Every finding on record at Anita Hospice Inc.

Upon patient record review, 3 of 8 (Patient #6, 7, 8) did not have evidence that the patient chooses a health care provider, including an attending physician. Patients 6, 7, 8 Election Statement has no space to clarify patient chose physician. The Patient Rights form includes that the patient has the right to choose, but admitting documentation has no prompt or space to verify patient made choice.

Upon patient record review 1 of 8 (Patient #6) 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 #6: SOC 4/16/19. The patient refused SC services. The patient refused MSW until 7/14/22. There was no assessment of the psychosocial and spiritual needs within the 5 day time frame as prompts in EMR were left blank.

Upon patient record review, 1 of 8 (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: Patient refused SC and also refused MSW until 7/14/19. No is no evidence that bereavement was discussed/offered. RNs only reference to bereavement in initial assessment is that patient has adult children.

Upon patient record review, 2 of 14 (Patient #2. #3) 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 #2: SC order for 1 admission, recert and as needed monthly for spiritual needs. No defined frequency for monthly, cannot be as needed. Patient #3. Initial MSW freq to perform initial assessment thru telehealth, recert and then as needed monthly. No defined frequency for monthly, cannot be as needed. SC freq order for 1 admission / initial assessment thru telehealth and as needed monthly. No defined frequency for monthly, cannot be as needed.

Upon patient record review, 2 of 8 (Patient #2, 4) 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 #2: SOC 7/18/22. Caregiver called office 5/31/23 to report no BM. Milk of Mag was administered with no results. Nurse notified MD and received new order to add Senna 8/6 mg po qd. There was no POC update to include related problems/goals/interventions. Patient #4: SOC 8/6/22. Call from PCG 8/21/22 that patient experiencing symptoms of thrush and diarrhea x 3 days. Hospice RN contacted MD and obtained order for Nystatin and Immodium. There was no POC update to include related problems/goals/interventions.

Upon client record review, 3 of 8 (Patient #1, 2, 3) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1: Initial Medical Social Worker frequency documented as Initial assessment, evaluate and assess 1x per month and 2x as needed for psychosocial and emotional support and concern and any sudden change in psychosocial status/needs for patient family, PCG. The patient was only seen once by MSW for initial 7/24/22 assessment visit. There were no visits documented for August, September. Patient #2: Initial MSW to perform initial assessment thru telehealth during recertification and then 1 visit as needed monthly. No MSW visits made beyond initial 7/29/22 assessment visit. SC order for 1 admission, recert and as needed monthly for spiritual needs. Patient declined initial SC, but order not updated and no documentation Aug visit offered/declined. Patient #3. Initial MSW freq to perform initial assessment thru telehealth, recert and then as needed monthly,,,,Only documented MSW visits were 7/31, 8/27, 9/27/22. No change to frequency orders. SC freq order for 1 admission / initial assessment thru telehealth ... and as needed monthly... Only SC visit documented was 7/29/22. There were no changes in ordered frequencies.

Upon patient record review, 1 of 8 (#2) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient #2: SOC 7/18/22. Initial orders for HA 1/wk. Corresponding HA assignment sheet date 7/18/22 assigned HA 1x/wk. 7/28/22 IDG HA increased frequency to 2x/wk per family request. The HA assignment sheet was not updated by RN. However, HA began providing visits 2x/wk.

Upon personnel record review, 1 of 11 (Personnel #1) did not have evidence that the administrator is a hospice employee and possesses the education and experience required by the governing body. Personnel #1 Administrator job description requires 4 years HC management. Prior experience as administrator with health care group describes responsibilities of preparing, organizing and storing info in paper and/or digital form. When questioned regarding management experience, there was no additional verification offered.

Upon contract review, 1 of 5 (Wound Pro contract) did not have evidence the 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 Wound Pro Contract: The contract does not specify requirement that services are unrelated to the hospice diagnosis and verified in writing, as unrelated by the Hospice Medical Director, in the rare circumstance that service would therefore be billable to 3rd party payor. Payment is responsibility of hospice provider under the hospice Medicare benefit for care/treatment related to the hospice diagnosis. Neither does the contract verify that the patient will not be billed for any services rendered. There is no Medical Director documentation in clinical records (#2, 4) to support determination that these services are unrelated.

Upon patient client record review, 6 of 8 (Patient #1, 2, 3, 6, 7, 8) 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: The election statement does not include choice of physician. There is a separate document that identifies patient's choice to allow hospice to choose physician. Patient #2: Informed Consent and treatment Authorization includes hospice care effective date of 7/18/22, signed by POA. The space to elect the physician is left blank on this form. A separate Hospice Election form has an effective date of 7/15/22 with signature by patient and signature date of what looks like 7/15/22 with the 5 marked over to be an 8. There is a 3rd form for physician choice. This form defers to hospice and is signed by POA, so L515 is not cited. Patient #3: Informed Consent and treatment authorization form is blank for physician choice. Includes effective date for hospice. There is another form for patient MD choice that patient defers to hospice, so L515 is not cited. There is no separate election form for this record. Patients #6, 7, 8: Election Statement has no space to clarify patient chose physician. The Patient Rights form includes the right, but there is no documentation to confirm patient's choice.

Upon patient client record review, 3 of 8 (Patient #6, 7, 8) did not evidence that each patient record contains physician orders. Patient Records #6, 7, 8 did not have evidence of physician order for discharge, although visits/documentation stopped abruptly.

Upon client record review, 3 of 8 (Patient #6, 7, 8) 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 #6 SOC 4/16/19. Last SN note 7/30/19. Last IDG 7/27/19. No further documentation regarding disposition of patient. There is no DC summary to send to MD. Patient #7: SOC 4/19/19. Last SN note 7//26/19. Last IDG 7/27/19. No further documentation regarding disposition of patient. There is no DC summary to send to MD. Patient #8: SOC 6/01/19. Last SN visit note 7/27/19. Last IDG 7/27/19. No further documentation regarding disposition of patient. There is no DC summary to send to MD.

Upon inpatient contract review, 1 of 5 (Rowland Convalescent contract) did not have evidence that the inpatient facility has identified an individual within the facility who is responsible for the implementation of the provisions of the agreement. SNF Contract does not include provisions regarding that the facility has identified an individual within the facility who is responsible for the implementation of the provisions of the agreement.

Upon personnel record review, 3 of 11 (Personnel #9, 10,11) 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. Personnel 9, 10, 11: The agency was unable to obtain criminal background check for contracted personnel before the end of survey.