Every finding on record at Aasta Hospice

Based on interview and record review, the agency failed to participate in a full-scale community-based disaster exercise every two years, for two of two sampled years. As a result, the agency may have been less prepared for disasters. --- Findings: On 7/16/24 at 4 P.M., an interview and record review was conducted with the Data Analyst (DA) of the emergency review binder. The disaster exercises in 2023 and 2024 were reviewed, and did not involve community-based exercises. The DA stated, the agency did not conduct any community-based disaster exercises in 2023 or 2024. The agency did not have a policy which directed them to participate in a full-scale community-based disaster exercise.

Based on interview and record review, the agency failed to ensure a patient's responsible party was informed of the discharge for one of four discharged records reviewed (8). As a result, Patient 8 was discharged from hospice service without the responsible party's input. --- Findings:Per the agency's Plan of Care for the certification period of 6/15/23 through 9/12/23, Patient 8 was admitted to the agency on 6/15/23 with diagnoses to include senile degenerative of the brain (mental decline). A review of Patient 8's clinical record was conducted. Per the Discharge Summary Note dated 8/9/23, the Skilled Nurse documented that Patient 8 refused service. There was no documented evidence of involving the responsible party before discharging Patient 8 from hospice service. The Skilled Nurse was not available for the interview. On 7/19/24 at 11:22 A.M., a joint interview and record review was conducted with the Director of Patient Care Services (DPCS). The DPCS stated Patient 8 had dementia, and the wife was the decision-maker. The DPCS further stated the wife should have been part of the discharge. Per the agency's policy and procedure, dated 4/21, titled Discharge from Hospice Program, "...[the agency name] will provide service to a patient and family/caregiver as long as the patient is certified as terminally ill..."

Based on interview and record review, the agency failed to ensure the registered nurse participated in the interdisciplinary group (IDG) meeting for one of 15 sampled patients (10). As a result, Patient 10 was at risk of not providing consistent and quality care. --- Findings:Per the agency's Plan of Care for the certification period of 5/20/24 through 8/17/24, Patient 10 was admitted to the agency on 5/20/24 with diagnoses to include heart failure. A review of Patient 10's clinical record was conducted. Per the IDG note dated 7/9/24, there was no evidence that the Registered Nurse participated in the meeting. On 7/19/24 at 11:34 A.M., a joint interview and record review was conducted with the Director of Patient Care Services (DPCS). The DPCS stated the registered nurse should participate in the IDG meeting and document it. The DPCS stated Patient 10's registered nurse did not sign the IDG meeting note. Per the agency's undated policy, titled Interdisciplinary Group Meeting, "...Members at the interdisciplinary group meeting will sign..."

Based on interview and record review, the agency failed to ensure the interdisciplinary group (IDG) reviewed the plan of care at least every 15 days for one of 15 sampled patients (7). As a result, Patient 7s plan of care may not have reflected their current care needs. --- Findings: Per the agencys Plan of Care for the certification period of 7/28/23 through 10/25/23, Patient 7 was admitted to the agency on 7/28/23 with diagnoses to include Cerebral Arteritis (a disease of blood flow to the brain). On 7/19/24 at 10:25 A.M., an interview and record review was conducted with the Director of Patient Care Services (DPCS). The DPCS stated, she was unable to find documentation of the IDG reviewing Patient 7s plan of care on 10/3/23, but it should have been done. Per the agencys undated policy, titled Interdisciplinary Group Meeting, ";...The interdisciplinary group will meet...to discuss patient and family/caregiver changes and progress and updates to the plan of care...no less frequently than every 15 days..."

Based on interview and record review, the agency failed to ensure the plan of care was reviewed and revised for two of 15 sampled patients (10, 12). As a result, there was a potential for the patients not to receive care and services. --- Findings:1. Per the agency's Plan of Care for the certification period of 5/20/24 through 8/17/24, Patient 10 was admitted to the agency on 5/20/24 with diagnoses to include heart failure. A review of Patient 10's clinical record was conducted. Per the Plan of Care/ IDG (Interdisciplinary Group) Review, dated 5/20/24, Patient 10 had the order to be seen by the home health aide (HA) once weekly. In the same document, under visit frequency, HA was indicated as declined. There was no documented evidence of Patient 10 or the responsible party declining the HA. On 7/19/24 at 11:34 A.M., a joint interview and record review was conducted with the Director of Patient Care Services (DPCS). The DPCS stated Patient 10's plan of care should have been revised to avoid confusion. 2. Per the agency's Plan of Care for the certification period of 5/24/24 through 8/21/24, Patient 12 was admitted to the agency on 5/24/24 with diagnoses to include heart failure. A review of Patient 12's clinical record was conducted. Per the Communication Log dated 6/24/24, the family requested that the CHHA [Certified Home Health Aide] visit the patient once a week, effective today. There was no evidence that the plan of care was revised. On 7/19/24 at 11:05 A.M., a joint interview and record review was conducted with the DPCS. The DPCS stated she received Patient 12's request, got busy with other office work, and could not update the physician. Per the undated agency's policy and procedure, titled The Plan of Care, "...The plan of care will be reviewed and revised as frequently as deemed necessary..."

Based on interview and record review, the agency failed to complete the home visits per the plan of care (POC) for 6 of 15 sampled patients (1, 4, 5, 9, 11, 13). As a result, there was a potential for the patients to not receive their needed care and services. Findings: --- 4. Per the agency's POC for the certification period of 5/20/24 through 8/17/24, Patient 9 was admitted to the agency on 5/20/24 with diagnoses to include heart disease. Per the POC, the CHHA was to visit the patient twice a week.A review of Patient 9's clinical record was conducted. There was no evidence that the CHHA visited Patient 9. On 7/19/24 at 11:25 A.M., a joint interview and record review was conducted with the DPCS. The DPCS stated they were not able to schedule the CHHA to visit. 5. Per the agency's POC for the certification period of 5/24/24 through 7/22/24, Patient 11 was admitted to the agency on 5/24/24 with diagnoses to include heart disease. Per the POC, the Licensed Vocational Nurse (LVN) was to visit the patient once a week.A review of Patient 11's clinical record was conducted. During the week of 6/16/24 through 6/24/24, there was no evidence of the LVN visit. On 7/19/24 at 11:43 A.M., a joint interview and record review was conducted with the DPCS. The DPCS stated the LVN should have created a missed visit note. 6. Per the agency's POC for the certification period of 6/24/24 through 9/21/24, Patient 13 was admitted to the agency on 6/24/24 with diagnoses to include heart disease. Per the POC, the CHHA was to visit the patient twice a week.A review of Patient 13's clinical record was conducted during the weeks of 6/30/24 through 7/6/24 and 7/7/24 through 7/13/24. There was one CHHA visit instead of two, and no documented evidence of a missed visit note. On 7/19/24 at 11 A.M., a joint interview and record review was conducted with the DPCS. The DPCS stated the visit was missed, and the CHHA should have created a note and notified the office. Per the agencys policy, titled Missed Visits, revised April 2021, ";...If a visit is missed and not rescheduled the clinician will...Document in the patients clinical record the...Reason for the missed visit..." 1. Per the agency's POC for the certification period of 4/19/24 through 7/17/24, Patient 1 was admitted to the agency on 4/19/24 with diagnoses to include heart failure. Per the agencys Physicians Order, dated 4/19/24, there was an order for the Certified Home Health Aide (CHHA) to visit Patient 1 one time per week, and for the Skilled Nurse (SN) to visit Patient 1 one time per week. A review of Patient 1s clinical record was conducted. There was no evidence of a CHHA visit or missed visit note on the week of 4/14/24 through 4/20/24. There was also no evidence of an SN visit or missed visit note on the week of 7/7/24 through 7/13/24. On 7/19/24 at 10:25 A.M., an interview and record review was conducted with the Director of Patient Care Services (DPCS). The DPCS stated, the order for the CHHA to visit Patient 1 was entered late, so the CHHA did not know to provide the visit before the week ended. The DPCS further stated, the SN visited Patient 1 on the wrong week, which resulted in there being no SN visit on the week of 7/7/24, but the SN should have visited on that week. 2. Per the agency's POC for the certification period of 6/24/24 through 9/21/24, Patient 4 was admitted to the agency on 6/24/24 with diagnoses to include Parkinsons disease (a disorder of the nervous system that effects movement). Per the agencys Physicians Order, dated 7/9/24, there was an order to, ";...Increase CHHA to twice a week effective today..." A review of Patient 4s clinical record was conducted. There was only one CHHA visit note instead of two, and there were no missed visit notes on the week of 7/7/24 through 7/13/24. On 7/19/24 at 10:25 A.M., an interview and record review was conducted with the DPCS. The DPCS stated, the CHHA should have visited Patient 4 on the week of 7/7/24, but they only went one time. 3. Per the agency's POC for the certification period of 4/19/24 through 7/17/24, Patient 5 was admitted to the agency on 4/19/24 with diagnoses to include heart failure. Per the POC, the CHHA was to visit the patient one time per week. A review of Patient 5s clinical record was conducted. There was no evidence of a CHHA visit or missed visit note on the week of 4/14/24 through 4/20/24. On 7/19/24 at 10:25 A.M., an interview and record review was conducted with the DPCS. The DPCS stated, the scheduled CHHA should have visited Patient 5 on the week of 4/14/24, but they quit without notifying the agency and did not complete the visit.

Based on interview and record review, the agency failed to ensure the medical director or physician designee reviewed the patient's clinical record and provided written documentation that the patient's life expectancy was six months or less before the recertification period for two of 15 sampled patients (9 and 10). As a result, there was a potential for the patients to continue hospice services without an adequate assessment of the patient's needs. --- Findings: 1. Per the agency's Plan of Care for the certification period of 5/20/24 through 8/17/24, Patient 9 was admitted to the agency on 5/20/24 with diagnoses to include heart disease. A review of Patient 9's clinical record was conducted. Per the Certification of Terminal Illness (CTI) #2, dated 5/29/24, the physician's narrative section was blank. 2. Per the agency's Plan of Care for the certification period of 5/20/24 through 8/17/24, Patient 10 was admitted to the agency on 5/20/24 with diagnoses to include heart failure. A review of Patient 10's clinical record was conducted. Per the Certification of Terminal Illness (CTI) #2, dated 5/29/24, the physician's narrative section was blank. On 7/19/24 at 11:30 A.M., a joint interview and record review were conducted with the Director of Patient Care Services (DPCS). The DPCS stated that the CTIs for Patients 9 and 10 were incomplete. The DPCS further stated the physician should have created a narrative note. Per the agency's policy and procedure, dated 4/20, titled Certification of Terminal Illness, "...At the recertification, the hospice Medical Director must compose and sign the narrative based on a review of the patient's medical record..."

Based on interview and record review, the agency failed to ensure the clinical record contained signed copies of the notice of patient's rights and election statement date (the agreed admission date) for two of 15 sampled patients (9 and 13). As a result, there was a potential for Patient 9 and 13 to be unaware of their rights and delay hospice services. --- Findings:1. Per the agency's Plan of Care for the certification period of 5/20/24 through 8/17/24, Patient 9 was admitted to the agency on 5/20/24 with diagnoses to include heart disease. A review of Patient 9's admission binder was conducted. There was no evidence of an effective date for the election of benefit, and it was not dated. 2. Per the agency's Plan of Care for the certification period of 6/24/24 through 9/21/24, Patient 13 was admitted to the agency on 6/24/24 with diagnoses to include heart disease. A review of Patient 13's admission binder was conducted. There was no evidence that Patient 13 had received a copy of the patient's rights and had an effective date for the election of benefit. On 7/19/24 at 11:30 A.M., a joint interview and record review was conducted with the Director of Patient Care Services (DPCS). The DPCS stated the clinical records of Patient 9 and Patient 13 were incomplete. The DPCS further stated the consent should be completed with the election date, signature of the patient or responsible party, and date. Per the agency's policy and procedure, dated 4/21, titled Rights/Responsibilities, "...The patient, authorized decision-maker, or legal representative will be informed during the initial assessment visit, in advance of furnishing care, of:... C. The right to elect hospice service...5. The patient and/or representative will to sign the Patient Rights and Responsibilities form confirming that he/she has received a copy of the notice..."

Based on interview and record review, the agency failed to ensure the Plan of Care (POC) and visit notes were completed timely and authenticated for 15 of 15 sampled patients (1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15).As a result, the patient's clinical records were incomplete, which could lead to incorrect patient information. --- 8. Per the agency's Plan of Care for the certification period of 6/15/23 through 9/12/23, Patient 8 was admitted to the agency on 6/15/23 with diagnoses to include senile degenerative of the brain (mental decline). The POC was not signed by the physician.9. Per the agency's Plan of Care for the certification period of 5/20/24 through 8/17/24, Patient 9 was admitted to the agency on 5/20/24 with diagnoses to include heart disease. The POC was not signed by the physician.10. Per the agency's Plan of Care for the certification period of 5/20/24 through 8/17/24, Patient 10 was admitted to the agency on 5/20/24 with diagnoses to include heart failure. The POC was not signed by the physician.A review of Patient 10's clinical record was conducted. Per the Comprehensive Nursing Assessment, the home visit happened on 5/20/24. However, the document was closed on 7/17/24 (58 days to complete the assessment). 11. Per the agency's Plan of Care for the certification period of 5/24/24 through 7/22/24, Patient 11 was admitted to the agency on 5/24/24 with diagnoses to include heart disease. The POC was not signed by the physician.A review of Patient 11's clinical record was conducted. Per the Visit Note, the home visit happened on 7/7/24. However, the document did not have a narrative note. The question about imminently dying, fall, and safety issues were blank. The visit note was not signed and dated.12. Per the agency's Plan of Care for the certification period of 5/24/24 through 8/21/24, Patient 12 was admitted to the agency on 5/24/24 with diagnoses to include heart failure. The POC was not signed by the physician.A review of Patient 12's clinical record was conducted. Per the Visit Note, the home visit happened on 6/30/24. However, the document did not have a narrative note. The question about imminently dying, fall, and safety issues were blank. The visit note was not signed and dated.On 7/19/24 at 11:43 A.M., a joint interview and record review was conducted with the DPCS. The DPCS stated Patient 10, Patient 11 and Patient 12's clinical records were incomplete. The DPCS further stated she would like the visit notes completed within 48 hours. 13. Per the agency's Plan of Care for the certification period of 6/24/24 through 9/21/24, Patient 13 was admitted to the agency on 6/24/24 with diagnoses to include heart disease. The POC was not signed by the physician. 14. Per the agency's Plan of Care for the certification period of 6/4/24 through 8/2/24, Patient 14 was admitted to the agency on 6/4/24 with diagnoses to include pulmonary fibrosis (lung disease). The POC was not signed by the physician. 15. Per the agency's Plan of Care for the certification period of 3/24/23 through 6/21/23, Patient 15 was admitted to the agency on 3/24/23 with diagnoses to include heart failure. The POC was not signed by the physician. On 7/18/24 at 12:15 P.M., an interview was conducted with the DPCS. The DPCS stated, the agencys physician did not sign patient POCs. The agency could not provide a policy for clinical data entries and timeframe, or signing the POC. Findings: 1. Per the agency's Plan of Care for the certification period of 4/19/24 through 7/17/24, Patient 1 was admitted to the agency on 4/19/24 with diagnoses to include heart failure. The POC was not signed by the physician. 2. Per the agency's Plan of Care for the certification period of 6/29/24 through 8/27/24, Patient 2 was admitted to the agency on 3/1/24 with diagnoses to include cerebral infarction (a stroke). The POC was not signed by the physician. On 7/18/24 a review was conducted of Patient 2s clinical record. The HA (hospice aide) Visit Notes on the dates of 6/13/24, 6/20, 6/27, 7/5, and 7/11 were not signed and completed. On 7/19/24 at 10:25 A.M., an interview was conducted with the Director of Patient Care Services (DPCS). The DPCS stated, the unsigned visit notes should have been signed within 48 hours of the visits. 3. Per the agency's Plan of Care for the certification period of 6/17/24 through 9/14/24, Patient 3 was admitted to the agency on 6/17/24 with diagnoses to include heart failure. The POC was not signed by the physician. 4. Per the agency's Plan of Care for the certification period of 6/24/24 through 9/21/24, Patient 4 was admitted to the agency on 6/24/24 with diagnoses to include Parkinsons disease (a disorder of the nervous system that effects movement). The POC was not signed by the physician. On 7/18/24 a review was conducted of Patient 4s clinical record. The HA Visit Notes on the dates of 6/26/24, 7/4, and 7/11 were not signed and completed. On 7/19/24 at 10:25 A.M., an interview was conducted with the DPCS. The DPCS stated, the unsigned visit notes should have been signed within 48 hours of the visits. 5. Per the agency's Plan of Care for the certification period of 4/19/24 through 7/17/24, Patient 5 was admitted to the agency on 4/19/24 with diagnoses to include heart failure. The POC was not signed by the physician. 6. Per the agency's Plan of Care for the certification period of 9/11/23 through 12/9/23, Patient 6 was admitted to the agency on 9/11/23 with diagnoses to include cerebral infarction (a stroke). The POC was not signed by the physician. 7. Per the agency's Plan of Care for the certification period of 7/28/23 through 10/25/23, Patient 7 was admitted to the agency on 7/28/23 with diagnoses to include cerebral arteritis (a disorder of blood flow to the brain). The POC was not signed by the physician.

Condition of Participation: Emergency Preparedness

Upon observation, there was no evidence the hospice has developed and maintained an emergency preparedness plan that must be reviewed, and updated at least every two years. Emergency Preparedness plan did not have a date, portions of the information were current yet portions were from prior to the change in ownership in 2022 and included previous leadership team members.

Upon observation, there was no evidence the Emergency Preparedness plan: • Is based on and includes a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach • Includes strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care Hazardous risk assessment was not dated unsure when the last assessment was performed.

Upon observation, there was no evidence the hospice develops and maintains an emergency preparedness communication plan that complies with federal, state, and local laws and must be reviewed and updated every two years. The communication plan was not dated, portions were current and portions contained leaders from 2022 and prior.

Upon observation, there was no evidence of emergency preparedness training and testing program that is based on the emergency plan, policies and procedures and the communication plan.

Upon personnel record review, 3 of 15 (Personnel #2, 3, 11) did not have evidence Emergency Preparedness training including: • Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles • Demonstrate staff knowledge of emergency procedures • Provide emergency preparedness training at least annually • Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others • Maintain documentation of all emergency preparedness training

Upon observation, there was no evidence the agency has conducted exercises to test the emergency plan every two years. No evidence of a community full-scale exercise to test the emergency plan. Verbally stated the plan was activated January of 2024, no documentation provided for this event.

Upon patient record review, 1 of 14 (Patient #5) did not have evidence that the patient has received effective pain management and symptom control from the hospice for conditions related to the terminal illness. It is documented in initial nursing assessment on 05/24/24 that patient was experiencing pain during visit. There was no evidence of care plan problems/interventions/goals for this pain and no evidence of pharmalogical and/or non-pharmalogical interventions requested from the physician.

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

Upon patient record review 1 of 14 (Patient #11) 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 11 admitted on 5/24/23 initial spiritual assessment completed on 5/30/24.

Upon patient record review 7 of 14 (Patient #2-8) 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 2, 4, 5, 6 no evidence of an initial spiritual or psychosocial assessment. Patient 3, 7 initial spiritual assessment on 4/23/24 note is blank, unable to determine if assessment was completed as it is not documented. Patient 8 initial spiritual assessment on 4/20/24 note is blank, unable to determine if assessment was completed as it is not documented.

Upon patient record review, 10 of 14 (Patients #1 through #10) 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, 2, 3, 6, 7, 8, 10: Oxygen is not listed in patient’s medication profile. Patient 2: RN visit on 5/21/24 documented scheduled stool softener and this was not included on the medication profile. Patient 4: Nurse visit made 5/26/24, documentation indicated use of Tylenol. There is no Tylenol listed in patient’s medication record. Patient 5: Nurse visit made 5/24/24, documentation indicated use of Tylenol. There is no Tylenol listed in patient’s medication record. Patient 6: RN documentation indicated use of Tylenol. There is no Tylenol listed in patient’s medication record. Patient 8: Nurse visit made 4/18/24, documentation indicated use of ibuprofen. There is no ibuprofen located in patient’s medication record. Bacitracin and Neosporin in patient’s medication profile without location for application. Patient 9: Nurse visit made 5/29/24, documentation indicated use of Tylenol. Tylenol is not located on patient’s medication profile. Patient 10: Voltaren Gel is listed on patient’s medication profile. No application site is indicated in this order. There is no acetaminophen max. dose warning on patient’s medication profile for the Tylenol was 500mg q4 prn fever and Norco was 5/325 q4 prn, in addition there was no direction on which pain medication to take for level of pain.

Upon patient record review, 5 of 14 (Patient #2, 4, 5, 6, 12) 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 2, 4, 5, 6, 12 no evidence of an initial bereavement risk assessment.

Upon patient record review, 4 of 14 (Patient #1, 3, 7, 9) 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 not an updated nursing comprehensive assessment after 5/8/24. Patient 3 there is not an updated nursing comprehensive assessment after 5/17/24. Patient 7 comprehensive nursing assessments completed on 5/2/24 and 5/18/24. Patient 9 comprehensive nursing assessments completed on 5/10/24 and 5/29/24.

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

Upon patient record review, 1 of 14 (Patient #8) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient 8 no evidence of a wound assessment from 4/18/24 to current.

Upon patient record review, 9 of 14 (Patient #2-10) 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 2 admitted on 5/16/24 and did not have a care plan started until 5/29/24. Patient 3 no evidence of bleeding precautions, taking Eliquis. Patient 4 admitted on 5/24/24 and did not have a care plan. No evidence of a care plan to include problems, goals and interventions for the following identified problems bleeding precautions, taking Aspirin, dyspnea, heart failure, fall risk, or oxygen use and safety. Patient 5 admitted on 5/24/24 and did not have a care plan. No evidence of a care plan to include problems, goals and interventions for the following identified problems dyspnea, weight loss, heart failure, fall precautions, oxygen use and safety, skin precautions, coping, or spiritual distress. In addition, did not have a diet on the plan of care ordered. Patient 6 admitted on 5/20/24 and did not have a care plan. No evidence of a care plan to include problems, goals and interventions for the following identified problems dyspnea, skin precautions, fall precautions, diuretic use, heart failure, or constipation. Patient 7, 9, 10 oxygen was ordered, no care plan for oxygen use and safety. Patient 8 both spiritual care and social work are ordered to see the patient, no evidence of spiritual or psychosocial problems, goals, and interventions. Oxygen is ordered, no care plan for oxygen use and safety. Patient 10 on Aspirin and identified as high risk for aspiration, no bleeding or aspiration precautions.

Upon patient record review, 3 of 14 (Patient #2, 4, 5) did not have evidence that the plan of care includes all services necessary for the palliation and management of the terminal illness and related conditions which including interventions to manage pain and symptoms. Patient 2, 4, 5 no evidence of a care plan interventions for pain or symptom management. Patients with pain and anxiety.

Upon patient record review, 8 of 14 (Patient #1-3, 6-10) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient 1 SN ordered 1x week and prn. No quantity for prn. SW ordered prn, no routine frequency or quantity for prn. SC ordered 1xm and prn, no quantity for prn. Patient 2 SN ordered 1x week and prn. No quantity for prn. SW and SC ordered 1x month and prn. No quantity for prn. Patient 3 SW and SC ordered 1x month and prn. No quantity for prn. Patient 6 SW and SC ordered 1x month and prn. No quantity for prn. SN ordered 1x week and prn. No quantity for prn. Patient 7 SW ordered prn, no routine frequency. Patient 8 SC ordered 1x month and prn. No quantity for prn. Patient 9 SW ordered prn, no routine frequency or quantity for prn. SC ordered prn, no routine frequency or quantity for prn Patient 10 SN ordered 1x week and prn. No quantity for prn. SW and SC ordered 1x month and prn. No quantity for prn.

Upon patient record review, 8 of 14 (Patient #2, 4-6, 8-11) 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: RN visit on 5/21/24 documented scheduled stool softener and there wasn't an order for this. Patient 4: Nurse visit made 5/26/24, documentation indicated use of Tylenol. There is no physician’s order for Tylenol located in patient’s record. Patient 5: Nurse visit made 5/24/24, documentation indicated use of Tylenol. There is no physician’s order for Tylenol located in patient’s record. Nurse visit made 5/24/24 indicates patient has insulin dependent diabetes. There is no physician’s order for insulin in patient’s record. Patient 6: RN visit made 5/20/24, documentation indicated use of Tylenol. There is no physician’s order for Tylenol located in patient’s record. Patient 8: During hospice visit made on 4/18/24, documentation indicated use of ibuprofen. There is no physician’s order for ibuprofen in patient’s medical record. Patient has colostomy documented in initial assessment. There are no physician's orders for the care of this colostomy. Patient 9: During nurse visit made 5/29/24, documentation indicated use of Tylenol. There is no physician’s order for Tylenol in patient’s medical record. Patient 10: Voltaren Gel is listed ordered and doesn't include the application site. There is no acetaminophen max. dose warning on patient’s medication profile for the Tylenol was 500mg q4 prn fever and Norco was 5/325 q4 prn, in addition there was no direction on which pain medication to take for level of pain. Patient 11: Patient has foley catheter per initial RN visit documentation however, there was no evidence of physician's order for catheter or catheter care in medical record.

Upon patient record review, 6 of 14 (Patient #2-4, 6, 8, 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 2 nursing documented patient using a cane and walker, no evidence of DME orders. Patient 3 nursing documented patient using walker, wheelchair and shower chair, no evidence of DME orders. Patient 4 nursing documented patient using a walker, no evidence of DME orders. Patient 6 nursing documented patient using cane, walker, and shower chair, no evidence of DME orders. Patient 8 nursing documented patient using purewick catheter, and shower chair, no evidence of DME orders. Patient 9 nursing documented patient using overbed table, wheelchair, and shower chair, no evidence of DME orders.

Upon patient record review, 7 of 14 (Patient #1-3, 7-10) 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 1, last IDG care plan update was 4/30/24 and for the problems on the care plan the last revision was completed 1/23/24 the updates from 1/23/24 to 4/30/24 were all exactly the same. Patient 3, 7, 8, 9, 10 last IDG care plan update was 4/30/24. It was documented that the care plans were updated with no information change from one period to the next. Patient 2 was admitted 5/16/24. No care plans present until 5/29/24 however, still did not have evidence of problems/goals/interventions for fall risk, seizure precautions, anxiety, constipation, dyspnea, psychological or spiritual distress needs identified in the comprehensive assessment.

Upon client record review, 8 of 14 (Patient #1-3, 6-10) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 1 SW visits completed on 3/24/24, 4/24/24 and 5/23/24 without an order. SC ordered 1xm, no evidence of visits completed after 2/19/24. SN visits ordered 1x week and RN ordered q 14 days, no evidence of RN visit after 5/8/24. RN visits completed on 4/15/24, 4/22/24, 5/1/24, 5/8/24. Patient 2: SC, SW visits ordered on admission (5/16/24) to be completed within 5 days. Neither visit was completed. Patient 3: RN visits ordered as RN supervisory visits every 14 days. RN has not visited patient since 4/24/24. Patient 6: SN visits ordered once weekly and PRN. LVN visited patient twice during this Medicare week. Neither of these visits were a PRN visit. Patient 7: RN visits ordered as RN supervisory visits every 14 days. RN visited patient on 4/19/24 and 4/30/24. RN then visited again on 5/2/24. Patient 8: RN visits ordered as RN supervisory visits every 14 days. RN visited patient on 4/22/24 and 5/3/24. SC visits ordered monthly. SC has not visited patient. Patient 9: SN visits ordered as weekly and PRN. Nurse visits made on the following dates: 5/8/14, 5/10/24, 5/14/24, 5/29/24. Patient 10: SN visits ordered weekly and PRN. Nurse visits made 4/30, 5/14 (this visit is blank); 5/22, 5/28.

Condition of Participation: Quality Assessment and Performance Improvement.

Upon observation, there was no evidence the program shows measurable improvement in indicators related to improved palliative outcomes and hospice services.

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 QAPI plan did not have a date and did not have specific indicators to be measured or specific data to be audited. They did track demographic information.

Upon observation, there was no evidence the board of directors/governing body approves the frequency and detail of the data collection.

Upon observation, there was no evidence QAPI activities focus on high risk ,high volume, or problem prone areas.

Upon observation, there was no evidence Quality Assessment and Performance Improvement activities focus on high risk, high volume or problem-prone areas by considering incidence, prevalence, and the severity of problems.

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 number and scope of distinct QAPI projects conducted annually is based on the needs of the hospice's population and internal organizational needs and must reflect the scope, complexity, and past performance of the hospice's services and operations. No projects for QAPI.

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. Agency documented 2024 Q1 meeting titled Champion Hospice but the data referred to Orangevale Hospice for the customer satisfaction. No QAPI projects documented. Another document for Q1 2024 titled 2024, but contained information referring to infections in 2023 for Q1.

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

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. Only had demographic information no patient record audit information or data to make improvements.

Upon personnel record review, 5 of 15 (Personnel #2, 4, 6, 7, 11) did not have evidence that the hospice routinely provide substantially all core services directly by hospice personnel (The hospice issues a W-2 form for the employee). These services include: • Physician services (may contract for physician services) • Nursing • Medical social services • Counseling Personnel 2 and 11 did not have a W-2. Personnel 4, 6, 7 are 1099 staff.

Upon personnel record review, 1 of 15 (Personnel #7) did not have evidence that all bereavement services are provided by a qualified counselor in accordance with applicable laws and regulations, professional practice standards, the hospice's policies and procedures and/or job descriptions which includes experience or education in grief or loss counseling.

Condition of Participation: Hospice Aide and Homemaker Services. L607

Upon patient record review, 9 of 14 (Patient #1-3, 5-10) 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 aide care plan included the following tasks without a frequency: turn and reposition, walker, record bowel movement, diet listed as other with no details, feeding assistance, change linen, check vitals also without a frequency or parameters. Patient 2: No aide care plan in place from admission until 5/29/24. Patient 3: Aide care plan does not indicate use of cane or shower chair for patient. Patient’s plan of care includes cane for ambulation and shower chair. Frequencies missing: dressing patient; all housekeeping tasks. Vital signs also without frequency or parameters. Patient has an order for oxygen and there are no oxygen precautions on the aide care plan. Patient 5: Patient’s aide care plan is missing. Patient 6: Patient’s aide care plan is missing. Patient 7: Aide care plan does not list frequency for the following tasks: record bowel movements; transfers; dressing; change linens; vital signs. Additionally, care plan has no parameters indicated for measuring vital signs. Patient 8: Aide care plan does not list frequency for the following tasks: record bowel movements; transfer assistance: diet/fluid assistance; housekeeping tasks; vital signs. Additionally, the vital sign task does not include parameters for reporting to RN. Aide care plan is also missing the following precautions: bleeding and oxygen. Patient 9: Aide frequency order written as 1-2 times weekly. Aide care plan does not list frequency for the following tasks: record bowel movements; transfer assistance: diet/fluid assistance; dressing; linen change; vital signs. Additionally, the vital sign task does not include parameters for reporting to RN. Aide care plan is also missing the following precautions: bleeding. Patient 10: Aide care plan does not list frequency for the following tasks: record bowel movements; transfer assistance: diet/fluid assistance; dressing; linen change; vital signs. Additionally, the vital sign task does not include parameters for reporting to RN. Aide care plan is also missing the following precautions: oxygen.

Upon patient record review 9 of 14 (Patient #1-3, 5-10) 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: aide visit on 5/8/24 did not document incontinence care which should be every visit. Aide visit 5/20/24 did not document assist with toileting or shower which should be every visit. Also, on 5/20/24 aide documented right elbow applied and doesn’t specify what was applied and this was not on the aide care plan. Aide visit on 5/22/24 aide documented helped ambulate to the restroom/toilet yet the care plan was for incontinence care every visit. Also documented gave partial with warm washcloth, no shower as on aide care plan. Also documented open wound left healing ointment applied and this was not on the aide care plan. Patient 2: Patient admitted on 5/16/24. Weekly aide visits ordered 5/16/24. There have been no aide visits made since patient admission. Patient 3: Patient has been receiving weekly aide visits. There is no physician’s order for aide visits. Patient’s aide documentation indicates- 4/22/24 visit-no documentation of tasks: incontinence and incontinence care; shaving face; brushing hair; housekeeping tasks; infection control precautions. 5/9/24 visit-no documentation of tasks: shave, lotion, linens. Medication assistance was provided to patient. There is no definition provided in patient record re: medication assistance. 5/16/24 visit-no documentation of tasks: incontinence, medication, shower, hair (brush and shampoo); shave, lotion, housekeeping tasks. Patient 5: Patient admitted on 5/24/24. Weekly aide visits ordered 5/24/24. There have been no aide visits made since patient admission. Patient 6: Patient’s plan of care includes an order for aide visits weekly. There have been no aide visits since admission on 5/20/24. Patient 7: Aide visit on 5/8/24, the following tasks had no documentation: bowel and bladder; shower; all housekeeping tasks. Aide visit on 5/15/24, the following tasks had no documentation: toileting, shower. Aide visit on 5/22/24, the following tasks had no documentation: toileting, shower, linen change. Patient 8: Aide visits 5/10/24, 5/17/24, 5/24/24 all indicate patient received partial bed bath. Aide care plan indicates patient to receive shower. No aide visit made week of 4/29/24. No missed visit documentation located. Patient 9: Aide visit 5/17/24 indicated that patient received shower. Narrative note states patient did not receive shower. Toileting task has no documentation. Aide visit 5/20/24 indicates patient received sponge bath. Care plan states patient to receive shower. Aide visit 5/22/24 indicates patient received bed bath. Care plan states patient to receive shower. Dressing and aspiration precautions tasks had no documentation. Patient 10: No aide visit made week of 5/22/24 and no missed visit documentation located.

Upon patient record review 6 of 14 (Patient #1, 2, 3, 7, 9, 10) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs. Patient 1 no aide supervision documented after 5/8/24. Patient 3 aide supervisory visit performed on 5/3/24, and no evidence of aide supervision after 5/3/24. Patient 7 aide supervisory visits performed on 5/2/24 and 5/18/24. Patient 9 aide supervisory visits performed on 5/10/24 and 5/29/24. Patient 10 aide supervisory visit last performed on 4/30/24.

Upon observation, there was no evidence the annual report documents the use of volunteers providing day to day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract personnel. No documentation of the volunteer usage for 2023.

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 provided oversight to ensure: -Core staff for nursing, medical social services, counseling were provided directly by hospice personnel/W-2 employees -staff were qualified for positions, properly hired with background checks and documents, and trained -the agency had a Quality Assessment Performance Improvement program -there was an effective emergency preparedness program -ensure agency was following established policies and procedures regarding patient care and billing requirements, such as CTI completion

Upon observation, there was no evidence the hospice is primarily engaged in providing the following care and services: • Nursing services • Medical supplies (including drugs and biologicals) and medical appliance Patient 11 had multiple wounds, one wound requiring special wound care/debridement the others with regular wound care being provided. The owner/alternate administrator stated that the wound care company was billing the insurance and the hospice was not paying for the regular wound care. Patient 13 had wound care provided by a contracted wound care company that was regular wound care not a specialty wound care. The owner/alternate administrator stated the wound care company is billing the insurance and that the hospice is not paying the wound care company.

Upon personnel record review, 5 of 15 (Personnel #2, 3, 5, 7, 11) did not have evidence the hospice employees and contract employees have received orientation on the hospice philosophy.

Upon personnel record review, 3 of 15 (Personnel #2, 3, 5) did not have evidence that the hospice employees have received orientation on their specific job requirements.

Upon personnel record review, 6 of 15 (Personnel #2, 3, 5, 7, 8, 11) did not have evidence that a skills competency assessment, specific to each discipline had been conducted for all personnel including volunteers initially during orientation.

Condition of Participation: Medical Director.

Upon patient record review, 5 of 14 (Patient #4-8) 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 4, 5, 6, 7, 8 the CTI does not include a narrative from the hospice medical director there is a sentence that states to see above documented by the RN and that the patient is terminally ill and support certifying with a prognosis of less than 6 months.

Upon patient record review, 3 of 14 (Patient #1, 9, 10) did not have evidence that before the recertification period for each patient, the medical director or physician designee must review the patient's clinical information and provide written documentation that it is anticipated that the patient's life expectancy is 6 months or less. Patient 1 there is no evidence of a CTI for the 7th benefit period starting on 5/24/24. Patient 9 there is no evidence of a CTI for the 5th benefit period starting on 4/30/24. Patient 10 there is no evidence of a CTI for the 3rd benefit period starting on 4/24/24.

Condition of Participation: Clinical Records.

Upon patient client record review, 7 of 14 (Patient #4, 6, 8, 9, 11-13) 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 4 no evidence of an effective date on the election, no date signed and no witness by a hospice staff member. Patient 6 elected to receive the notice of non-covered items and it was not provided to the patient. Patient 8 elected to receive the notice of non-covered items upon admission 4/18/24 and it was provided on 4/22/24. Patient 9 Evidence indicated that patient wanted the written notice of non-coverages upon admission 3/1/24. This document was not provided within 72 hours. Patient 9, 12 no evidence of an effective date for the election of benefit. Patient 11 no evidence of an effective date for the election of benefit, it was signed on 5/24/24 and care started on 5/25/24. Patient 11, 12, 13 did not elect or decline to elect an attending physician.

Upon patient client record review, 5 of 14 (Patient #2-5, 7) did not have evidence that each patient record contains Physician certification and recertification of terminal illness. Patient 2 elected Dr RB as their attending, there is not a CTI from the attending physician. Patient 3 elected Dr RB as their attending, there is not a CTI from the attending physician. Patient 4 elected Dr JA as their attending, there is not a CTI from the attending physician. Patient 5 elected Dr CC as their attending, there is not a CTI from the attending physician. Patient 7 elected Dr FG as their attending, there is not a CTI from the attending physician.

Upon patient client record review, 1 of 14 (Patient #4) did not have evidence that each patient record contains Advance Directives. Patient 4 was a DNR and documented a POLST, no evidence of a copy of the DNR or POLST.

Upon patient client record review, 1 of 14 (Patient #4) did not evidence that each patient record contains physician orders. Patient 4 no evidence of an order for the patient’s level of care (routine).

Upon patient client record review, 2 of 14 (Patient #9, 10) 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 9 daughter signed consents for hospice services on 3/1/24. This individual is identified as "daughter," without printed name for proper identification. On hospice consents dated 3/1/24, patient indicated that they wanted to make a DPOA choice. The information for the DPOA is blank. Patient 9 and 10 hospice consents and election were signed by a staff member and the signature was illegible, and did not include credentials.

Upon SNF/NF contract review, 1 of 3 (Villas Las Palmas) did not have evidence that specifies the provision of hospice services in the facility, including: A provision that the SNF/NF or ICF/IID immediately notifies the hospice if: • A significant change in a patient's physical, mental, social or emotional status occurs • Clinical complications appear that suggest a need to alter the plan of care • When a need to transfer a patient from the SNF/NF or ICF/MR arises, and the hospice makes arrangements for, and remains responsible for, any necessary continuous care or inpatient care necessary related to the terminal illness and related conditions • A patient dies

Upon SNF/NF contract review, 1 of 3 (Villas Las Palmas) did not have a provision stating that the hospice reports all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by anyone unrelated to the hospice to the SNF/NF administrator within 24 hours of the hospice becoming aware of the alleged violation.

Upon SNF/NF contract review, 1 of 3 (Villas Las Palmas) did not have a delineation of the responsibilities of the hospice and the SNF/NF to provide bereavement services to SNF/NF personnel.

Upon personnel record review, 5 of 15 (Personnel #3, 5, 7, 8, 11) did not have evidence that personnel credentialing activities are conducted to verify qualifications of all credentialed/licensed personnel in the positions they hold at the time of hire, at renewal or in accordance with specific state practice act requirements.

Upon personnel record review, 1 of 15 (Personnel #3) did not have evidence in the personnel files that if no state licensing, certification or registration requirements exist for personnel qualifications for a Registered Nurse or Licensed Practical Nurse. The following requirements must be met for a: • Registered Nurse – A graduate of a school of professional nursing

Upon personnel record review, 4 of 15 (Personnel #2, 3, 5, 8) did not have evidence of criminal background checks being obtained in accordance with state requirements. In the absence of state requirements, criminal background checks are obtained within three months of the date of employment for all states that the individual has lived or worked in the past 3 years.