Every finding on record at Alfa Home Health and Hospice, LLC

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 There was not evidence of a documented community-based risk assessment, utilizing an all-hazards approach.

Upon patient record review, 2 of 11 (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: The medication profile on 11/12 23 indicated order for oxygen 2L NC PRN daily. RN recertification note on 12/26/23 stated patient was on 3L NC for PRN use. There was not evidence of an order to change the liter flow. Corrected onsite. Patient#2: The nurse documentation indicated patient is on 2L NC "at bedside for PRN use." Oxygen therapy was not included on the medication profile. Corrected onsite.

Upon patient record review, 1 of 11 (Patient #2) 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#2: The SW visit order included PRN visits without frequency for those visits.

Upon patient record review, 2 of 11 (Patient #1,#2) 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: The record indicated on 11/12/23 an order for oxygen 2L NC PRN daily. RN recertification note on 12/26/23 stated patient was on 3L NC for PRN use. There was not evidence of an order to change the liter flow. Corrected onsite. Patient#2: The nurse documentation indicated patient is on 2L NC "at bedside for PRN use." Oxygen therapy was not included on the medication profile. Corrected onsite.

Upon client record review, 1 of 11 (Patient #2) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient#1: The record indicated order on 12/25/23 of skilled nurse visit frequency at 1x/week. There was no evidence of a visit the week of 1/1/24.

Upon personnel record review, 1 of 8 (Personnel #4 ) 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#4: Record indicated MSW was working under a contract with hospice's partner, Alfa Home Health Agency and filing under W9 tax status. Corrected onsite.

Upon patient record review, 2 of 11 (Patient #8,#9) 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#8, #9: There was no evidence of a one month follow up call to the bereaved.

Upon patient record review 2 of 11 (Patient #1,#2) 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: The visit frequency on the aide plan of care was indicated at 2WK12 on 11/19/23. There was no evidence of a visit until a 12/7/23 when a new aide frequency for 1WK1, 2WK9 was ordered. Patient#2: The aide plan of care indicated to perform vital signs each visit. The record indicated that this task was not performed as evidenced by aide documenting "N/A" on visits 12/1/23-1/4/24.

Upon patient client record review, 1 of 11 (Patient #1) did not have evidence that each patient record contains Advance Directives. Patient#1: The record indicated patient was a DNR. There was not evidence of an out of hospital DNR in patient's record.