Every finding on record at Aseracare Hospice-Hamilton, L.L.C.

Upon observation, there was no evidence the Emergency Plan communication plan must includes a primary and alternate means for communicating with hospice's employees and Federal, state, tribal, regional, and local emergency management agencies. There was no evidence of alternate means for communicating with the employees. Corrected on site.

Upon patient record review, 2 of 14 (Patient #1,#2) 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: Medication profile dated 10/5/2023 included O2 2L PRN SOB, no evidence of a route. Corrected on site. Patient #2: During home visit with patient in SNF, SNF had medication list/profile dated 3/25/2024 Maalox 15ml PO Q 4 hrs. PRN heartburn, this medication was not on the hospice agency medication profile. Corrected on site.

Upon patient record review, 1 of 14 (Patient #10) 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 #10: SOC date 11/1/2023, completed Bereavement assessment dated 11/7/2023 (6 days).

Upon patient record review, 2 of 14 (Patient #1, #2) 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: Order dated 10/5/2023 included O2 2L PRN SOB, no evidence of a route. Corrected on site. Patient #2: During home visit with patient in SNF, SNF had dated 3/25/2024 Maalox 15ml PO Q 4 hrs. PRN heartburn, this medication was not in the Hospice agency orders/POC. Corrected on site.

Upon patient record review, 2 of 14 (Patient #3, 11) 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 aide plan of care included "visit frequency of 1x 2 for bath and personal care". The tasks listed are nutrition-offer fluids/snack, tidy bathroom/bedside, companionship visit, report pain. Corrected on site to homemaker services. Patient #11: Patient had an O2 order, no evidence of Oxygen precautions on the aide Plan of care/assignment sheet.

Upon observation, there was no evidence the annual report documents the use of volunteers providing day to day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract personnel. Total for 2023 was 1.69%, Year to date 2024 is 1.47%.

Upon personnel record review, 1 of 13 (Personnel #2) did not have evidence the alternate administrator's personnel record verifies that: • The employee has appropriate education and experience requirements • There is a signed job description for this role • The employee has been orientated to this role Personnel #2: There was no evidence of a signed job description. Corrected on site.

Upon personnel record review, 3 of 13 (Personnel #1, #2, #8) did not have evidence of criminal background checks being obtained in accordance with state requirements. In the absence of state requirements, criminal background checks are obtained within three months of the date of employment for all states that the individual has lived or worked in the past 3 years. Personnel #1, #2, #8: No evidence of criminal background checks. Each of these individuals were employees of previous company, records cannot be located. OIG and Sex offender registry ran today for survey.