Every finding on record at All Lives Matter Hospice

Upon personnel record review, 4 of 14 (Personnel #3,#7,#9,#10) did not have evidence Emergency Preparedness training including: • Provide emergency preparedness training at least annually • Maintain documentation of all emergency preparedness training

Upon observation, there was no documentation of enacting the emergency plan during the recent fires located in the service area.

Upon patient record review 1 of 14 (Patient #5) 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 5: Psychosocial and bereavement initial assessments completed 6/27/24 with start of care 6/21/24

Upon patient record review, 5 of 14 (Patients #2,#3,#5,#6,#10) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications. Patient 2: The medication profile contained azithromycin ordered for 5 days on 1/20/24, listed as a current medication. Patient 3: The medication profile contained Miralax oral powder with no instructions to mix with a diluent. During the home visit, the patient had amoxicillin, zithromax, zantac, morphine tablets, ativan, and acidophilus that was not on the medication profile. The profile also contained lactobacillus that was not in the patient's home. Patient 5: During the home visit, the patient had sinemet, aricept, morphine, ativan, and tylenol suppositories that were not on the medication profile. Patient 6: The medication profile contained a lidocaine topical patch with no area defined for administration. Patient 10: The medication profile contained atropine for excessive secretions with the wrong route of administration as in eyes rather than oral or sublingual. During the home visit, the patient did not have comfort medication morphine and atropine that were listed on the medication profile.

Upon patient record review, 2 of 14 (Patients #2,#6) 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: The medical record identified the patient has been receiving spiritual care visits. There was no evidence of problems, goals, and interventions related to spiritual needs included in the plan of care. Patient 6: The medical record identified the patient has been receiving social work visits. There was no evidence of problems, goals, and interventions related to psychosocial needs included in the plan of care.

Upon patient record review, 3 of 14 (Patients #3,#6,#10) 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 3: The medical record contained an order for Miralax oral powder with no instructions to mix with a diluent. Patient 6: The medical record contained an order for lidocaine topical patch with no area defined for administration. Patient 10: The medical record contained an order for atropine for excessive secretions with the wrong route of administration as in eyes rather than oral or sublingual.

Upon patient record review, 1 of 14 (Patient #4) 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 equipment and supply needs. Patient 4: The medical record contained nursing documentation 1/10/25 identifying patient use of a nebulizer. There was no evidence of an order for the nebulizer included in the plan of care.

Upon patient record review, 2 of 14 (Patients #5,#14) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient 5: The medical record contained nursing documentation 12/13/24 identifying patient issues with dysphagia. There was no evidence the plan of care was updated to include problems, goals, and interventions related to dysphagia. Patient 14: The patient was discharged 9/19/24 due to extended prognosis. There was no evidence the plan of care was updated to include discharge plans.

Upon patient record review, 3 of 14 (Patients #1,#6,#7) 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 medical record contained an ordered nursing visit frequency of twice weekly. There were three scheduled visits completed the week of 1/5/25. Patient 6: The medical record contained an ordered nursing visit frequency of twice weekly. There were three scheduled visits completed the week of 1/12/25. Patient 7: The medical record contained an ordered nursing visit frequency of once weekly. There were two scheduled visits completed the week of 1/26/25. Corrected on site with clinician identifying visit 1/30/25 as a PRN visit.

Upon patient record review, 1 of 14 (Patient #12) 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. • 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 12: There was no evidence of a bereavement care plan or documentation of support given to the bereaved.

Upon patient record review 1 of 14 (Patient #7) 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 Patient 7: There was no evidence the aide completed the assigned task of obtaining vital signs on 1/24/25, 1/27/25, 1/29/25, and 1/31/25.

Upon observation, there was no evidence the hospice documented the cost savings achieved through the use of volunteers. Documentation must include the following: • The identification of each position that is occupied by a volunteer • The work time spent by volunteers occupying those positions • Estimates of the dollar costs that the hospice would have incurred if paid employees occupied the positions identified in paragraph (d)(1) of CFR 418.78 for the amount of time specified in paragraph (d)(2) of CFR 418.78 The agency did not provide documentation of volunteer cost savings.

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. There was no record of volunteer utilization rate.

Upon patient record review, 6 of 14 (Patients #2,#3,#4,#5,#6,#10) 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. Patient 2: The medical record contained orders for social work visits monthly and spiritual care visits once a certification period. The POC summary misidentified the social work frequency as once each certification period and spiritual care once monthly. Patient 3: The CTI for benefit period nine starting 12/3/24 misidentified date of the face to face as completed 12/30/24. Patient 4: The medical record contained an order for spiritual care visits being declined. The POC summary misidentified spiritual care as once each certification period. Patient 5: The medical record contained orders for nursing frequency once weekly and social work visits once monthly. The POC summary misidentified the nursing frequency as twice weekly and social work visits once each certification period. The CTI for benefit period three starting 12/18/24 misidentified date of the face to face as completed 1/24/25. Patient 6: The CTIs for benefit period four starting 9/4/24 and benefit period five starting 11/3/24 misidentified dates of face to face as completed 2/29/24 and 7/23/24. Patient 10: The medical record contained an order for aide visits three times weekly. The POC summary misidentified the frequency as twice weekly. The record also contained an initial bereavement assessment identified visit done 12/14/24 but the electronic signature stated signed 12/7/24.

Upon observation, there was no evidence that when the hospice provides durable medical equipment under contract, then the DMEPOS provider is accredited by a CMS approved accreditation organization.