Every finding on record at Almighty Hospice Care, Inc.

Upon 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 #5: The record indicated the patient has Parkinson's and signed consents that include having received information about the services covered under the hospice benefit and the election of hospice on admission on 05/17/25 The nurse charted the patient was confused and forgetful although oriented to person and place but not oriented to time on admission and the Social Worker documented in the comprehensive psychosocial comprehensive assessment the patient was confused on 05/18/25. The nurse also documented the patient had worsening forgetfulness and was taking donepezil 5mg daily for memory support. She has a medical history of CVA as well.

Upon patient record review, 1 of 14 records reviewed (Patient #5) did not have evidence that the hospice informed and provided written information to the patient concerning its policies on advance directives, including a description of applicable state law. Patient #5: The record indicated the patient has Parkinson's and signed consents and the election of hospice on admission 05/17/25 The nurse charted the patient was confused and forgetful although oriented to person and place but not time on admission and the Social Worker documented on admission the patient was confused on 05/18/25. The nurse also documented the patient had worsening forgetfulness and was taking donepezil 5mg daily for memory support. She has a medical history of CVA.

Upon patient record review, 1 of 14 records reviewed (Patient #5) did not have evidence that the hospice obtained the patient's or representative's signature confirming that they received a copy of the Patient's Rights and Responsibilities. Patient #5: The record indicated the patient has Parkinson's and signed consents that included confirming she received a copy of the patient rights and responsibilities and the election of hospice on admission 05/17/25. The nurse charted the patient was confused and forgetful although oriented to person and place but not oriented to time on admission and the Social Worker documented on the psychosocial comprehensive assessment the patient was confused on 05/18/25. The nurse also documented the patient had worsening forgetfulness and was taking donepezil 5mg daily for memory support. She has a medical history of CVA.

Upon observation, there was no evidence the patient has the right to voice grievances/complaints regarding treatment or care that is (or fails to be) furnished and lack of respect of property by anyone who is furnishing care/service on behalf of the hospice. Patient #5: The record indicated the patient has Parkinson's and signed consents that included which included the right to voice grievances/complaints regarding treatment or care and the election of hospice on admission 05/17/25 The nurse charted the patient was confused and forgetful although oriented to person and place but not oriented to time on admission and the Social Worker documented on the psychosocial comprehensive assessment the patient was confused on 05/18/25. The nurse also documented the patient had worsening forgetfulness and was taking donepezil 5mg daily for memory support. She has a medical history of CVA.

Upon patient record review, 1 of 14 records reviewed (Patient #5) did not have evidence that if a state court has not adjudged a patient incompetent, any legal representative designated by the patient in accordance with state law may exercise the patient's rights to the extent allowed by state law. Patient #5: The record indicated the patient has Parkinson's and signed consents that included the right to exercise the patient's rights and the election of hospice on admission 05/17/25 The nurse charted the patient was confused and forgetful although oriented to person and place but not oriented to time on admission and the Social Worker documented on the psychosocial comprehensive assessment the patient was confused on 05/18/25. The nurse also documented the patient had worsening forgetfulness and was taking donepezil 5mg daily for memory support. She has a medical history of CVA.

Upon client record review, 1 of 14 (Patient #5) did not have evidence that the plan of care included IDG's documentation of the patient's or families level of understanding, involvement and agreement with the plan of care. Patient #5: The record indicated the patient has Parkinson and signed consents that include having received information about the services covered under the hospice benefit and the election of hospice on admission on 05/17/25 The nurse charted the patient was confused and forgetful although oriented to person and place but not oriented to time on admission and the Social Worker documented in the comprehensive psychosocial comprehensive assessment the patient was confused on 05/18/25. The nurse also documented the patient had worsening forgetfulness and was taking donepezil 5mg daily for memory support. She has a medical history of CVA as well.

Upon patient record review, 1 of 14 (Patient #5) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient #5: The record indicated the patient has Parkinson's and signed consents that include having received information about the services covered under the hospice benefit and the election of hospice on admission on 05/17/25 The nurse charted the patient was confused and forgetful although oriented to person and place but not oriented to time on admission and the Social Worker documented in the comprehensive psychosocial comprehensive assessment the patient was confused on 05/18/25. The nurse also documented the patient had worsening forgetfulness and was taking donepezil 5mg daily for memory support. She has a medical history of CVA as well.

Upon patient record review, 1 of 14 charts reviewed (Patient #5) did not have evidence of the appropriate documentation for release of confidential information. Patient #5: The record indicated the patient has Parkinson's and signed consents to include appropriate documentation for the release of confidential information and the election of hospice on admission 05/17/25 The nurse charted the patient was confused and forgetful although oriented to person and place but not time on admission and the Social Worker documented on admission the patient was confused on 05/18/25. The nurse also documented the patient had worsening forgetfulness and was taking donepezil 5mg daily for memory support. She has a medical history of CVA.

Upon patient record review, 1 of 14 records reviewed (Patient #5) did not have evidence that the patient received information about the services covered under the hospice benefit. Patient #5: The record indicated the patient has Parkinson's and signed consents that include having received information about the services covered under the hospice benefit and the election of hospice on admission on 05/17/25 The nurse charted the patient was confused and forgetful although oriented to person and place but not oriented to time on admission and the Social Worker documented in the comprehensive psychosocial comprehensive assessment the patient was confused on 05/18/25. The nurse also documented the patient had worsening forgetfulness and was taking donepezil 5mg daily for memory support. She has a medical history of CVA as well.

Upon patient record review, 1 of 14 (Patient #5) did not have evidence that the patient received information about the scope of services that the hospice will provide and specific limitations on those services. Patient #5: The record indicated the patient has Parkinson's and signed consents that include having received information about the services covered under the hospice benefit and the election of hospice on admission on 05/17/25 The nurse charted the patient was confused and forgetful although oriented to person and place but not oriented to time on admission and the Social Worker documented in the comprehensive psychosocial comprehensive assessment the patient was confused on 05/18/25. The nurse also documented the patient had worsening forgetfulness and was taking donepezil 5mg daily for memory support. She has a medical history of CVA as well.

Upon patient record review 2 of 14 records reviewed (Patient #6, #9) 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 #6: The record indicated the nurse completed a section titled Spiritual Screening (required for HIS) she marked the spiritual distress rating as "mild" and documented a spiritual care visit was needed. She documented the spiritual distress was mild but did not document the individualized reason/reasons as to why there was mild spiritual distress. The spiritual distress was marked as mild, it was unclear if it was for the patient and or family. In addition, the Chaplain did not make a visit, he completed a phone assessment and section 5 for the caregiver spiritual distress comprehensive assessment was left blank. The spiritual comprehensive assessment was not fully completed. Patient #9: The record indicated the nurse completed a section titled Spiritual Screening (required for HIS) she left the question blank for the spiritual distress rating. She documented a spiritual visit was needed. The record indicated the patient was admitted to hospice on 12/28/24, there was no spiritual comprehensive assessment completed at the time of the survey.

Upon patient record review, 10 of 14 records reviewed (Patient #1-#10) 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 #1-10: There was no evidence in the record of an ongoing process to monitor the effectiveness of drugs therapy, drug side effects, actual or potential drug interactions, duplicate therapy and or drug therapy currently associated with laboratory monitoring when there was medication changes. The place to document that this was being done was left blank on every IDG meeting for these patients. Patient #1: The record indicated the patient was to get triple antibiotic ointment one thin layer TID to the affected areas, there was no evidence of where the medication was to be applied. COS. Patient #2: Upon home interview the Social Worker interpreted for the caregiver and surveyor. The pharmacy labeled the medications in English. The Caregiver was not able to read the English writing and stated how often three different medications were being given for the following: Bethanechol Chloride 10 mg po TID was ordered but was only being given once a day per the caregiver, Mobic 7.5mg po BID was ordered and was only being given as needed for pain per the caregiver and Metoprolol Succinate 25mg po BID was ordered but was only being given once a day per the caregiver.

Upon patient record review, 7 of 14 records reviewed (Patient #1, #3, #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 record indicated the patient was taking Eliquis 2.5mg po QDAY, there was no planning for bleeding precautions to reflect the patient/family goals and interventions based on the problem at the time of the survey. COS. Patient #3: The record indicated the patient had no mortuary at the time of hospice admission. The care plan was not individualized to reflect the patient and family goals and interventions based on the problem at the time of the survey. Patient #6: There was no mortuary and no funeral plans to reflect the patient and family goals and interventions based on the problem at the time of the survey. Patient #7: The record indicated the patient was a full code, had no mortuary and no funeral planning at the time of hospice admission. The care plan was not individualized to reflect the patient and family goals and interventions based on the problem at the time of the survey. Patient #8: The record indicated the patient had no mortuary and no funeral planning at the time of hospice admission. The care plan was not individualized to reflect the patient and family goals and interventions based on the problem at the time of the survey. Patient #9: The record indicated the patient had no mortuary and no funeral planning at the time of hospice admission. The care plan was not individualized to reflect the patient and family goals and interventions based on the problem at the time of the survey. Patient #10: The record indicated the patient had no mortuary, no funeral planning and was a full code at the time of hospice admission. The care plan was not individualized to reflect the patient and family goals and interventions based on the problem at the time of the survey.

Upon patient record review, 9 of 14 records reviewed (Patient #1, #3, #4, #5, #6, #7, #8, #9, #10) 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 #1: The order for physician visits were as needed for medical needs and recertifications, there was no scope and frequency. COS. In addition, the MSW was ordered as needed, for recertification and ongoing psychosocial evaluation and support, there was no scope and frequency. COS Patient #3: The MSW was ordered as needed, for recertification and ongoing psychosocial evaluation and support, there was no scope and frequency. COS. Patient #4: The MSW was ordered as needed, for recertification and ongoing psychosocial evaluation and support, there was no scope and frequency. COS. Patient #5: The order for physician visits were as needed for medical needs and recertifications, there was no scope and frequency. COS. In addition, the MSW was ordered as needed, for recertification and ongoing psychosocial evaluation and support, there was no scope and frequency. COS. Patient #6: The order for physician visits were as needed for medical needs and recertifications, there was no scope and frequency. COS. In addition, the MSW was ordered as needed, for recertification and ongoing psychosocial evaluation and support, there was no scope and frequency. COS. Patient #7: The MSW was ordered as needed, for recertification and ongoing psychosocial evaluation and support, there was no scope and frequency. COS. Patient #8: The MSW was ordered as needed, for recertification and ongoing psychosocial evaluation and support, there was no scope and frequency. COS. Patient #9: The MSW was ordered as needed, for recertification and ongoing psychosocial evaluation and support, there was no scope and frequency. COS. Patient #10: The MSW was ordered as needed, for recertification and ongoing psychosocial evaluation and support, there was no scope and frequency. COS.

Upon patient record review, 1 of 14 records reviewed (Patient #1) 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 the order for the triple antibiotic ointment was to be applied as one thin layer TID to the affected areas, there was no evidence of where the medication was to be applied. COS.

Upon patient record review 1 of 14 records reviewed (Patient #6) did not have evidence that the IDG ensures that the care and services provided are based on all assessments of the patient and family needs. Patient #6: The record indicated the patient was admitted to hospice on 05/17/25, the spiritual comprehensive assessment indicated the spiritual distress rating was mild and a spiritual care visit was needed. There was no spiritual care visit made. In addition, the record indicated the social worker had an intervention to facilitate a life review, there were no scheduled follow up visits at the time of the survey.

Upon observation, there was no evidence the hospice investigates all adverse events, incidents, accidents, variances or unusual occurrences that involve patient care and develops a plan of correction to prevent the same or similar event from occurring again. Upon home visit the caregiver stated she had called after hours with requests. She stated, "Diana requested me to send her pictures and she would call the doctor and get us what we need." The owner who was referenced in the caregiver quotes stated she takes the calls like "an answering service". When she was asked to see the call logs there was no after hours documentation of calls being received by the owner. The agency did not have an on call log to identify, monitor, report, investigate and document all unusual occurrences that involve patient care after hours. In addition, the caregiver stated there was a group text with family and hospice staff to report needs. There was no after hours documentation under the communication notes in the chart at the time of the survey regarding this referenced after hours request.

Upon patient record review, 8 of 14 charts reviewed (Patient #1, #3, #5, #6, #7, #8, #9, #10) did not have evidence that Social work services are based on the patient's psychosocial assessment and the patient/family's needs and acceptance of these services. Patient #1: The record indicated the psychosocial assessment confirmed the patient was depressed, sad and had moderate anxiety. The patient did not have a mortuary at the time of admission and or up to the time of the survey. The Social Worker made a visit on 02/15/24 and did not make a follow up visit until 04/25/24. The psychosocial needs were not being met. Patient #3: The record indicated the psychosocial assessment confirmed the patient was depressed, sad and had moderate anxiety, there has been no follow up visit at the time of the survey. In addition, there was no mortuary listed on admission and no follow up. Patient #5: The record indicated the patient and family both had moderate anxiety, no mortuary listed and no funeral plans on hospice admission. There has been no follow up visit at the time of the survey. Patient #6: The record indicated the patient and family had no mortuary or funeral plans on hospice admission. There has been no follow up visit at the time of the survey. Patient #7: The record indicated the patient and family had no mortuary, no funeral plans and was a full code at the time of hospice admission. There has been no follow up visit at the time of the survey. Patient #8: The record indicated the patient and family had no mortuary and no funeral plans at the time of hospice admission. There was no follow from the assessment on 3/7/25 until 6/5/25. In addition on 3/7/25 the psychosocial comprehensive assessment confirmed the patient was depressed, sad and concerned about what will happen with family when she is gone. There was no follows on addressing these needs at the time of the survey. Patient #9: The record indicated the patient and family had no mortuary and no funeral plans at the time of admission on 12/28/24. There was no follow up until 3/29/25. There are no mortuary and no funeral plans at the time of the survey. Patient #10: The record indicated the patient and family had no mortuary, no funeral plans and was a full code at the time of hospice admission on 12/01/24. There was no follow up until 3/2/25. These psychosocial needs were not being met.

Upon patient client record review, 1 of 14 (Patient #5) 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 #5: The record indicated the patient has Parkinson's and signed consents that include having received information about the services covered under the hospice benefit and the election of hospice on admission on 05/17/25 The nurse charted the patient was confused and forgetful although oriented to person and place but not oriented to time on admission and the Social Worker documented in the comprehensive psychosocial comprehensive assessment the patient was confused on 05/18/25. The nurse also documented the patient had worsening forgetfulness and was taking donepezil 5mg daily for memory support. She has a medical history of CVA as well.

Upon patient client record review, 3 of 14 (Patient #1, #2, #6) did not have evidence that each patient record contains Advance Directives. Patient #1:  The record indicated there was a MPOA but no document was on file.  COS. Patient #2:  The copy of the MPOA was not on the chart at the time of the survey.  COS. Patient #6: The record indicated the care plan written stated the MSW will provide information on execution of DPOAHC and obtain a copy. There was evidence the patient had this document, there was no copy of file at the time of the survey.

Upon patient client record review, 2 of 14 records reviewed (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 record indicated someone signed the consent forms and election for hospice services, there was no evidence of who this person was as the signature is not legible. COS. Patient #2: The record indicated the daughter-in-law signed the consents, the signature was not legible. COS.

Upon observation, there was no evidence the hospice discussed the policies and procedures for managing the safe use and disposal of controlled drugs with the patient or representative and the family in a language and manner that they understand to ensure that these parties are educated regarding the safe use and disposal of controlled drugs. Patient #5: The record indicated the patient has Parkinson's and signed consents to include the safe use and disposal of controlled drugs and the election of hospice on admission on 05/17/25 The nurse charted the patient was confused and forgetful although oriented to person and place but not oriented to time on admission and the Social Worker documented on the psychosocial comprehensive assessment the patient was confused on 05/18/25. The nurse also documented the patient had worsening forgetfulness and was taking donepezil 5mg daily for memory support. She has a medical history of CVA.

Upon client record review, 1 of 14 records reviewed (Patient #5) did not have evidence that the written policies and procedures for managing controlled drugs was provided and discussed. Patient #5: The record indicated the patient has Parkinson's and signed consents that included written policies and procedures for managing controlled drugs were provided and discussed and the election of hospice on admission on 05/17/25 The nurse charted the patient was confused and forgetful although oriented to person and place but not oriented to time on admission and the Social Worker documented on the psychosocial comprehensive assessment the patient was confused on 05/18/25. The nurse also documented the patient had worsening forgetfulness and was taking donepezil 5mg daily for memory support. She has a medical history of CVA.

Upon observation, there was no evidence there is a CLIA certificate for the hospice performing waived testing. The record indicated there are orders for the nurse to check the blood sugars over 300 (pt #5), they do not have a CLIA in place and would not be able to carry out the orders should the need arise.