Every finding on record at Ahc Home Health of Sacramento, LLC

Upon patient record review, 1 of 14 (Patient #5) 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 #5 - Medication profile contained but no longer using Latanoprost ophthalmic, Diclofenac topical or Albuterol with Nebulizer. During home visit interview, wife who manages medication states patient has not used in several months.

Upon patient record review, 3 of 14 (Patient #5, 7, 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 #5 - POC dated 09/12/24 contained "change Foley Catheter as ordered" - did not contain size or frequency. Patient #7 - POC dated 10/15/24 contained "perform wound care to R middle toe clean with NS apply A&D ointment daily and PRN" no modifier for PRN. Patient #11 - POC dated 09/04/24 contained "flush Foley catheter as needed" did not have solution, amount, frequency or modifier for as needed. Also contained "change Foley Catheter every 30 days and as needed - did not contain Foley or balloon size and no modifier for as needed.

Upon client record review, 2 of 14 (Patient #11, 12) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #11 - Visit note 09/05/24 Foley catheter changed then again on 10/10/24. Order on POC states to change every 30 days and PRN - greater than 30 days between catheter changes. Visit note 11/09/24 - SN removed and discontinued Foley Catheter but no order documented. Patient #12 - POC dated 10/06/24 did not contain wound care but daily visits made to perform wound care to abdominal wound - order not written until 10/21/24 (effective date).

Upon patient record review, 1 of 14 (Patient #1) 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 Patient #1 - did not have evidence of a bereavement plan of care that included the kind of bereavement services to be offered or the frequency of service delivery.

Upon patient record review 2 of 14 (Patient #7, 13) 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 #7 - Aide care plan "change linen" 1 x week but aide changed twice on week 2 and week 4. Also during home visit aide shampooed patients hair but task not on aide care plan. Patient #13 - Aide care plan "change linen" 1 x week but aide changed twice on week 2 and week 5.

Upon personnel record review, 1 of 14 (Personnel #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 #11 - SLP skills competency assessment performed by PT.

Upon patient record review, 1 of 2 applicable patients (Patient #1) did not have evidence in the patient record that hospice aide assignments and duties include the tasks to be completed and the frequency of those tasks. Patient #3 - Aide care plan contained give bed bath/shower every visit without documentation that patient is cognitively or functional able to make decision.

Upon patient record review 1 of 2 applicable patients (Patient #3) did not have evidence documentation in the patient record that a hospice aide provides services that are ordered by the interdisciplinary group and included in the plan of care. Patient #3 - Aide gave shower on 11/09/2021, 11/11/2021 and 11/18/2021 but aide care plan was for bed bath.

Upon personnel record review, 1 of 13 applicable (Personnel #15) 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. Personnel #15: Agency was not able to provide a file for the contracted ST at the time of survey. Agency has not yet used the ST.

Upon personnel record review, 1 of 1 applicable (Personnel #15) 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 #15: Agency was not able to provide a file for the contracted ST at the time of survey. Agency has not yet used the ST.

Upon personnel record review, 1 of 5 applicable (Personnel #15) 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 #15: Agency was not able to provide a file for the contracted ST at the time of survey. Agency has not yet used the ST.