Every finding on record at Accord Hospice, Inc.

Upon patient record review, 2 of 19 (Patient #5, 15) 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: Admitted with indwelling Foley catheter. No related problems, goals, interventions. Patient #10: Per initial SN assessment includes that patient needs supplemental continuous oxygen when up; at rest, she needs it from time to time. Further references that patient has history of SpO2 in 70's. There is no related problems, goals, interventions. Patient 15: Patient has order for Oxygen 2-5 LPM NC with no related problems, goals, interventions. There is a Respiratory problem, but it does not include Oxygen and/or related education/safety precautions as intervention.

Upon patient record review, 5 of 19 (Patient #1, 5, 6, 9, 11) 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. Patients #5, 6: The POC only includes frequency of SC 3 prn as needed for the initial and ongoing frequency. This is not a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs. Patient #1, 9, 11: The POC only includes frequency of MSW 3 prn as needed for the initial and ongoing frequency. This is not a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs.

Upon patient record review, 1 of 19 (Patient #10) 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 #10: Per initial SN assessment includes that patient needs supplemental continuous oxygen when up; at rest, she needs it from time to time. Further references that patient has history of SpO2 in 70's. There is no order for oxygen other than concentrator in DME.

Upon patient record review, 1 of 19 (Patient #7) 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 #7: Patient admitted 11/6/24 and experienced conjunctivitis requiring Tobramycin eye drops 12/5 and again 12/15/24. There were no updates to problems, goals, interventions.

Upon client record review, 4 of 19 (Patient #2, 7, 9, 16) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #2: Admitted 11/16/24. Order for music therapy volunteer 2x/mo since initial POC and thru 1/22/25. The notes in record are notes for massage therapy volunteer 11/26 and 12/10/24. There are no additional notes and there is no order to discontinue or evidence that further services were declined. Patient #7: SN Visits 12/16, 12/23, 12/30/24 - SN noted that hip bones and sacral bone covered with Duoderm to prevent any breakdown. No further reference in SN Visit notes 1/6, 1/13, 1/20/25 visits. There are no orders to start, change or stop the Duoderm treatment. Patient #9: A single volunteer visit is documented 12/9/24. There is no order to start or discontinue and no evidence that further visits were declined. Interview with staff state this was a training visit and actually should not have been documented in EMR as actual volunteer visit. Patient #16: Admitted 3/21-6/17/25 with MSW frequency of 1-2/month and duration of 90/qtr. Only 1 visit was made 3/21/24 with no update to orders/POC and no documented decline of further visits.

Upon patient record review, 3 of 19 (Patient #17, 18, 19) 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 Patients# 17. 18, 19: The bereavement services offered and/or care plan do not clearly reflect the individual needs of the bereaved. There is record of one call to unspecified bereaved, with voice mail left regarding condolences and services available. There is no additional documentation of attempts to assess individual needs/desires for services. There is no clearly identified and individualized bereavement care plan, although routine mailings are sent at intervals.

Upon personnel record review, 1 of 15 (Personnel #7) 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 #7: Agency form does not specify types of bath and/or shampoos and does not specifically include nail care, toileting and elimination therefore no evidence of specific competency for these items for aide.

Upon patient record review, 2 of 19 (Patient #2,14) 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 #2: Admitted 11/16/24. Aide care plan has frequency of 5x/week. Initial POC has 5x week frequency, but subsequent IDG/POC meetings have Freq 3x/wk since thru 1/22/25. Aide is following aide care plan for 5x week frequency. Patient #14: Patient SOC 11/14/24. 12/24/24 order for Oxygen 2-5 lpm via NC. The problems, goals and interventions were updated, but aide care plan was not updated to include Oxygen therapy, flow rate and/or relate safety precautions.

Upon patient client record review, 1 of 19 (Patient #6) 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 #6: IDG Meeting note entry 1/22/25: "Patient continues to have seizures, however, less frequently." There was no additional documentation referencing seizure activity. Interview with staff pointed out that patient is actually on seizure medication for history of syncopal episodes, not seizures activity. Conclude that documentation was in error.

Upon client record review, 1 of 19 (Patient #15) did not have evidence that if a patient revokes the election of hospice care or is discharged from hospice in accordance with §418.26, the hospice must forward to the patient's attending physician: • A copy of the hospice discharge summary • The patient's clinical record, if requested Patient #15: There is no comprehensive discharge summary included in EMR to send to physician, if requested.

Upon client record review, 1 of 19 (Patient #15) did not have evidence that the discharge summary includes all required information. Patient #15: There is no comprehensive discharge summary included in the record.

Upon observation, there was no evidence a copy is provided of the hospice written policies and procedures on the management and disposal of controlled drugs to the patient or patient representative and family. There is no evidence that a copy is provided of the hospice written policies and procedures on the management and disposal of controlled drugs.

Based on staff interview, it was determined the Hospice failed to ensure counseling services were available for patients and families. This has the potential to affect all patients and families serviced by the Hospice with a current census of 124 patients. --- Findings include: 1. During the entrance interview conducted on 05/14/2024 with the Administrator and Director of Operations, the Administrator stated that currently the Hospice does not have a Chaplain or Spiritual Counselor on staff. 2. During an interview with the Director of Operations on 05/14/2024 at approximately 11:00AM, the Director of Operations stated and confirmed that the Hospice has not had a Chaplain or Spiritual Counselor since 12/11/2023.

Upon observation, there was not evidence of contracts/agreements with other facilities/agencies/Hospices to receive Accord's patients in the event that Accord Hospice cannot provide care to their patients during an emergency.

Upon patient record review, 1 of 11 (Patient #2) did not contain a complete/comprehensive Medication Profile. The section of the Medication Profile intended for the entry of Allergies, if any, had been left blank.

Upon patient record review, 1 of 11 (Patients #2) did not contain evidence that the Plan of Care included all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments: Patient #2: A Physician order was obtained on 03/03/22 for, "May apply dressing to sacral area once weekly p.r.n. for protection, by Hospice nurse". This is not a complete order, as it does not clarify the 'type' of dressing (RN is applying adhesive foam dressing). Nor does it make it clear that the in-home caregiver may re-apply the dressing if loose or soiled.

Upon patient record review, 2 of 11 (Patients #3 and 7) did not contain a Plan of Care which included all services necessary for the palliation and management of the terminal illness and related conditions; specifically DME and Supply needs: Patient #3: During Surveyor-attended home visit on 04/06/22 it was noted that the patient had a hospital bed. A verbal order was obtained on 01/20/22 for, "Apply Knee Spacer for positioning and support at all times, due to a non-treated, suspected hip fracture. ALF staff to manage." These DME/Supplies were not included on the most current IDG POC. Patient #7: The admitting RN noted that she had ordered a shower chair. This was not included on the most current IDG POC.

Upon patient record review, 1 of 11 (Patients #1) did not have evidence that the IDG had ensured that the care and services were provided in accordance with the Plan of Care: Patient #1: The 10/7/21 admitting RN documented, "Skin tear below the left knee." The initial 90-day, Physician-signed orders included, "Clean with Normal Saline and cover with Tegaderm film." The wound care section of the same 10/7/21 SOC nursing note, had an entry of, "There are no problems to display for this section." Thus, it is not clear as to whether the RN conducted the wound care as ordered.

Upon personnel record review, 1 of 1 applicable (Personnel #9) did not contain evidence of the conduct of an Aide Skills Competency Evaluation, which included all CMS-required content. An RN conducted such Skills Competency between 11/16-11/18/2021. However, the following tasks were not verified for competency: • Recognizing emergencies, and knowledge of emergency procedures, and their application • The physical, emotional, and developmental needs of and ways to work with the populations served by the hospice, including the need for respect for the patient, his or her privacy and his or her property

Upon patient record review, 1 of 1 applicable (Patient #8) did not contain evidence that the Discharge Summary included all CMS-required information. It did not contain the following: • A summary of the patient's stay, including treatments, symptoms and pain management • The patient's current plan of care • The patient's latest physician orders In addition the patient record did not contain evidence that the Discharge Summary included all ACHC-required information. It did not contain the following: • Patient's physician • Hospice diagnosis • A brief description of all services provided and ongoing needs that cannot be met • Discharge orders, instructions, medication profile and allergies, if discharge is other than patient death • Presence of Advance Directives, if any

Upon inpatient contract review, 1 of 2 applicable (ECR/RIP) did not contain verbiage that the Hospice patient's inpatient clinical record, shall include: 1) a record of all inpatient services furnished and events regarding care that occurred at the facility; 2) that a copy of the Discharge Summary shall be provided to the Hospice at the time of discharge; and 3) that a copy of the inpatient clinical record is available to the Hospice at the time of discharge.

Upon inpatient contract review, 1 of 2 applicable (ECR/RIP) did not contain verbiage that the Inpatient Facility has identified an individual within the Facility who is responsible for the implementation of the provisions of the agreement.

Upon client record review, 2 of 3 applicable (Patient #3 and 5) did not have evidence that a written hospice plan of care is established and maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided is in accordance with this hospice plan of care. Patient #3 An order was obtained on 01/20/22 for, "Left lower leg (LLL) skin tear. Cleanse Normal Saline or wound cleanser, pat dry, apply Triple ATB Ointment, then dry dressing. Three times per week and prn soiling. Facility Nurse to manage wound." On the 01/25/22 SNV, the nurse documented, "LLL skin tear dressing changed", without the details of the actual wound care provided. Patient #5: A verbal order was obtained on 02/24/22 for, "Volunteer 1-2 times per month." There was no documented evidence of the Hospice following through with this order.

Upon patient record review, 1 of 3 applicable (Patient #5) did not contain evidence that the Hospice Plan of Care identifies the care and services that are needed, and specifically identifies which provider (Nursing Facility or Hospice) is responsible for performing the respective functions that have been agreed upon and included in the Hospice Plan of Care. Patient #5: A Physician order was obtained on 02/15/22 for, "Cleanse with Normal Saline, pat dry, apply Exufiber AG, then Kerlix." This is not a complete order, as it is not clear as to the location of the patient's body it is referring to, how frequently it is to be provided, nor who is to provide such wound care, the Hospice or the SNF staff.