Every finding on record at Advance Hospice and Palliative Care, Inc.

Upon patient record review, 5 of 5 (Patient #1, #2, #3, #4, #5) did not have evidence of the appropriate documentation for release of confidential information. Patient 1, 2, 3, 4, 5: There was no evidence of documentation for release of confidential information.

Upon client record review, 1 of 5 (Patient #3) 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 3: SOC IDG dated 8/17/2022, next IDG occurred 9/2/2022 16 days later.

Upon personnel record review, 1 of 8 applicable (Personnel #5) did not have evidence the hospice employees and contract employees have received orientation on the hospice philosophy. Personnel 5: There was no evidence of an orientation for this employee.

Upon observation, there was no evidence the organization follows their policies and procedures to maintain the the patient's clinical record in confidential manner. Office was left open with all patient charts in view, no staff members in attendance. Found a male in doorway, when asked if he was part of the office he stated no, I asked if anyone was in office he answered no, I asked what he was doing there, stated nothing and walked down hall away from office.

Upon client record review, 1 of 1 applicable (Patient #5) did not have evidence that the hospice forwarded a summary and a copy of the patient record, if requested, to a facility when transferring the patient to that facility. Patient 5: There was no evidence of a transfer summary, or evidence of same being forwarded to the facility where the patient was transferred.

Upon observation, there was missing evidence that the agency had established an emergency preparedness program. The agency was unable to locate any documentation in regards to the Emergency Preparedness Program.

Upon observation, there was missing evidence that the agency had established a Communication Plan as part of the Emergency Preparedness Plan. The agency was unable to locate any documentation in regards to the Emergency Preparedness Program.

Upon patient record review, 1 of 5 (Patient #1) 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. Patient #1: During the Surveyor conducted home visit, the medications in the home were reviewed. It was noted, the following medications were in the home, but not included in the review during the Initial Comprehensive Assessment. (a) The medication Tylenol with Codeine #3, prescribed on 12/27/2021 was not included on the medication review. (b) Gabapentin prescribed on 12/27/2021, was not included on the medication review. (c) Os Cal 500mg, over the counter vitamin was not included on the medication review.

Condition of Participation: Infection Control.

Upon observation, there was missing evidence the board of directors/governing body approves the frequency and detail of the data collection. During the Survey, the Alternate Administrator verbalized she was unable to locate any information in regards to the Governing Body or Governing Body Meetings, including, approval and frequency of the QAPI detail and data collection.

Upon observation, there was missing evidence of involvement of the governing body in the development of the Quality Assessment/Performance Improvement (QAPI) program.

Upon personnel record review, 1 of 1 applicable (Personnel #5) did not have evidence in the personnel file that a competency assessment was conducted on the aide.

Condition of Participation: Organization and Administration of Services.

Upon observation, there was missing evidence of BOD/governing body minutes to reflect the involvement in the hospice's management and administration of its resources to provide hospice services to patients and families. Agency unable to locate any information in regards to the Governing Body or Governing Body Meetings.

Upon observation, there was missing 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. Agency unable to locate any information in regards to the Governing Body or Governing Body Meetings. Additionally, the governing body did not demonstrate responsibility for the operation of the hospice as evidenced by the following: there was a compliant COVID vaccination program in place; that the agency had an Emergency Preparedness Program; Involvement and improvement of the agency QAPI program; ensuring confidentiality of patient records; that all staff have a completed competency assessment.

Upon personnel record review, 4 of 8 applicable (Personnel #2, #3, #4 and #5) did not have evidence the hospice employees and contract employees had received orientation on the hospice philosophy. Employees had a form in the record called "Personnel Orientation Checklist" however, the form was blank in all three records.

Upon personnel record review, 4 of 6 applicable (Personnel #1, #2, #3, and #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. Personnel #1, #2, #3, and #11: On the document "Initial Competency Assessment", the Evaluation Method" and "Competency Validation Indicated by Preceptors Initials and Date" were left blank on the entire document. There was also no "Supervisor Signature" on the last page.

Upon observation, there was missing evidence the organization follows their policies and procedures to maintain the the patient's clinical record in confidential manner. On April 21, 2022, the Surveyor entered the Agency at 0930 to begin the Initial Survey. Upon entry, into the Agency, there were no hospice personnel present in the Agency, however, the building maintenance man was in the hospice office where the Clinical Records were laying on top of the filing cabinet unsecured. The Alternate Administrator arrived on site at 1015 and was informed of the violation in regards to the Clinical Records being left unprotected. The Alternate Administrator verbalized understanding. On April 22, 2022, the Surveyor entered for day 2, where the Alternate Administrator verbalized there had been a roof leak the night before and all documentation that had been left on the table had gotten wet and would be unable to be reviewed at this time. Once again, the Clinical records were unsecure and had been left on the table where the Contractors were in the office cleaning up and repairing the ceiling damage. There were no hospice employees in the office with them during that time.

Upon client record review, 1 of 1 applicable (Patient #5) did not have evidence that the hospice forwarded a summary and a copy of the patient record, if requested, to a facility when transferring the patient to that facility. Patient #5: On 1/10/2022, the patient was transferred to another Hospice Agency. There was no documentation in the Clinical Record to indicate the receiving Hospice had received the transfer summary.

Upon personnel record review, 1 of 1 applicable (Personnel #7) 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 #7: There was no documentation to review to ensure the Occupational Therapist would be provided by a qualified therapist as the agency was unable to produce a personnel record for the contracted OT.

Upon personnel record review, 1 of 3 applicable (Personnel #7) did not have evidence that the hospice obtained a criminal background check on all contracted individuals who have direct patient care and access to patient records. Personnel #7: The Agency was unable to provide an employee record for an OT.

Based on observation and interview with the Alternate Administrator, there was missing documentation to indicate the hospice had a process for ensuring that documentation which confirms recognized clinical contraindications for Covid-19 vaccination exemptions, had been signed and dated by a licensed practitioner.