Every finding on record at Asa Hospice Care, Inc.

Upon patient record review, 5 of 10 (Patients # 3, 4, 6, 8, 9) did not have evidence in the patient record that the comprehensive assessment takes into consideration the imminence of death. Patients # 3, 4, 6, 8, 9: The comprehensive assessment in the patients' medical records did not contain evidence that during the comprehensive assessment the imminence of death was taken into consideration.

Upon patient record review, 5 of 10 (Patients # 3, 4, 5, 6, 7) 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. Patients # 3, 4, 5, 6, 7: The patient's most current plan of care contained orders for the bereavement counselor that stated, "BC as needed. There was no indication of the quantity of visits or scope.

Upon patient record review, 3 of 10 (Patients # 3, 6, 8) 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 # 3: The patient's aide plan of care dated 11/2/25 contained instructions to change the linens. There was no indication of the frequency for the task to be performed by the aide. Patient # 6: The patient's aide plan of care dated 5/2/25 contained instructions to turn and reposition, change linens, and equipment as specified by RN instructions. There was no indication of the frequency for the task to be performed by the aide. Patient # 8: The patient's aide plan of care dated 12/19/23 contained instructions to turn and reposition, and equipment as specified by RN instructions. There was no indication of the frequency for the task to be performed by the aide.

Upon personnel record review, 9 of 12 (Personnel # 1, 2, 3, 7, 8, 9, 10, 11, 12) did not have evidence the hospice employees and contract employees have received orientation on the hospice philosophy. Personnel # 1, 2, 3, 7, 8, 9, 10, 11, 12: The personnel records did not contain evidence of employee orientation on the hospice philosophy.

Upon contract review, 1 of 4 the SNF/NF contract for Chandler Convalescent Center did not have a provision stating that the hospice reports all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by anyone unrelated to the hospice to the SNF/NF administrator within 24 hours of the hospice becoming aware of the alleged violation.

Upon observation, 1 of 3 applicable (Patient #2) there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient #2: Observed nurse remove gloves and apply a second pair with no evidence of sanitizing before apply second pair of gloves per agency policy 5.7.1.

Upon patient client record review, 5 of 5 (Patient #1, #2, #3, #4, #5) did not have evidence that each patient record contains Advance Directives. Patients #1-#5: The comprehensive assessments indicated each patient elected DNR and a POLST was completed however, there was no evidence of physician signature. [#1, #2, #3-corrected on site]

Upon SNF/NF contract review, SNF contract did not have evidence of the manner in which the SNF/NF and the hospice are to communicate with each other and how each will document such communications to ensure that the needs of patients are addressed and met 24 hours a day. corrected on site