Every finding on record at Allied Hospice and Palliative Care, Inc

Upon patient record review, 1 of 14(Patient #10) did not have evidence that the patient has received effective pain management and symptom control from the hospice for conditions related to the terminal illness. Patient #10: During the initial assessment, the RN did not document the patient's self identified pain threshold, but described the patients pain at a level 7. There was no evidence of any interventions to this pain assessment.

Upon patient record review, 3 of 14 (Patient #1, 2, 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 #1: Miralax does not contain reconstitution instructions. Amoxicillin 875/125mg one daily for 5 days was started on 07/12/24 but was never discontinued. Azithromycin was started at 250mg daily for 3 days on 07/12/24 and was never discontinued. Patient #2: The patient medication list includes Norco 10/325mg . The medication is listed as PRN, however, there is no listed frequency. Patient #7: The patient is on oxygen. Oxygen is not included on the medication list.

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

Upon patient record review, 3 of 14 (Patients #7, 8, 10) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient #7: On 08/22/24, patient caregiver called stating patient was having symptoms of a UTI. Doctor ordered Cipro. There was no nursing assessment completed. No follow up call or nurse visit for 7 days on 08/29/24. On 10/10/24, the nurse documented that the caregiver reported new excoriation on sacrum. No assessment performed, however, nurse ordered for aide to apply zinc at brief changes. On 10/17/24, Nurse saw patient again. Caregiver describes a stage one pressure area on sacrum. No physical assessment done by nurse. On 10/22/24 the nurse visited again, where caregiver reported area was resolved. There was not any evidence of this area ever being assessed by nurse. Patient #8: On 12/16/24, the patient caregiver complained of insomnia during a nurse visit. The doctor prescribed Ambien, a controlled substance. No follow up phone call or visit from a nurse occurred until 12/23/24 (7 days). Patient #10: This patient was admitted on 01/03/25. The nurse documented that the patient complained of depression, fear, hopelessness, and suicidal ideation. There was no follow up on suicidal ideation until nurse visit on 01/06/25. It was also on 01/06/25 that a social worker did an initial assessment, though there was no evidence of a self harm assessment being performed or of follow up being completed on any of the psychosocial complaints documented from initial nurse visit.

Upon patient record review, 10 of 14 (Patient #1, 2, 3, 4, 5, 6, 7, 8, 9, 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 #1: The neurological plan of care does not include goals or interventions for seizures. There is no interventions or goals for GI, including constipation. There are no interventions or goals for MSW or for spiritual care. Patient #2: The plan of care for this patient does not show evidence of interventions or goals for pain. There are no interventions or goals for Cardiac, which is the patients primary diagnosis. There are also no interventions or goals for Ascites and liver disease with frequent need for paracentesis, or fall precautions. The Respiratory plan of care addresses oxygen use, however, patient is a smoker and there are no interventions or goals related to smoking with oxygen use. The respiratory plan of care does not include interventions or goals for nebulizer or suction machine use. There are no interventions or goals for MSW or for spiritual care. Patient #3: The plan of care does not include interventions or goals for anticoagulation use or bleeding precautions. There are no interventions or goals for MSW or for spiritual care. Patient #4: The plan of care does not include interventions or goals for pain, liver disease, cardiac, oxygen use, and there are no interventions or goals for MSW or for spiritual care. Patient #5: The plan of care does not include interventions or goals for oxygen use, seizures, pain with opiate use, GU with urinary retention, sleep/insomnia, nausea and vomiting, anticoagulant use and bleeding precautions, and there are no interventions or goals for MSW or for spiritual care. Patient #6: The plan of care does not include interventions or goals for constipation, depression/anxiety, diabetes, pain with opiate use, nutrition with megace, sleep/insomnia, anticoagulant use and bleeding precautions, and there are no interventions or goals for MSW or for spiritual care. Patient #7: The plan of care does not include interventions or goals for anticoagulant use or bleeding precautions, diabetes, constipation, infection, neurological disease with primary diagnosis of cerebral infarct, and there are no interventions or goals for MSW or for spiritual care Patient #8: The plan of care does not include interventions or goals for neurological as primary diagnosis is cerebral infarct. There are no interventions or goals for anticoagulant use and bleeding precautions, pain, constipation, or sleep/insomnia. There are no interventions or goals for MSW or for spiritual care. Patient #9: The plan of care does not include interventions or goals for primary diagnosis of senile degeneration of the brain. There are no interventions or goals for cardiac with edema, pain with daily opiates, frequent UTI's, and there are no interventions or goals for MSW or for spiritual care Patient #10: The plan of care does not include interventions or goals for patient primary diagnosis of Huntington's disease. there are no interventions or goals for pain, fall risk, respiratory, or sleep and insomnia. There are no interventions or goals for MSW or spiritual care including interventions or goals related to suicidal ideation.

Upon patient record review, 3 of 14 (Patient #1,2,7) 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: Miralax does not contain reconstitution instructions. Patient #2: The order for Norco 10/325mg . The medication is listed as PRN, however, there is no listed frequency. Patient #7: The patient is on oxygen with no evidence of order for oxygen.

Upon patient record review, 10 of 14 (Patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 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 equipment and supply needs. Patient #1: The plan of care does not include supplies. Patient is using briefs, gloves, and lotion. Patient #2: There are no supplies or DME identified on the plan of care. Patient #3: There are no supplies or DME identified on the plan of care. Patient #4: There are no supplies or DME identified on the plan of care. Patient #5: The only DME listed on the plan of care is the oxygen concentrator. The cane and nebulizer are not on the plan of care. Patient #6: The only DME listed on the plan of care is the oxygen concentrator. The cane and nebulizer are not on the plan of care. Patient #7: The only DME listed on the plan of care is the oxygen. The plan of care does not include the bed or the walker. There are no supplies identified on the plan of care. Patient #8: There are no supplies or DME identified on the plan of care. Patient #9: There are no supplies or DME identified on the plan of care. Patient #10: There are no supplies or DME identified on the plan of care.

Upon personnel record review, 1 of 13 (Personnel #10) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) ·Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff. ·Reading and recording temperature, pulse, and respiration ·Safe transfer techniques and ambulation. ·Normal range of motion and positioning ·Appropriate and safe techniques in personal hygiene and grooming that include-- ·(A) Bed bath ·(B) Sponge, tub, and shower bath ·(C) Shampoo, sink, tub, and bed ·(D) Nail and skin care ·(E) Oral hygiene ·(F) Toileting and elimination The other subject areas in this section may be evaluated through written examination, oral examination or after observation of a Hospice Aide with a patient. Personnel #10: The personnel file showed that all competencies were verbal and there was no evidence that appropriate and safe techniques for (A) Bed bath, (B) Sponge, tub, and shower bath, (C) Shampoo, sink, tub, and bed, (D) Nail and skin care, (E) Oral hygiene, or (F) Toileting and elimination was performed on an actual or pseudo patient.

Upon personnel record review, 2 of 13 (Personnel #3, 4) did not have evidence that the hospice employees have received orientation on their specific job requirements. Personnel #3: The DON personnel file did not contain a job specific orientation/competency for a registered nurse. The DON has been doing RN visits on patients. Personnel #4: The alternate DON personnel file does not contain a job specific orientation or competency for DON/ALT DON

Upon personnel record review, 3 of 13 (Personnel #2, 3, 4) 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 #2: The file did not contain evidence of a skills competency assessment for volunteer coordinator or bereavement coordinator. Personnel #3: The file did not contain evidence of a skills competency assessment for a registered nurse. Personnel #4: The file did not contain evidence of a skills competency assessment for ALT DON.

Upon patient client record review, 14 of 14 (Patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14) 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. Patients 1-14: Patients signed blank ABN and Revocation, as well as transfer forms upon admission to hospice.

Upon client record review, 1 of 14 (Patient #12) did not have evidence that if a patient revokes the election of hospice care or is discharged from hospice in accordance with §418.26, the hospice must forward to the patient's attending physician: • A copy of the hospice discharge summary • The patient's clinical record, if requested Patient #12: The record does not contain evidence that the discharge summary was sent to a physician.

Upon client record review, 1 of 14 (Patient #12) did not have evidence that the discharge summary includes all required information. Patient #12: The discharge summary did not include proof of the patient plan of care.

Upon patient record review, 3 of 14 (Patients #2, 7, 8) did not have evidence in the patient record that the interdisciplinary group, as part of the review of the plan of care, determines the ability of the patient and/or family to safely self-administer drugs and biologicals to the patient in his or her home. If the patient and/or family are not capable of safely administering drugs and biologicals in the home, the hospice must address this issue in the patient's plan of care. Patient#2: Upon initial assessment, RN did not assess the patient's or the caregiver's ability of safe administration of medication. Patient#7: Upon initial assessment, RN did not assess the patient's or the caregiver's ability of safe administration of medication. patient #8: Upon initial assessment, although RN assessed that patient was not able to safely administer medications, they did not assess the caregiver's ability to safely administer medications.

Upon personnel record review, 1 of 13 (Personnel #8 ) 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 #8: There was no evidence of the current license for the contract ST.

Upon personnel record review, 1 of 13 (Personnel #7 ) did not have evidence all Occupational Therapy Services are provided by a qualified licensed Occupational Therapist (OT) in accordance with the state's Occupational Therapy Practice Act and the hospice's policies and procedures and/or job descriptions. Personnel #7: There was no evidence of the current license for the contract OT.

Upon personnel record review, 1 of 13 (Personnel # 6) did not have evidence all Physical Therapy Services are provided by a qualified licensed Physical Therapist (PT) in accordance with the state's Physical Therapy Practice Act and the hospice's policies and procedures and/or job descriptions. Personnel #6: There was no evidence of the current license for the contract PT.

Upon personnel record review, 3 of 13 (Personnel #6,7,8) 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. The agency was unable to produce therapy files.

Upon patient record review, 2 of 11 (Patients #4 and #5) did not have evidence in the patient record that the comprehensive assessment included a bereavement component which included 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 #4 and #5: There was no documentation to indicate a Bereavement Risk Assessment had been completed by any discipline and incorporated into the plan of care.

Upon patient record review, 1 of 3 applicable (Patient #9) did not have evidence the hospice offered bereavement counseling that included: • 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 deliveryClinical Record #9: Review of a document titled, "Individual Bereavement Plan of Care", revealed an entry dated 8/10/2021 from the Bereavement Coordinator stating, ..."talked with daughter who said is doing well but brother is still having a hard time dealing with her father's death . Spoke to the brother and he cried the whole time we prayed together, said it's hard to talk about. I will continue with calls and prayers." There was no documentation to indicate any additional follow-up to the family as stated by the Bereavement Coordinator.

Upon observation, there was no evidence that the hospice documented and demonstrated viable and ongoing efforts to recruit and retain volunteers. Review of the Volunteer binder, revealed there was no documentation to indicate there had been ongoing Volunteer recruitment for the year 2021.

Upon patient client record review, 3 of 11 (Patient #9, #10 and #11) 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 #9: (1) A document titled "Individual Bereavement Plan of Care", listed areas of bereavement tasks to be completed. As the tasks were completed, dates were placed in the corresponding box. There were no names by the dates to indicate who had completed the tasks. (2) There was no signature on the post-death Bereavement Assessment to indicate who had completed the Assessment. Patient #10: (1) A document titled "Individual Bereavement Plan of Care", listed areas of bereavement tasks to be completed. As the tasks were completed, dates were placed in the corresponding box. There were no names by the dates to indicate who had completed the tasks. (2) There was no signature on the post-death Bereavement Assessment to indicate who had completed the Assessment. Patient #11: (1) A document titled "Individual Bereavement Plan of Care", listed areas of bereavement tasks to be completed. As the tasks were completed, dates were placed in the corresponding box. There were no names by the dates to indicate who had completed the tasks. (2) Chaplain visits documented on 7/25/21 and 8/22/21, patient expired on 7/22/21.

Upon client record review, 2 of 2 applicable (Patients #6 and #8) did not have evidence that the discharge summary included all required information. Patients #6 and #8: The discharge summary did not include a summary of the patient's stay, the patient's current plan of care and latest physician orders.

Upon SNF/NF contract review, 1 of 1 applicable (contract #4) did not have a delineation of the responsibilities of the hospice and the SNF/NF to provide bereavement services to SNF/NF personnel.