Every finding on record at Allheal Home Health Inc.

Upon patient record review 1 of 8 (Patient #7) did not have evidence that the hospice Registered Nurse must complete an initial assessment within 48 hours after the election of hospice care in accordance with §418.24 Patient #7: No documented RN initial assessment completed within 48 hours of hospice election.

Upon patient record review 2 of 8 (Patient #1, 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 #1: Patient admitted 12/7/24. Psychosocial assessment completed 12/16/24. Patient #5: Patient admitted 6/18/24. Psychosocial assessment completed 8/29/24

Upon patient record review, 1 of 8 (Patient #7) 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 #7: Medication profile completed but does not include indication of medications and/or side effects.

Upon patient record review, 2 of 8 (Patient #1, 3) 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 #1: Patient admitted 12/7/24. Initial bereavement assessment not completed until 12/18/24. Patient #3: Patient admitted 3/5/25. Initial bereavement assessment 3/11/25.

Upon patient record review, 1 of 8 (Patient #5) 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 #5: Admitted on 6/18-12/12/24. There is no evidence of an Initial Plan of Care.

Upon patient record review, 2 of 8 (Patient #5, 6) 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 #5: Patient admitted on 6/18/24-12/12/24. First documented IDG meeting was on 9/23/24. There were no signatures of all disciplines to verify who was present. The disciplines were actively involved with the patient therefore there was no evidence the IDG reviewed/ revised the plan of care. First complete documented IDG was 11/6/24. Patient #6: Patient admitted on 7/18/24. Patient discharged/death 9/21/24. No documented IDG meetings/reviews at all. The disciplines were actively involved with the patient therefore there was no evidence the IDG reviewed/ revised the plan of care.

Upon patient record review, 1 of 8 (Patient #8) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #8: No order for visits made. SN visits made Aug 2, 5, 6, 11, 2024 and SC visit 8/5/24

Upon patient record review 2 of 8 (Patient #4, 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 #4: 12/6/24 order for Hospice Aide 3/week. No visit documentation for aide visits until Jan 14. Patient #6: No physician ordered frequency for Hospice Aide service. Visits provided Aug 30, Sept, 2, 4, 6, 9, 11, 13, 16, 18, 2024.

Upon patient record review, 1 of 14 (Patient #7) did not have evidence that the medical director or physician designee provides written certification that it is anticipated that the patient's life expectancy is 6 months or less if the illness runs its normal course. The physician must consider the following when making this determination: • The primary terminal condition • Related diagnosis • Current subjective and objective medical findings • Current medication and treatment orders • Information about the medical management of any of the patient's conditions unrelated to the terminal illness Patient #7: There is no documented certification of terminal illness and no documented verbal certification received.

Upon patient record review, 3 of 8 (Patient #1,5,6) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient #1: Informed Consent and Election of Benefits have effective date of 12/6/24. Documents signed 12/7/24. Initial Comprehensive assessment completed 12/8/24. SOC in other documents is identified as 12/7/24. Patient #5: Informed Consent and Election of Benefits have effective date of 6/14/24. Papers signed 6/18/24 Patient #6: Both elect to receive and decline to receive are checked. Addendum provided has non covered diagnoses, including IDDM, but non-covered meds are blank.

Upon patient record review, 1 of 8 (Patient #7) did not have evidence that each patient record contains Physician certification and recertification of terminal illness. Patient #7: There is no documented certification of terminal illness and no documented verbal certification received.

Upon patient client record review, 1 of 8 (Patient #7) did not have evidence that each patient record contains physician orders Patient #7: Record contains no physician orders.

Upon patient record review, 2 of 8 (Patient #4, 7) 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 #4: 12/30/24 physician order for PT, OT, SLP referrals for evaluation. The PT was actually intended for a different patient (named in record). The OT referral was declined by patient. The SLP not provided until 1/28/25. Patient #7: Patient admitted 6/25/24. RN made visit 6/28/24 and made notation of time and occurrences during time in home. Example "0904: RN arrived at patient home and assessed patient no resp no pulse."; "0911: Dr. Zock called and informed of death and gave order to pronounce; "1000: Allheal Chaplain arrived." There is no actual date on the note and/or signature. RN notation made on back of clinical HP from prior facility discharge.

Upon patient record review, 1 of 8 (Patient #6) did not have evidence that the hospice assumes responsibility for professional management of the resident's hospice services in accordance with the hospice plan of care. The hospice is responsible for providing all hospice services including: • Ongoing assessment, care planning, monitoring, coordination and provision of care by the Hospice IDG • Assessment, coordination and provision of any needed general inpatient or continuous care • Consultation about the patient's care with facility staff • Coordination by the hospice RN for the implementation of the plan of care for the patient • Provision of hospice aide services, if these services are determined necessary by the IDG to supplement the nurse aide services provided by the facility • Provision, in a timely manner, of all supplies, medications, and DME needed for the palliation and management of the terminal illness and related conditions • Financial management responsibility for all medical supplies, appliances, medications and biologicals related to the terminal illness and related conditions • Determination of the appropriate level of care to be given to the patient (routine homecare, inpatient, or continuous care) • Arranging any necessary transfers from the facility, in consultation with the facility personnel Patient #6: SNF resident admitted 7/18/24-9/21/24. There is no documented Plan of Care. The patient was admitted with Foley Catheter and Pleural drain. There is a written physician order related to hospice and facility nurses coordinating drainage, but no related problems, goals, interventions. There are no orders related to Foley catheter management. There is no form of interdisciplinary plan of care, problems, goals, interventions at all. There are no documented interdisciplinary group meetings/reviews of plan of care.

Upon patient record review, 1 of 8 (Patient #6) did not have evidence that a written hospice plan of care is established and maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided is in accordance with this hospice plan of care. Patient #6: There is no documented Plan of Care in the patient's hospice medical record.

Upon patient record review, 1 of 8 (Patient #6) did not have evidence that the hospice provided the following information: • The most recent hospice plan of care specific to each patient • Hospice election form and any Advance Directives specific to each patient • Physician certification and recertification of the terminal illness specific to each patient • Names and contact information for hospice personnel involved in hospice care of each patient • Instructions on how to access the hospice's 24-hour on-call system • Hospice medication information specific to each patient • Hospice physician and attending physician (if any) orders specific to each patient Patient #6: SNF records not available for review as patient was discharged at time of survey. There was no evidence a plan of care was provided to the facility.

Condition of Participation: Initial and Comprehensive Assessment of the Patient.

Upon patient record review 2 of 7 (Patient #1,#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#1: The record indicates patient was admitted on 12/10/24. The spiritual assessment was completed on 12/16/24. Patient#5: The record indicates patient was admitted on 7/18/24. The spiritual assessment was completed on 7/26/24.

Upon patient record review 3 of 7 (Patient #5,#6,#7) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient#5,#6,#7: There is no evidence of an initial psychosocial assessment being completed within 5 days.

Upon patient record review, 3 of 7 (Patient #1,#2,#3) 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:During home visit there was evidence that the following medications were on the medication profile but were not found in the home: acetaminophen 650 suppository, furosemide 20mg, and hyoscyamine 0.125mg. Also, Trilogy 200mcg/62.5mcg, 25 1 puff a day was found in the patient home. However, there was no evidence of this medication listed on the medication profile. Patient#2: During the home visit there was evidence that the following medications are on the medication profile but were not found in the home: donepezil 5mg, fluoxetine 20mg, and olanzapine 5mg. The following medications were found in the home but are not listed on medication profile: clonidine 0.3mg patch and acetaminophen 650mg suppository PRN. The caregiver states patient is receiving these medications. In addition, the medical record contained an order for olanzapine 5mg with no indication on the medication profile for what medication is being taken for. Patient#3: During home visit there was evidence of the following medications are on the medication profile but were not found in the home: hyoscyamine 0.125mg and morphine sulfate 20mg/ml. During survey the following medications were in the home but are not on the agency medication profile: iron repair 22mg, Januvia 50mg, CoQ10 100mg, Potassium CL ER 10meq, and Rosuvastatin 40mg. The caregiver confirmed patient is taking these medications.

Upon patient record review, 1 of 7 (Patient #6) 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#6: There is no evidence of an initial bereavement being completed.

Condition of Participation: Interdisciplinary Group, Care Planning, and Coordination of Services. L536

Upon patient record review, 4 of 7 (Patient #2,#4,#5,#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 record indicates that the patient has terminal diagnosis of cerebral vascular disease and nutritional needs including a mechanical soft diet, honey-nectar thick liquids, and aspiration precautions. There is no evidence of problems, goals or interventions related to these needs. Corrected on site. Patient#4: There is no evidence of a plan of care with any problems, goals or interventions prior to patient passing in the patient chart. Patient#5: The record indicates the patient has a foley catheter, a plurex drain, and requires a soft diet. There are no goals or interventions related to these needs. In addition, the patient was admitted with a terminal diagnosis of Waldenstroms Macroglobulinemia. There is no evidence of problems, goals or interventions related to this diagnosis. Patient#6: There is no evidence of a plan of care in patient chart.

Upon patient record review, 5 of 7 (Patient #1,#2,#3,#4,#6) 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: Trilogy 200mcg/62.5mcg, 25 1 puff a day was found in the patient home. However, there was no evidence of this medication listed on the plan of care orders. Patient#2: The medical record contained an order for olanzapine 5mg with no indication for what medication is being taken for. COS. In addition, the following medications were found in the home with no orders: clonidine 0.3mg patch and acetaminophen 650mg suppository PRN. The caregiver states patient is receiving these medications. Patient#3: The medical record contained an order for lidocaine-Prilocaine 2.5% 1 topical medication and zinc oxide with no area defined for administration on the orders. COS. In addition, during survey the following medications were in the home with no orders: iron repair 22mg, Januvia 50mg, CoQ10 100mg, Potassium CL ER 10meq, and Rosuvastatin 40mg. The caregiver confirmed patient is taking these medications. Patient#4: The medical record contained nursing documentation upon admission identifying patient use of oxygen. There was no evidence of an order for oxygen dose, frequency, and delivery method. COS. Patient#6: There is no evidence of any physician orders present in chart. There is evidence in chart that indicates patient was receiving morphine sulfate.

Upon patient record review, 2 of 7 (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 equipment and supply needs. Patient#1: During the home visit, it was observed that the patient has a rollator, oxygen, nebulizer, bedside commode, and shower chair. There is no evidence of equipment listed on the POC. Patient#2: During the home visit, it was observed that the patient has a hospital bed, half rails, wheelchair, shower chair. There is no evidence of equipment listed on POC.

Upon patient record review, 6 of 7 (Patient #1,#2,#3#,4,#5,#6) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient#1:There is no evidence of a order indicating frequency of visits/services for nursing, medical social worker, and chaplain. Patient#2: The record indicates on 12/6/24 physician order states "hospice services to be provided by hospice aide, nurse, medical social worker, bereavement, volunteer coordinator, and chaplain for patient care". There is no evidence of specific frequencies ordered for the different disciplines. Patient#3: During home visit it was noted that multiple paper nurse visits documented by RN found in home for visits 11/10/24, 11/13, 1/5/25, 1/7, 1/20, 1/23, 1/27. There is no evidence these visits had been uploaded to the patient chart. In addition, there is no evidence of a order indicating frequency of visits/services for nursing, aide, medical social worker, and chaplain. Patient#4: There is no evidence of a order indicating frequency of visits/services for nursing and chaplain. Patient#5: There is no evidence of a order indicating frequency of visits/services prior to 8/30/24. On 8/30/24 there is an order indicating frequency for nursing only. In addition, the record indicates there is nursing documentation that indicates patient having respiratory issues and was ordered an x-ray on 8/20/24. There is no evidence if x-ray was completed or of any follow up in chart. Corrected on site. Patient#6: There is no evidence of a order indicating frequency of visits/services prior to 7/12/24. On 7/12/24 there is a frequency order for nursing services. On 9/2/24 there is a frequency order for aide services.

Upon observation, there was no evidence the hospice ensures that non-core services are provided to hospice patients and their families according to applicable laws and regulations. Non-core services include Physical Therapy, Occupational Therapy and Speech-Language Pathology. Patient #1: The record indicates patient was referred to PT on 12/30/24. There is evidence in patient record of email communication with therapy company stating therapy was not available to patients in that area. Therapy has not yet been provided to patients as of the start of survey. Administrator contacted a PT from Allhealth who made a visit to patient during survey with notes uploaded to chart. COS Patient#2: The record indicates OT and ST was requested by family for this patient on 12/6/24. There is evidence in patient record of email communication with therapy company stating therapy was not available to patients in that area. Therapy has not yet been provided to patients as of the start of survey. Agency spoke with family who has refused OT. Administrator contacted a ST from Allhealth who made a visit to patient during survey with notes uploaded to chart. COS.

Condition of Participation: Hospice Aide and Homemaker Services. L607

Upon patient record review 4 of 7 (Patient #2,#3,#5,#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 • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient#2: The record indicates aide documented "bed bath" as only task performed on 12/10/24, 12/12, 12/17, 12/19, 12/24, 12/26, 12/28, 12/30, 1/2/25, 1/4, 1/9, 1/7, 1/11. There is no evidence aide addressed assigned task of changing linens when soiled, continence care, fall precautions, or skin precautions. No visits documented after1/11/25. Late documentation submitted during survey, was submitted for visits 1/7/25, 1/11, 1/14, 1/16, 1/18, 1/25, 1/28. In addition, there was no evidence of a physician order indicating aide services/frequency. Patient#3: The record indicate the aide plan of care was completed on 12/9/24 assigned aide to assist with shower, assist with dress, change linens if soiled, light housekeeping, oral care, skin care, and provide companionship. On visit 1/9/25 aide only documented doing light housekeeping. There are no other aide visits documented. In addition, there was no evidence of a physician order indicating aide services/frequency. The RN documentation indicates Aide frequency is 3 times a week. Patient#5: The record indicates aide documented on aide visit 8/30/24 that she "assisted with ADL such as dressing, brush, total bed bath, HOB elevated, skin care, moisturizer, regular medium BM 8/30, etc". The plan of care also list assist with clothing, foley care, shampoo, and foot care. The aide did not document these tasks were completed. In addition, there was no evidence of a physician order indicating aide services/frequency. Patient#7: The record indicates documented visits for 10/22/24, 10/24, 10/26 that aide gave a bed bath and dressed the patient. The aide only documents giving a bed bath on the following visits: 10/29/24, 10/31, 11/2, 11/5, 11/9, 11/12, 11/21, 11/25, 12/2, 12/12. The aide plan of care also list the following task to be addressed at each visit: document last BM, encourage fluids, foot care, oral care, perineal care, shampoo, and skin care. The aide did not document these tasks were completed. In addition, there was no evidence of a physician order indicating aide services/frequency.

Upon patient record review 3 of 7 (Patient #2,#5,#7) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs. Patient#2: The record indicates aide services started 12/10/24. There is evidence a supervisory aide visit was completed 17 days later on 12/27/24. There is no evidence of a supervisory aide visit being completed from 12/27 to present. Patient#5: There is no evidence of supervisory aide visits completed between 8/9/24 - 9/6/24. Patient#7: There is no evidence of supervisory aide visit being completed between 10/24/24 to present.

Upon patient record review, 2 of 7 (Patient #1,2) 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#1: The Physician order for PT was found in the chart patient #2. COS. In addition, paper nurse visits were turned in after survey started for the dates of 1/9/25, 1/14, and 1/23. There is no evidence of the clinicians printed legible name and credentials. The signature is not legible. Patient#2: Paper nurse visits were turned in after survey started for the dates of 1/6/25, 1/9, 1/13,1/16, 1/19, 1/23. There is no evidence of the clinicians printed legible name and credentials. The signature is not legible.