Every finding on record at All Family Hospice Inc.

Upon home visit interview/observation, there was no evidence that during the initial assessment visit in advance of furnishing care, the hospice provided the patient and/or family with verbal (meaning spoken) and written notice of the Patient's Rights and Responsibilities in a language and manner that the patient understands. Patient 1: Pt is alert and oriented times 3. He signed his own consents. He stated via nurse interpreter that he cannot speak or read English and he was alone during admission on 8/29/24. The The Patient Rights and Responsibilities were given to the pt in English not in Armenian the language the pt understands. Patient 3: The patient and caregiver were the only two present during admission on 9/10/24, per pt and caregiver via nurse interpreter. The pt signed his own consents and is alert and oriented x3. Pt and care giver stated "no" when asked if they can speak or read English. The Patient Rights and Responsibilities were given to the pt in English not in Armenian the language the pt and caregiver understands.

Upon patient record review, 14 of 14 (Patient #1,2,3,4,5,6,7,8,9,10,11,12,13,14) did not have evidence in the patient record that the comprehensive assessment takes into consideration the imminence of death. Patients 1,2,3,4,5,6,7,8,9,10,11,12,13,14: the medical records did not have evidence in the patient record that the comprehensive assessment takes into consideration the imminence of death. The section on imminence of death was blank and this was not addressed in the narrative.

Upon patient record review, 4 of 14 (Patient #1,3,10,13) 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: Patient 1: Upon home visit finding pt is taking Losartan 100-25mg the medication profile has 100-12.5, the fill date on the bottle is 9/30/24. Pt is taking Metoprolol succinate since 9/5/24 and medication profile has Metoprolol tartrate. Pt is taking Protonix since 9/30/24 medication profile has Omeprazole. Corrected on site Patient 3: The medication profile contains Clotrimazole 1 topical as directed. There is no dose or frequency or site and Triamcinolone Cream 1 topical as directed. There is no site, frequency or dose documented. Upon home visit finding the patient is taking Vitamin D3 5000 units daily since 5/24/24. This is not on the medication profile. Corrected on site. Patient 10: The medication profile contains Diclofenac 1 gel topical. There is no site noted to apply to or dosage. The medication profile also has Salonpas with no site to apply. Corrected on site. Patient 13: The SN documented on 12/17/24 pt is taking Melatonin for sleep. This was not added to the medication profile.

Upon patient record review, 1 of 14 (Patient #7) 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 7: Record did not contain evidence of an initial bereavement assessment being completed.

Upon patient record review, 1 of 14 (Patient #10) 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 10: The comprehensive assessment 3/22/24 contains documentation by the RN pt requires a cane and walker. There was no fall risk care plan initiated.

Upon patient record review, 7 of 14 (Patient #1,2,3,6,9,10,13) 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 SN documented on 10/18/24 "Caregiver reminded to apply barrier cream with each diaper change". This is not on the POC, SN removed from documentation stating it was an error, pt does not wear diapers or use barrier cream. The POC 8/29/24 contains orders for both "SC with in 5 days of admission and once each certification period" and "SC declined". There was no evidence in the documentation of who refused the SC. Upon home visit finding pt is taking Losartan 100-25mg the POC has 100-12.5, the fill date on the bottle is 9/30/24. Pt is taking Metoprolol succinate since 9/5/24 and POC has Metoprolol tartrate. Pt is taking Protonix since 9/30/24 POC has Omeprazole. Corrected on site. Patient 2: The POC 6/10/24 contains orders for both "SC with in 5 days of admission and once each certification period" and "SC declined". There was no evidence in the documentation of who refused the SC. Patient 3: The POC contains Clotrimazole 1 topical as directed. There is no dose or frequency or site and Triamcinolone Cream 1 topical as directed. There is no site, frequency or dose documented. The POC contains orders for both SC with in 5 days of admission and once each certification period and SC declined. There was no evidence in the documentation of who refused the SC. Upon home visit finding the patient is taking Vitamin D3 5000 units daily since 5/24/24. This is not on the POC. Medication orders all corrected on site. Patient 6: The POC 8/28/24 contains orders for both "SC with in 5 days of admission and once each certification period" and "SC declined". There was no evidence in the documentation of who refused the SC. Patient 9: The POC 9/16/24 contains orders for both "SC with in 5 days of admission and once each certification period" and "SC declined". There was no evidence in the documentation of who refused the SC. Patient 10: The POC contains an order for Diclofenac 1 gel topical. There is no site noted to apply to or dosage. POC also has Salonpas with no order for where to apply. Corrected on site. Patient 13: The SN documented on 12/17/24 pt is taking Melatonin for sleep. This was not added to the POC.

Upon client record review, 3 of 14 (Patient #3,5,8) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 3: The POC contains an order for SN 1 time per week and 2 prn for symptom management or change in condition. The RN made a visit on 10/8/24 and the LVN made a visit 10/10/24 both in the same Medicare week. Both visits were routine and the RN was not making a supervisory visit. The RN made a visit 9/24/24 routine and the LVN made a visit 9/26/24 that was routine as well in the same Medicare week. The RN was not making a supervisory visit and neither visit was PRN. There was no evidence of an order to increase visits for either of these weeks. The RN amended the note and entered the supervisory visit in the supervisory visit section. Patient 5: The SN documented on 10/14/24 "Administered the prescribed pain medication and advised the caregiver on nonpharmacological interventions. There is no evidence the nurse followed the POC. Patient 7: The SN made a visit on 10/3/24 from 6-7pm and the documentation is blank, there was another SN visit 10/7/24 from 12-1pm and the only thing documented was pain "0". Therefore, unable to confirm visits completed. In addition, per agency Documentation Policy all documentation is to be turned in within 24-48 hours of visit. Patient 8: The POC contains an order for SN 1 time per week and 2 prn for change in condition or symptom management. The LVN saw the pt on 10/10/24 as a routine visit and the RN saw the pt on 10/13/24 as a routine visit and it was not a supervisory visit. There is no evidence of an order to increase visits that Medicare week. The RN amended the note and entered the supervisory visit in the supervisory visit section. The SN made a visit on 10/13/24 @0700-0730 the documentation is not completed yet therefore unable to confirm visit made. In addition, per agency Documentation Policy all documentation is to be turned in within 24-48 hours of visit.

Upon patient record review, 1 of 14 (Patient #6) 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 6: The aide POC contains an order for pajamas/gown with no frequency.

Upon patient record review 1 of 14 (Patient #6) 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 6: The aide POC has an order for aspiration precautions every visit. The aide did not do this task on any visit from 8/30/24-10/18/24.