offers bereavement counseling that includes: • Making bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. Bereavement counseling also extends to residents of a SNF/NF or ICF/IID when appropriate and identified in the bereavement plan of care • Ensuring that bereavement services reflect the needs of the bereaved • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery Patient #8: The record indicated bereavement services were accepted on/ after the patient's death. There was no evidence of a bereavement plan of care. Patient #9: The record indicated a bereavement plan of care developed on 5/1/23. There was no evidence of any bereavement interventions included on the bereavement plan of care.

Upon observation, there was no evidence the hospice documents or demonstrates viable and ongoing efforts to recruit and retain volunteers.

Upon observation, there was no evidence the hospice documented the cost savings achieved through the use of volunteers. Documentation must include the following: • The identification of each position that is occupied by a volunteer • The work time spent by volunteers occupying those positions • Estimates of the dollar costs that the hospice would have incurred if paid employees occupied the positions identified in paragraph (d)(1) of CFR 418.78 for the amount of time specified in paragraph (d)(2) of CFR 418.78 There was no evidence the hospice documented cost savings achieved through the use of volunteers.

Upon patient record review, 2 of 15 (Patient #5,#6) did not have evidence that the medical director or physician designee provides written certification that it is anticipated that the patient's life expectancy is 6 months or less if the illness runs its normal course. The physician must consider the following when making this determination: • The primary terminal condition • Related diagnosis • Current subjective and objective medical findings • Current medication and treatment orders • Information about the medical management of any of the patient's conditions unrelated to the terminal illness Patient #5: The medical record does not contain an appropriately completed initial certification of terminal illness by the medical director or alternate medical director. The physician's narrative was completed by the attending. Patient #6: The medical record does not contain an appropriately completed initial certification of terminal illness. The certification of terminal illness did not contain evidence of consideration for the patient's terminal illness, related diagnosis, medical management of conditions, or medications and treatment orders.

Upon patient client record review, 1 of 15 (Patient #14) did not have evidence that each patient record contains: • Signed election statement in accordance with 418.24 Patient #14: The Election of Benefit (EOB) form had two items that were not completed. (1) The choice of an attending physician was not filled in in the space provided on the form. (2): The Election of Benefit (EOB) Effective Date for benefits to begin was not filled in in the space provided on the form.