Every finding on record at Art of Hospice, Inc.

Upon patient record review, 5 of 5 (Patient #1, 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. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy Patient 1, 2, 3, 4, 5: The patients' oxygen does not appear on the medication lists. (corrected onsite)

Upon patient record review, 1 of 5 (Patient #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 5: The patient requires the use of a CPaP machine for palliation and symptom management; however, this DME does not appear on the plan of care. (corrected onsite)

Upon patient record review, 5 of 14 (Patients #1,#2,#3,#7,#9) 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: The medical record contained nursing documentation upon admission identifying patient use of oxygen. There was no evidence of oxygen listed on the medication profile. Corrected on site. Patient 2,3: The medication profiles contained aspercreme topical ointment with no area defined for administration. Patient 7: The medication profile contained aspercreme topical ointment with no area defined for administration, miralax oral powder with no instructions for a diluent, and thick-it powder with no instructions for appropriate consistency. Patient 9: The medication profile contained thick-it powder with no instructions for appropriate consistency.

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

Upon patient record review, 9 of 14 (Patients #1,#2,#3,#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: There was no evidence of problems, goals, and interventions related to social work visits. Corrected on site. Patient 2: There was no evidence of problems, goals, and interventions related to social work visits. Corrected on site. Patient 3: There was no evidence of problems, goals, and interventions related to social work visits. Corrected on site. Patient 5: There was no evidence of problems, goals, and interventions related to social work visits. The medical record contained nursing documentation upon recertification 5/3/23 identifying patient was a high risk for skin impairment. There was no evidence of problems, goals, and interventions related to risk for skin impairment. Corrected on site. Patient 6: There was no evidence of problems, goals, and interventions related to social work visits. Corrected on site. Patient 7: There was no evidence of problems, goals, and interventions related to social work visits. Corrected on site. Patient 8: There was no evidence of problems, goals, and interventions related to social work visits. Corrected on site. Patient 9: There was no evidence of problems, goals, and interventions related to social work and spiritual care visits. Corrected on site. Patient 10: There was no evidence of problems, goals, and interventions related to social work and spiritual care visits. Corrected on site.

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 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 medical record contained ordered social work and spiritual care frequencies of once every recertification and as needed. Corrected on site. Patient 2: The medical record contained an ordered social work frequency of once every recertification and as needed. Corrected on site. Patient 3: The medical record contained ordered social work and spiritual care frequency as one time and as needed. Corrected on site. Patient 4: The medical record contained an ordered social work frequency of evaluation within 5 days and then to follow up on recertification if applicable. Corrected on site. Patient 5: The medical record contained an ordered social work frequency of evaluation within 5 days and then to follow up on recertification if applicable, and an ordered spiritual care frequency of once every recertification plus as needed. Corrected on site. Patient 6: The medical record contained an ordered spiritual care frequency of one time plus as needed. Corrected on site. Patient 7: The medical record contained ordered social work and spiritual care frequencies of once every recertification and as needed. Corrected on site. Patient 8: The medical record contained ordered social work and spiritual care frequencies of once every recertification and as needed. Corrected on site. Patient 9: The medical record contained ordered social work and spiritual care frequencies of once every recertification and as needed. Corrected on site. Patient 10: The medical record contained an ordered spiritual care frequency of monthly and as needed. Corrected on site.

Upon patient record review, 5 of 14 (Patients #1,#2,#3,#7,#9) 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 medical record contained nursing documentation upon admission identifying patient use of oxygen. There was no evidence of an order for oxygen. Corrected on site. Patient 2: The medical record contained an order for aspercreme topical ointment with no defined area for administration. Corrected on site. Patient 3: The medical record contained an order for aspercreme topical ointment with no defined area for administration, and an order for a foley catheter with no defined balloon size. Corrected on site. Paitent 7: The medical record contained an order for aspercreme topical ointment with no defined area for administration, an order for miralax oral powder with no instructions for a diluent, and an order for thick-it with no instructions for safe consistency. Corrected on site. Patient 9: The medical record contained an order for thick-it with no instructions for safe consistency. Corrected on site.

Upon patient record review, 6 of 14 (Patients #3,#4,#5,#6,#7,#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 3: The medical record contained nursing documentation upon recertification 6/5/23 identifying patient use of a cane and walker. There was no evidence of the cane and walker included as DME on the plan of care. Corrected on site. Patient 4: The medical record contained nursing documentation upon admission identifying patient use of a wheelchair. There was no evidence of the wheelchair included as DME on the plan of care. Corrected on site. Patient 5: The medical record contained nursing documentation upon recertification 5/4/23 identifying patient use of a wheelchair. There was no evidence of the wheelchair included as DME on the plan of care. Corrected on site. Patient 6: The medical record contained nursing documentation upon admission identifying patient use of a hospital bed, air mattress, wheelchair, nebulizer, and hoyer lift. There was no evidence of the bed, mattress, wheelchair, nebulizer and lift included as DME on the plan of care. Corrected on site. Patient 7: The medical record contained nursing documentation upon most recent recertification visit identifying patient use of an air mattress, shower chair, and wheelchair. There was no evidence of the mattress, shower chair, and wheelchair included as DME on the plan of care. Corrected on site. Patient 10: The medical record contained nursing documentation upon admission identifying patient use of a walker and wheelchair. There was no evidence of the walker and wheelchair included as DME on the plan of care.

Upon client record review, 1 of 14 (Patients #8,#10) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 8: The medical record contained ordered social work and spiritual care visits once every recertification. There was no evidence of a social work visit during benefit period 3 and no spiritual care visit during benefit period 4. Patient 10: The medical record contained ordered social work and spiritual care visits once monthly. There was no evidence of May visits for social work or spiritual care.

Upon observation, there was no evidence the hospice documented the cost savings achieved through the use of volunteers. Documentation must include the following: • The identification of each position that is occupied by a volunteer • The work time spent by volunteers occupying those positions • Estimates of the dollar costs that the hospice would have incurred if paid employees occupied the positions identified in paragraph (d)(1) of CFR 418.78 for the amount of time specified in paragraph (d)(2) of CFR 418.78

Condition of Participation: Organization and Administration of Services.

Upon observation, there was no evidence the hospice is directed by a Board of Directors/governing body which assumes full legal authority and responsibility for the operation of the hospice. The administrator and governing body allowed the medical director effective 5/2/22 to practice medicine violating his probation requirements.

Upon observation, there was no evidence the hospice designates a physician to serve as Medical Director which includes: • The Medical Director must be a doctor of medicine or osteopathy who is an employee or is under contract. • When the Medical Director is not available, a physician designated by the hospice assumes the same responsibilities and obligations as the Medical Director. The contracted Medical Director Dr Armen Kazanchian license A53993, has a contract effective 5/2/22 and has signed the majority of the patients certification of terminal illness orders, orders as attending physician are signed and this physician has also signed the plan of care IDG updates. Dr Kazanchian is on probation according to the state of CA effective 2016, updated in 2018 and the probation remains in place that does not allow this physician to practice unless the patient is in a skilled nursing facility or other similar licensed facility. The orders signed by Dr K are after the 2018 date. Another MD contract is in place for Dr P effective 2/1/23.

Upon patient client record review, 7 of 14 (Patients #1,#2,#3,#5,#8,#9,#10) did not have evidence that each patient record contains signed election statement in accordance with 418.24. Patients 1,2,3,5,8,9,10: The medical records contained election forms identifying patients elected to receive the Notification of Hospice Non-Covered Items. There was no evidence the patients/representatives received the forms. Agency provided the notifications filled out, however, there was not evidence of patient reception.