Every finding on record at Aceso Hospice, Inc.

Upon patient record review 4 of 14(Patient #2,5,8,10) 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 2: Admission date 7/25/22. Initial spiritual assessment 8/15/22. Patient 5: Admission date 2/2/24. Initial spiritual assessment 2/16/24. Patient 8: Admission date 2/2/24. Initial spiritual assessment 2/13/24. Patient 10: Admission date 7/2/23, and was readmitted on 7/10/23. No evidence of initial spiritual assessment after 7/10 admission.

Upon patient record review, 2 of 14 (Patient #1,2) 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: All topical medications have no evidence of application sites. Fluocinonide ointment. Physician's order written 12/19/23. Application site indicated as affected area. Nystatin ointment. Physician's order written 6/14/24. Application site indicated as affected area. Patient 2: Bacitracin topical has no evidence of application site.

Upon patient record review, 6 of 14 (Patient #1,2,3,8,9,10) 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 1: Patient admitted 12/31/23. Initial bereavement assessment 1/10/24. Patient 2: Patient admitted 7/25/22. Initial bereavement assessment 8/15/22. Patient 3: Patient admitted 12/31/23. Initial bereavement assessment 3/21/23. Patient 8: Patient admitted 2/2/24. Initial bereavement assessment 2/13/24. Patient 9: Patient admitted 8/18/23. Initial bereavement assessment 9/13/23. Patient 10: Patient admitted 7/2/23 and 7/10/23. No evidence of an initial bereavement assessment.

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

Upon patient record review, 6 of 14 (Patient #2,4,5,6,7,9) 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: Patient has order for oxygen and oxygen is present in home. There is no oxygen care plan present in patient's plan of care. The registered nurses are unable to add oxygen to the respiratory care plan. In addition, UTI is part of the respiratory care plan instead of genitourinary care plan. Patient 4: Patient has documented 3 plus to 4 plus pitting edema to bilateral lower extremities. There is no evidence of an edema care plan. This is the patient where UTI risk is documented in the respiratory care plan. Patient 5: Patient's hospice diagnosis is acute on chronic respiratory failure. There is no evidence of a respiratory care plan or an oxygen care plan. Patient 6: Hospice diagnosis is vascular dementia. No evidence of cardiac care plan. Documented aspiration precautions. There is no evidence of an aspiration care plan. There is no evidence of an oxygen care plan despite oxygen ordered. Patient 7: Patient has honey thick liquids ordered. No evidence of an aspiration care plan. Patient 9: Patient has documented bleeding precautions. There is no evidence of high risk for bleeding care plan.

Upon patient record review, 10 of 14 (Patient #1-10) 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. Patients 1-10: All patients had PRN nursing visits ordered without evidence of a quantifier.

Upon patient record review, 4 of 14 (Patient #1,2,4,7) 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 1: All topical medications have no evidence of application sites. --Fluocinonide ointment. Physician's order written 12/19/23. Application site indicated as affected area. --Nystatin ointment. Physician's order written 6/14/24. Application site indicated as affected area. --Ambien orders written 5/30/24: Ambien 5 mg. Take 2 tabs PO QHS. Ambien 6.5mg PO QHS. Both of these orders remain active. --Treatments: (1) Aquaphor 41% topical ointment. Apply to affected area daily and cover with bandage for skin irritation. In this physician's order, there is no evidence of who is to apply this daily dressing. There is no evidence of the type of dressing to be placed over the ointment. This order was written 4/23/24. (2) Skin tear left forearm 2x1cm: Cleanse with NS, dry. Apply thin layer bacitracin, island dressing 2-3 times per week until healed. In this physician's order, there is no indication of who is to complete this treatment. Patient 2: Bacitracin topical has no evidence of application site. Bacitracin ointment. Physician's order written 6/13/24. Application site indicated as affected area. Patient 4: Patient has order for foley catheter. There is no evidence of foley catheter orders in the care plan. Patient 7: Verbal order, wound care. Cleanse with NS, pat dry. Cover with bacitracin and gauze. Order was written on 6/25/24. In this physician's order, there is no indication of site, frequency, type of gauze. There is also no indication of who is to perform wound care.

Upon client record review, 6 of 15 (Patient #1,3,6,7,8,9) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 3: Patient with physician's order for social work visit frequency of once monthly. There is evidence of MSW visits made 3/6/24 and 3/15/24. There is no evidence of a social work visit made in May 2024. Patient 7: Patient admitted 6/22/24. Physician's order written 6/22/24 for SN frequency of twice weekly. There is no evidence of second SN visit this week. SN visit during week of 6/23. Patient 8: Patient with physician's order for SN visits weekly. There is no evidence of SN visit 5/24/24-5/29/24. Patient 9: Patient with physician's order for MSW monthly. There is no evidence of a MSW visit in 3/24 or 5/24. Patient with physician's order for SC monthly. There is no evidence of SC visit in 3/24 or 6/24. Patients 1,3,6,7,8,9: All spiritual care visits including initial assessment are telephonic visits. There was no order for telephone visits and there is evidence that this is in direct violation of hospice's own policy.

Upon personnel record review, 1 of 13 (Personnel #6 ) 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. Personnel 6: Hospice agency's job description states bereavement counselor shall have education of a bachelors or masters degree or equivalent. Personnel has education of associates degree in bible studies. Further, there is no indication or evidence that personnel has received any education or training in counseling.

Upon observation, there was no evidence the hospice ensures that non-core services are provided to hospice patients and their families according to applicable laws and regulations. Non-core services include Physical Therapy, Occupational Therapy and Speech-Language Pathology.

Condition of Participation: Hospice Aide and Homemaker Services. L607

Upon patient record review, 6 of 14 (Patient #3,4,5,6,9,10) 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 3,6,10: Aide care plan has tasks with PRN included in frequency. Tasks include: clean patient environment and change linen. Patient 4: Aide care plan has task without frequency: ambulation. Patient 5: Aide care plan not entered in patient chart until 05/02/24. Aide visits were ordered and begun on 2/7/24. Additionally, Aide care plan has tasks with PRN included in frequency. Tasks include: clean patient environment and change linen. Both shower and bed bath listed in Aide care plan. Documentation indicates that Aide is choosing one of these for each visit. Patient 9: Aide care plan has tasks without frequency: wheelchair, diaper. In addition, Aide care plan has tasks with PRN included in frequency. Tasks include: clean patient environment and change linen.

Upon patient record review 6 of 14 (Patient #1,4,5,7,8,10) 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: No evidence of Aide visits made as per physician's order: 4/11/24-4/18/24; 4/26/24-5/2/24; 5/30/24-6/18/24. Patient 4: Patient admitted 6/21/24 with physician's order for HHA visits twice weekly. Medical record has no evidence of Aide visits made since admission. Patient 5: Patient admitted 2/7/24 with physician's order for HHA visits twice weekly. Visits made per MD order, however Aide care plan was not entered into medical record until 5/2/24 therefore, aide performed tasks w/out active care plan. Patient 7: Patient admitted 6/22/24. Physician's order written this date for Aide visits twice weekly. No evidence in medical record of Aide visits week of 6/22/24. Additionally, there is evidence of only one Aide visit the week of 6/25/24. Patient 8: Patient admitted 2/2/24. Aide visits ordered by the physician twice weekly. During current certification period, medical record documentation indicates patient seen only once weekly. Patient 10: Patient with physician's order for HHA visits twice weekly. There is no evidence in the medical record that the patient was seen by HHA while receiving hospice services.

Upon patient record review 1 of 14 (Patient #3) 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 3: No evidence in medical record that supervisory visit made since 6/14/24.

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. Monthly cost savings for past twelve months: July 2023: 4 percent August 2023 through October 2023: no data available November 2023: 1 percent December 2023: 1 percent

Upon observation, there was no evidence BOD/governing body minutes reflect the involvement in the hospice's management and administration of its resources to provide hospice services to patients and families. There was no evidence the BOD/governing body provides hospice services for all non-core services which includes: physical therapy, occupational therapy and speech-language pathology, or has the ability to provide all levels of care, specifically short-term inpatient and respite care. In addition, the BOD/governing body is unable to provide evidence of one medical director and an alternate to assume role and responsibility in his/her absence.

Upon observation, there was no evidence the hospice is primarily engaged in providing the following care and services: • Physical therapy, occupational therapy, speech-language pathology services • Short-term inpatient care The agency was unable to produce evidence of ability to provide these services.

Upon observation, there was no evidence the hospice designates a physician to serve as Medical Director which includes: • The Medical Director must be a doctor of medicine or osteopathy who is an employee or is under contract. • When the Medical Director is not available, a physician designated by the hospice assumes the same responsibilities and obligations as the Medical Director. The agency provided evidence of two physicians being designated as Medical Director

Upon contract review, 3 of 6 (Medical Directors and Assistant Medical Director contract) did not have evidence of a information in any of the contracts that specifically addressed who would fulfill the role of medical director or alternate medical director, if applicable.

Upon patient client record review, 8 of 14 (Patient #2,5,6,7,8,9,11,13) 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 2,5,6,7,8,9,11,13: Documents not signed by hospice staff

Upon client record review, 2 of 14 (Patient #11,12) 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

Upon client record review, 2 of 14 (Patient #11,12) did not have evidence of discharge summary that includes all required information.

Upon observation, there was no evidence the short term inpatient care facilities meet the following criteria of being a Medicare-certified hospital or a skilled nursing facility that also meets the standards specified in CFR 418.110(b) and 418.110(e) regarding 24-hour nursing services and patient areas. There is no evidence of active contract for short term hospice care.

Upon observation, there was no evidence of a contract to provide inpatient care for respite purposes in a Medicare or Medicaid certified nursing facility, if applicable.

Upon observation, there was no evidence the hospice assures that the inpatient facility that provides respite care has enough nursing personnel present on all shifts to guarantee that adequate safety measures are in place for hospice patients and that the routine, special, and emergency needs of all hospice patients are met at all times. There is no evidence of current contract for respite care

Condition of Participation: Personnel Qualifications.

Upon personnel record review, 1 of 13 (Personnel #13) 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. Personnel 13: The agency was unable to provide HR file for SLP.

Upon personnel record review, 1 of 13 (Personnel #12) did not have evidence all Occupational Therapy Services are provided by a qualified licensed Occupational Therapist (OT) in accordance with the state's Occupational Therapy Practice Act and the hospice's policies and procedures and/or job descriptions. Personnel 12: The agency was unable to provide HR file for OT.

Upon personnel record review, 1 of 13 (Personnel #11) did not have evidence all Physical Therapy Services are provided by a qualified licensed Physical Therapist (PT) in accordance with the state's Physical Therapy Practice Act and the hospice's policies and procedures and/or job descriptions. Personnel 11: The agency was unable to provide HR file for PT

Upon personnel record review, 3 of 13 (Personnel #11-13) 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. Personnel 11-13: The agency was unable to present HR files for PT/OT/SLP.