Every finding on record at A & Z Medical Group LLC

Upon patient record review 1 of 14 (Patient #7) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient 7:There is no evidence that the MSW completed a psychosocial assessment within 5 days.

Upon patient record review, 2 of 13 (Patient #2,#4) 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 2:The medical record includes nursing documentation that the patient is on a cardiac diet. There is no evidence that the plan of care includes an order for a cardiac diet. Patient 4:The medical record includes nursing documentation that the patient received education on a low sodium diet. There is no evidence that the plan of care includes an order for a low sodium diet.

Upon patient record review, 1 of 13 (Patient #9) 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 9:The medical record includes an order on 11/26/24 for Albuterol nebulizers for symptom management. There is no evidence that the plan of care includes nebulizer equipment and supplies.

Upon observation, there was no evidence the Emergency Plan communication plan includes all of the following: • Names and contact information for the following: • Hospice employees • Entities providing services under arrangement • Patients' physicians • Other hospices The agency emergency communication plan did not include the following: • Names and contact information for the following: • Hospice employees • Entities providing services under arrangement • Patients' physicians • Other hospices

Upon observation, there was no evidence the Emergency Plan communication plan must includes a primary and alternate means for communicating with hospice's employees and Federal, state, tribal, regional, and local emergency management agencies. The agency Emergency Communication Plan did not include primary and alternate means for communicating with the hospice's employees.

Upon patient record review, 1 of 5 (Patient #5) did not have evidence that the hospice informed and provided written information to the patient concerning its policies on advance directives, including a description of applicable state law. Patient #5: The electronic record did not have evidence of signed admission documents this information was provided to patient.

Upon patient record review, 1 of 5 (Patient #5) 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 #5: The electronic record did not have evidence of signed admission documents this information was provided to patient.

Upon observation, there was no evidence that the patient has the right: • To exercise his or her rights as a patient of the hospice • Have one's property and person treated with respect • To not be subjected to discrimination or reprisal for exercising his or her rights Patient #3: The RN arrived at the visit with her spouse driving her. This violates confidentiality and right to privacy for patient.

Upon patient record review, 1 of 5 (Patient #5) did not have evidence that if a state court has not adjudged a patient incompetent, any legal representative designated by the patient in accordance with state law may exercise the patient's rights to the extent allowed by state law. Patient #5: The electronic record did not have evidence of signed admission documents this information was provided to patient.

Upon client record review, 1 of 5 (Patient #5) did not have evidence that the plan of care included IDG's documentation of the patient's or families level of understanding, involvement and agreement with the plan of care. Patient #5: The patient record did not include any documentation.

Upon patient record review, 1 of 5 (Patient #5) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient #5: The electronic record did not have evidence of signed admission documents or election of benefits form that patient was given opportunity to elect attending.

Upon patient record review, 1 of 5 (Patient #5) did not have evidence of the appropriate documentation for release of confidential information. Patient #5: The electronic record did not have evidence of signed admission documents this information was provided to patient.

Upon patient record review, 1 of 5 (Patient #5) did not have evidence that the patient received information about the services covered under the hospice benefit. Patient #5: The electronic record did not have evidence of signed admission documents this information was provided to patient.

Upon patient record review, 1 of 5 (Patient #5) did not have evidence that the patient received information about the scope of services that the hospice will provide and specific limitations on those services. Patient #5: The electronic record did not have evidence of signed admission documents this information was provided to patient.

Condition of Participation: Initial and Comprehensive Assessment of the Patient.

Upon patient record review 1 of 5 (Patient #5) did not have evidence that the hospice Registered Nurse must complete an initial assessment within 48 hours after the election of hospice care in accordance with §418.24 Patient #5: There was no evidence of a hospice registered nurse completed an initial assessment within 48 hours of election of benefit.

Upon patient record review 5 of 5 (Patients #1, 2, 3, 4, 5) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient #1: The record did not include an assessment focusing on psychological, emotional or spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient #2: The record did not include an assessment focusing on psychological, emotional or spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient #3: The record did not include an assessment focusing on psychological, emotional or spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient #4: The record did not include an assessment focusing on psychological, emotional or spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient #5: The record did not include any evidence of a comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process

Upon patient record review, 5 of 5 (Patient #1, #2, #3, #4, #5) 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. There was no evidence of bereavement assessment on any of these patients.

Upon patient record review, 4 of 5 (Patients #1, 2, 3, 4) 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 #1: There is no evidence of any further nursing assessments after the initial comprehensive assessment. Patient #2: There is no evidence of any further nursing assessments after the initial comprehensive assessment. Patient #3: There is no evidence of any further nursing assessments after the initial comprehensive assessment. Patient #4: There is no evidence of any further nursing assessments after the initial comprehensive assessment.

Condition of Participation: Interdisciplinary Group, Care Planning, and Coordination of Services. L536

Upon patient record review, 1 of 5 (Patient #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 #5: There was no plan of care in the clinical record.

Upon client record review, 5 of 5 (Patients #1, 2, 3, 4, 5) did not have evidence that the IDG in collaboration with the attending physician reviewed, revised and documents the individualized plan as frequently as the patient's condition requires but no less frequently then every 15 calendar days. Patient #1:There is no evidence that the IDG documented sharing of information between all disciplines providing care and services in all settings. The IDG updates were not signed by the IDG team. There is no evidence that the MSW or SC participated in creation of the POC. Patient #2: IDG documented for 09/13/24. There is no further IDG that has been completed. There was an IDG meeting entered in the system for 09/27/24, however, it is not inclusive of input from core services. Patient #3: IDG documented for 09/13/24. There is no further IDG that has been completed. There was an IDG meeting entered in the system for 09/27/24, however, it is not inclusive of input from core services. Patient #4: IDG documented for 09/13/24. There is no further IDG that has been completed. There was an IDG meeting entered in the system for 09/27/24, however, it is not inclusive of input from core services. Patient #5: There was no evidence of any IDG available in patient record

Upon client record review, 4 of 5 (Patients #1, 2, 3, 4) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1: There is no evidence that the frequencies ordered for RN of once weekly were made. Patient #2: There is no evidence that the frequencies ordered for RN of once weekly were made. Patient #3: There is no evidence that the frequencies ordered for RN of once weekly were made. Patient #4: There is no evidence that the frequencies ordered for RN of once weekly were made.

Upon observation, there was no evidence the organization develops, implements, and maintains an effective, on-going, organization wide Quality Assessment and Performance Improvement (QAPI) program.

Upon observation, there was no evidence the program must use quality indicator data, including patient care, and other relevant data, in the design of the program. The agency had not created a QAPI program plan.

Upon observation, there was no evidence the QAPI program uses quality indicator data, including patient care and other relevant data in the design of its program. The hospice must use the data collected to: • Monitor the effectiveness and safety of services and quality of care • Identify opportunities and priorities for improvement The agency has not developed a QAPI plan.

Upon observation, there was no evidence Quality Assessment and Performance Improvement activities focus on high risk, high volume or problem-prone areas by understanding how they affect palliative outcomes, patient safety and quality of care.

Upon observation, there was no evidence the hospice documents what QAPI projects are being conducted, the reasons for conducting these projects, and the measurable progress achieved on these projects.

Upon observation, there was no evidence of involvement of the governing body and organizational leaders in the Quality Assessment/Performance Improvement (QAPI) program. The Agency had not developed or implemented a QAPI program.

Upon observation, there was no evidence the hospice's governing body is responsible for ensuring that the hospice-wide Quality Assessment and Performance Improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness. The Agency had not developed or implemented a QAPI program.

Upon observation, there was no evidence the hospice ensures the implementation of a hospice wide Quality Assessment/Performance Improvement (QAPI) program by the designation of a person responsible for coordinating QAPI activities. The agency did not develop or implement a QAPI program or designate person responsible.

Upon observation, there was no evidence in the QAPI reports that the hospice maintains a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases. The agency does not have an established QAPI plan.

Upon observation, there was no evidence licensed professionals participate in the hospice's QAPI program. There is not development of the QAPI program in this agency.

Condition of Participation: Hospice Aide and Homemaker Services. L607

Upon personnel record review, 1 of 12 (Personnel #9) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) ·Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff. ·Reading and recording temperature, pulse, and respiration ·Safe transfer techniques and ambulation. ·Normal range of motion and positioning ·Appropriate and safe techniques in personal hygiene and grooming that include-- ·(A) Bed bath ·(B) Sponge, tub, and shower bath ·(C) Shampoo, sink, tub, and bed ·(D) Nail and skin care ·(E) Oral hygiene ·(F) Toileting and elimination The other subject areas in this section may be evaluated through written examination, oral examination or after observation of a Hospice Aide with a patient. Personnel #9: There is no evidence of a competency assessment being completed with a patient or pseudo patient. corrected on site

Upon observation, there was no evidence the Home Health Aide competency evaluation is performed by a Registered Nurse in consultation with other skilled professionals, as appropriate. There was no evidence that the Home Health Aide had a competency evaluation by an RN

Upon personnel record review, 1 of 12 (Personnel #3) did not have evidence that the RN who supervises classroom and practical training possesses a minimum of 2 years nursing experience, at least 1 year of which must be in home care. Personnel #3: The Director of Clinical services did not have a resume in his HR file.

Upon patient record review, 4 of 5 (Patients #1, 2, 3, 4) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable. Patient #1: The aide POC did not include interventions specific to the patient needs including types of personal care to be provided. It did not include precautions related to the patient such as oxygen. Patient #2: The aide POC did not include interventions specific to the patient needs including types of personal care to be provided. It did not include precautions related to the patient such as oxygen. Patient #3: The aide POC did not include interventions specific to the patient needs including types of personal care to be provided. It did not include precautions related to the patient such as oxygen. Patient #4: The aide POC did not include interventions specific to the patient needs including types of personal care to be provided. It did not include precautions related to the patient such as oxygen.

Upon patient record review 4 of 5 (Patients #1, 2, 3, 4) 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: There is no evidence that the frequencies ordered for aide once weekly were carried out. Patient #2: There is no evidence that the frequencies ordered for aide once weekly were carried out. Patient #3: There is no evidence that the frequencies ordered for aide once weekly were carried out. Patient #4: There is no evidence that the frequencies ordered for aide once weekly were carried out.

Condition of Participation: Organization and Administration of Services.

Upon observation, there was no evidence the hospice is directed by a Board of Directors/governing body which assumes full legal authority and responsibility for the operation of the hospice. There was no evidence the Board of Directors/governing body or administrator provided oversight of agency ensuring patient needs are met by qualified individuals who have been properly trained. In addition, there is not evidence of Quality Assessment Performance Improvement program. The Administrator nor the Director of Clinical services were actively supervising and taking steps to ensure the quality of services due to not providing oversight for care of patients ensuring that patients were being seen as ordered to meet needs and that staff was properly trained.

Upon personnel record review, 8 of 12 (Personnel #1, 2, 3, 4, 8, 9, 11,12) did not have evidence that the hospice employees have received orientation on their specific job requirements.

Upon personnel record review, 8 of 12 (Personnel #1, 2, 3, 4, 8, 9, 11, 12) did not have evidence that a skills competency assessment, specific to each discipline had been conducted for all personnel including volunteers initially during orientation.

Upon patient record review, 1 of 5 (Patient #5) 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 record did not contain certification of terminal illness.

Upon patient client record review, 5 of 5 (Patients #1, 2, 3, 4, 5) did not have evidence that each patient record contains:(this references that the documentation is part of the patient record. Citing the inaccuracy of a component of the record is cited under other standards) • Initial plan of care • Updated plan of care • Initial assessments • Comprehensive assessments • Updated comprehensive assessments • Signed and dated clinical and progress notes Patient #1: The record did not contain an updated plan of care, all initial assessments, updated comprehensive assessments, or signed and dated clinical and progress notes. Patient #2: The record did not contain an updated plan of care, all initial assessments, updated comprehensive assessments, or signed and dated clinical and progress notes. Patient #3: The record did not contain an updated plan of care, all initial assessments, updated comprehensive assessments, or signed and dated clinical and progress notes. Patient #4: The record did not contain an updated plan of care, all initial assessments, updated comprehensive assessments, or signed and dated clinical and progress notes. Patient #5: The record was open without any clinical content, including assessments, plan of care, or signed and dated clinical or progress notes.

Upon patient client record review, 1 of 5 (Patient #5) 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 #5: The patient record did not contain election statement or signed consents.

Upon patient client record review, 4 of 5 (Patients #1, 2, 3, 4) 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. Patients #1, 2, 3, 4: IDG notes were incomplete and not signed.

Upon client record review, 1 of 5 (Patient #5) did not have evidence that the discharge summary includes all required information. Patient #5: There was no record of a discharge summary for this patient who went to the hospital on day 2 of care and was not readmitted.

Upon patient record review, 1 of 5 (Patient #5) did not have evidence in the patient record that the interdisciplinary group, as part of the review of the plan of care, determines the ability of the patient and/or family to safely self-administer drugs and biologicals to the patient in his or her home. If the patient and/or family are not capable of safely administering drugs and biologicals in the home, the hospice must address this issue in the patient's plan of care. Patient #5: There was no evidence in the patient record of any interdisciplinary group involvement in the POC or in the patient/caregiver's ability to safely administer drugs and biologicals.

Upon personnel record review, 1 of 12 (Personnel #7) did not have evidence that all Speech Therapy Services are provided by a qualified licensed Speech-Language Pathologist (SLP) or Audiologist in accordance with the state's Speech-Language Pathology Practice Act and the hospice's policies and procedures and/or job descriptions. Agency unable to provide speech language pathologist HR file.

Upon personnel record review, 1 of 12 (Personnel #7 ) did not have evidence the hospice obtained a criminal background check on all contracted individuals who have direct patient care and access to patient records. Agency unable to produce speech language pathologist HR file.