Every finding on record at Amadeo Hospice, Inc.

Upon observation, and interview with the Alternate Administrator, there was not evidence of Amadeo Hospice having a contract/written agreement with an other facility/agency/hospice to receive Amadeo's patients, in the event that Amadeo Hospice cannot provide care to their patients during an emergency.

Upon observation, and interview with the Alternate Administrator, there was not documented evidence that the Hospice had conducted an emergency drill/exercise to test their Emergency Plan prior to December 31, 2024.

Upon patient record review, 1 of 16 (Patient #4) did not contain evidence that the Plan of Care included all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments: Patient #4: The 08/09/24 IDG POC included treatment orders for multiple, scattered BLE wounds; each treatment frequency ranging from every 2-3 days. The Hospice nurse was not making home visits at this frequency. The RN Case Manager reported that the patient's wound care was being managed/completed by an in-home wound care provider. However, the Hospice's wound order did not include 'who' would be providing these wound treatments.

Upon observation, there was no evidence the hospice is in compliance with accepted professional standards and principles for all core services which includes nursing services, medical social services and counseling services. Patient #4: The agency did not have evidence of providing core services of wound care to the patient. The RN Case Manager reported that the patient's wound care to multiple, scattered BLE wounds was being managed/completed by an in-home wound care provider. There was lack of evidence in the medical record to support if the wound care was related or not related to the terminal diagnosis or related conditions.

Upon patient record review, 2 of 16 (Patients #7 and 16) did not contain evidence that the Hospice offers Bereavement counseling that includes: • The development of a Bereavement Plan of Care that notes the kind of bereavement services to be offered, and the frequency of such service delivery. • Ensuring that these Bereavement services reflect the needs of the bereaved. Patient #7: Per phone interview, the Bereavement Coordinator confirmed that the Hospice had sent a Sympathy Card to the patient's family, and made a condolence call within a week of death. However, there was no Bereavement Plan of Care established in writing to support/reflect these planned interventions, and follow-through. Patient #16: The Hospice was not able to locate an established written Bereavement Plan of Care, post the documented Post-death Bereavement Risk assessment that had been conducted.

Upon personnel record review, 1 of 11 (Personnel #8) did not contain evidence that an Aide Skills Competency Assessment had been conducted per CMS requirement: Personnel #8: DOH was 07/18/23. A Skills Competency Assessment was conducted on 07/18/23. However, the following skill was not assessed/documented for: The physical, emotional, and developmental needs of and ways to work with the populations served by the Hospice.

Upon personnel record review, 1 of 11 (Personnel #8) did not contain evidence that a Registered Nurse had made an annual on-site visit, to the location where a patient is receiving care, in order to observe and assess each Aide while he or she is performing care. The supervising nurse must assess the Aide's ability to demonstrate initial and continued satisfactory performance in meeting outcome criteria that include, but are not limited to: Creating successful interpersonal relationships with the patient and family.

Upon contract review, the agency did not have evidence of a contract/agreement to furnish any services under arrangement included that the hospice must retain administrative and financial management, and oversight of staff and services for all arranged services, to ensure the provision of quality care. Arranged care/services are supported by written contract/agreement that requires all care/services are: • Authorized by the hospice • Furnished in a safe and effective manner by qualified personnel • Delivered in accordance with the patient's plan of care Patient #4: Wound care was being provided by the wound clinic in the patient home but the agency did not have a contract/agreement in place to provide services. The RN Case Manager reported that the patient's wound care was being managed/completed by an in-home wound care provider. There was lack of evidence in the medical record to support if the wound care was related or not related to the terminal diagnosis or related conditions.

Upon patient record review, 1 of 16 (Patient #8) did not contain evidence that all entries were clear: Patient #8: The Physician CTI pre-certification period of 09/21/24 noted that the patient was on Oxygen 3 lpm continuous. The 09/21/24 IDG Meeting notes (order section) included,"Oxygen 2 lpm continuous. The 09/21/24 IDG Meeting notes (RN section) included,"Oxygen 2.5 lpm continuous. The 09/21/24 IDG Meeting notes (med list section) included,"Oxygen 2 lpm continuous. This documentation is unclear.

Upon Inpatient contract review, 1 of 4 (Desert Haven Care) did not contain the requirement that a copy of the Discharge Summary must be provided to the Hospice, at the time of discharge, from the Inpatient Facility.

Upon patient record review, 4 of 5 records (Patients #2,#3,#4,#5) 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. Patient 2: The medication profile contained Metformin with no strength identified in dose. Corrected on site. Patient 3: The medication profile contained Refresh Tears with no amount of drops identified in dose. Corrected on site. Patient 4: The medication profile contained Ventolin HFA inhaler with route identifies by mouth and no amount of puffs identified in dose. Patient 5: The medication profile contained Miralax with no amount identified in dose and Nystatin topical to unidentified affected area.

Upon patient record review, 2 of 5 records (Patients #3,#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 medications and treatments. Patient 3: The initial Physician Plan of Care Order contained Jevity tube feedings at 65ml/hr via Kangaroo Pump. There was no frequency identified as continuous or intermittent on a schedule. Patient 4: The initial Physician Plan of Care Order contained oxygen with no specified delivery method.

Upon patient record review, 3 of 5 records (Patients #2,#3,#5) 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 2: The medical record contained nursing documentation upon admission identifying patient use of hospital bed and wheelchair. There was no evidence of the bed and wheelchair included on the plan of care. Corrected on site. Patient 3: The medical record contained nursing documentation upon admission identifying patient use of specialty mattress, wheelchair, walker, shower chair and transfer board. There was no evidence of the mattress, wheelchair, walker, shower chair and transfer board included on the plan of care. Corrected on site. Patient 5: The medical record contained nursing documentation upon admission identifying patient use of a specialty mattress/overlay. There was no evidence of the mattress included on the plan of care.

Upon patient record review 1 of 1 applicable record (Patient #4) did not have evidence of 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 4: The medical record contained aide visit documentation 1/3/21, 1/5/21, and 1/7/21 identifying aide obtained vital signs including temperature, pulse, respirations, and blood pressure. There was no evidence of task assigned by the RN to obtain vital signs on the aide care plan. The aide visit documentation on 1/5/22 and 1/7/22 also identified that a bed bath was completed however there was no evidence to specify if partial or complete bed bath was given. The task assigned on the aide care plan was for a complete bed bath.

Upon patient client record review, 1 of 5 records (Patient #3) did not have evidence that each patient record contains Physician certification and recertification of terminal illness. Patient 3: The medical record contained consents and the election of benefit form with name of patient misspelled on the bottom of forms resulting in different first name.