Every finding on record at A Servant's Heart Hospice, LLC

Upon observation, there was no evidence the Emergency Preparedness plan included a process for cooperation and collaboration with tribal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation.

Upon observation, there was no evidence of contracts/agreements with other facilities/agencies/hospices to receive patients in the event the hospice cannot provide care to their patients during an emergency.

Upon observation, there was no evidence the communication plan included contact information for tribal emergency preparedness staff and no evidence the communication plan included a primary and alternate means for communicating with tribal emergency management agencies..

Upon patient record review and as observed during home visit, 1 of 19 (Patient #11) did not have evidence that an updated review were completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. During home visit the following medications were confirmed by the nurse and caregiver as active and still being taken daily by the patient which were already discontinued in the patient record medication profile; 1. Furosemide 20mg tab daily and 1 PRN for swelling in lower extremities discontinued on 10-14-23 2. Losartan 25mg 1 tab daily discontinued on 10-14-23 3. Trazadone 50mg 1 tab at bedtime discontinued on 11-03-23

Upon patient record review, 7 of 19 (Patient #4,5,6,7,9,11 &19) did not have evidence the plan of care included all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient #4 comprehensive assessment on 8-9-23 included patient's equipment;wheelchair, overbed table, hospital bed, half rail Patient #5 comprehensive assessment on 5-25-23 included patient's equipment, wheelchair and Oxygen Concentrator Patient #6 comprehensive assessment on 6-7-23 included patient's equipment shower chair and walker Patient #7 comprehensive assessment on 8-31-23 included patient's equipment hospital Bed , wheelchair, toilet Seat, shower chair Patient #9 comprehensive assessment on 5-13-23 included patient's equipment grab bars, handrails, raised toilet seat,walker, wheelchair Patient #11 comprehensive assessment on 10-13-23 included patient's equipment walker, bedrail, hospital bed, wheelchair, overbed table, Oxygen concentrator Patient #19 comprehensive assessment on 10-25-23 included patient's equipment Oxygen concentrator, Oxygen cylinder, wheelchair, overbed table which were not in the Plans of care.

Upon personnel record review, 1 of 15 (Personnel #2) did not have evidence in the personnel record of the job description in the position held as the alternate administrator. This was corrected with the evidence during closing on day 1.

Upon personnel record review, 2 of 15 (Personnel #11 &12) did not have evidence that a skills competency assessment, specific to these disciplines had been conducted initially during orientation. This was corrected with evidence presented on Day 3.

Upon client record review, 1 of 19 (Patient #16) did not have evidence that the hospice forwarded a summary and a copy of the patient record, if requested, to a facility when transferring the patient to that facility.

Upon client record review, 1 of 19 (Patient #15) did not have evidence that when the patient revoked the election of hospice care and was discharged from hospice in accordance with §418.26, the hospice forwarded to the patient's attending physician: • A copy of the hospice discharge summary and, • The patient's clinical record, if requested

Upon personnel record review, 2 of 15 (Personnel #14 & 15) did not have evidence that license credentialing activities were conducted to verify qualifications of these credentialed/licensed personnel in the positions they held at the time of hire. This evidence was presented on Day 3

Upon personnel record review, 1 of 15 (Personnel # 13) did not have evidence the hospice obtained a criminal background check on the contracted individual who will have direct patient care and access to patient records. This was corrected on Day 3