Every finding on record at Artemis Hospice and Palliative Care

Upon patient record review, 4 of 14 (Patients #1,2,4,6) 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: This patient had a fall pad. This was not included on the Plan of Care. Corrected on site. Patient #2: This patient had a walker and wheel chair. These were not included on the Plan of Care. Corrected on site. Patient #4: The record reflected that this patient had a wheel chair. This was not included on the Plan of Care. Corrected on site. Patient #6: The record reflected that this patient had a hospital bed, suction machine, O2 concentrator and a wheel chair. These were not included on the Plan of Care. Corrected on site.

Upon patient record review, 7 of 14 (Patients #1,2,3,4,6,7,12) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1: The POC listed LVN visit frequency of, 2 X's per week (9/6/24). There were no visits made by LVN for first or second Benefit Weeks. Patient #2: The POC listed LVN Visits 2X's per week (10/11/24). During 1st Benefit week there were no visits made by the LVN. Patient #3: The POC listed LVN visit frequency of, 2 X's per week (8/2/24). During 1st Benefit week there were no visits made by the LVN. Patients #4: The POC listed LVN Visits 2X's per week (11/1/24). During 1st Benefit week there were no visits made by the LVN. For second Benefit week there was one visit only on 11/6/24. Patient #6: The POC listed LVN Visits 2X's per week (9/20/24). During 1st Benefit week there were no visits made by the LVN. Patient #7: The POC listed LVN visit frequency of, 2 X's per week (10/10/24). For first Benefit Week there was only one visit on 10/11/24. Patient #12: The POC listed LVN Visits 1X's per week (6/22/24). During 1st Benefit week there were no visits made by the LVN.

Upon personnel record review, 1 of 12 (Personnel #9) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient. Personal #9: These following competencies from 42 CFR 418.76(3)(b) were not evaluated as direct observation while the aide is performing the tasks with a patient or pseudo-patient. They were only validated by verbal competency. ·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.

Upon patient record review 8 of 14 (Patients #1,2,3,4,5,6,7,12) did not have evidence 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 #1: The POC listed Aide visit frequency of, 2 X's per week (9/6/24). For first Benefit Week there was only one visit on 9/7/24. Patient #2: The POC listed Aide Visits 2X's per week (10/11/24). During 1st Benefit week there were no visits made by the Aide. Patient #3: The POC listed Aide visit frequency of, 2 X's per week (8/2/24). For first Benefit Week there was only one visit on 8/2/24. Patients #4 and #5: The POC listed Aide Visits 2X's per week (11/1/24). During 1st Benefit week there were no visits made by the Aide. Patient #6: The POC listed Aide Visits 2X's per week (9/20/24). During 1st Benefit week there were no visits made by the Aide. Patient #7: The POC listed Aide visit frequency of, 2 X's per week (10/10/24). For first Benefit Week there was only one visit on 10/11/24. Patient #12: The POC listed Aide Visits 2X's per week (6/22/24). During 1st Benefit week there were no visits made by the Aide.

Upon personnel record review, 3 of 12 (Personnel # 1, 4, 9) did not have evidence the hospice employees and contract employees have received orientation on the hospice philosophy. Corrected on Site.

Upon patient record review, 12 of 14 (Patients #1,2,3,4,5,6,7,8,9,10,11,12) did not have evidence that each patient record contains: • Signed election statement in accordance with 418.24 Patients #1,2,3,4,5,6,7,8,9,10,11,12: The Hospice Medicare Election statement did not include Effective Date, BFCC-QIO contact information or Notice of Non Coved Items addendum information.

Upon patient record review, 1 of 14 (Patient #10) 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 #10: This patent discharged from hospice services on 9/6/24. In discharge narrative there was a conflicting date in body of note that indicated DC date 9/1/24 (not 9/6/24). This date did not match other discharge indicators in heading of form (9/6/24).

Upon observation, there was no evidence of a contract to provide inpatient care for respite purposes in a Medicare certified hospice, if applicable.

Upon observation, there was no evidence of a contract to provide inpatient care for respite purposes in a Medicare or Medicaid certified nursing facility, if applicable.

Upon inpatient contract review, 1 of 7 (Mid-Wilshire Respite Contract) did not have evidence that the hospice supplies the inpatient provider with a copy of the patient's plan of care and specifies the inpatient services to be furnished.

Upon inpatient contract review, 1 of 7 (Mid-Wilshire Respite Contract) did not have evidence that the inpatient provider has established patient care policies consistent with those of the hospice and agrees to abide by the palliative care protocols and plan of care established by the hospice for its patients.

Upon inpatient contract review, 1 of 7 (Mid-Wilshire Respite Contract) did not have evidence that the hospice patient's inpatient clinical record includes a record of all respite services furnished and events regarding care that occurred at the facility; that a copy of the discharge summary be provided to the hospice at the time of discharge; and that a copy of the inpatient clinical record is available to the hospice at the time of discharge.

Upon respite contract review, 1 of 7 (Mid-Wilshire Respite 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.

Upon respite contract review, 1 of 7 (Mid-Wilshire Respite Contract) did not have evidence that the hospice retains responsibility for ensuring that the training of personnel who will be providing the patient's care in the inpatient facility has been provided and that a description of the training and the names of those giving the training are documented.

Upon respite contract review, 1 of 7 (Mid-Wilshire Respite Contract) did not have evidence of a method for verifying that the requirements for ACHC standard HSP1-8B and CFR 418.108c (1)-418.108c(5)are met.