Every finding on record at Athome Hospice Care LLC

Upon patient record review, 2 of 5 (Patient #4,5) 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 4 and 5 did not include any psychosocial goals or interventions on the plan of care.

Upon observation, there was no evidence the Emergency Preparedness plan: • Is based on and includes a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach • Includes strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care There was no evidence of a risk assessment. Corrected on site.

Upon review of policy and procedure, AD.E10 Emergency/Disaster Management did not include the process for the use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of state and federally designed health care professionals to address surge needs during an emergency.

Upon observation, there was no evidence of contracts/agreements with other facilities/agencies/hospices to receive patients in the event the hospice cannot provide care to their patients during an emergency. Corrected on site.

Upon observation, there was no evidence the hospice develops and maintains an emergency preparedness communication plan that complies with federal, state, and local laws and must be reviewed and updated every two years. There was no evidence of a communication plan. Corrected on site.

Upon patient record review, 3 of 14 (Patient #4, #6, #8) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient #4: There was an EOB, signed, blank area for name of Hospice, date EOB to commence or choice of attending physician. Patients #6, #8; There was no evidence the patient was allowed to choose a health care provider, there was no evidence of an EOB.

Upon patient record review, 2 of 14 (Patient #6, #8) did not have evidence of the appropriate documentation for release of confidential information. There was no evidence in the patient record for release of confidential information.

Condition of Participation: Initial and Comprehensive Assessment of the Patient.

Upon patient record review 2 of 14 (Patient #8, #14) 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 #8: SOC 3/9/2023, there was not evidence of a psychosocial assessment. Patient #14: SOC 3/14/2023, there was not evidence of a psychosocial assessment.

Upon patient record review 12 of 14 (Patient #1, #2, #3, #4. #5, #6, #7, #8, #10, #11, #12, #14) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patients #1, #2, #3, #4, #5, #6, #7, #8, #14: There was no evidence of a SC assessment. Patient #10, #11, #12: There was no evidence of a SW or SC assessment.

Upon patient record review, 11 of 14 (Patient #2, #4, #5, #7, #8, #9, #10, #11, #12, #13, #14) 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 #2: The med. profile dated 8/1/2023 included 02 2L/M, may increase up to 5L if 2L insufficient, no evidence of parameters or route. The medication orders dated 8/1/2023 included MS oral sol. 20mg/5ml 0.25ml Q4 hours for pain, and Tylenol ES 500mg Q 6 hours for mild/moderate pain. The MS did not specify when to administer. Corrected on site. Patient #4: The med. profile dated 9/27/2023 included Morphine and Oxycodone for pain, there were no parameters for when to administer for what level of pain, med. profile does not include ordered 02. Colace cap for soft stool 2x day hold if loose stool. No evidence of a route. Corrected on site. Patient #5: The med. profile dated 9/21/2023 did not include ordered 02. Corrected on site. Patient #7: The med. dated 3/22/2023 included Lidocaine patch transdermal 4%, 1 patch daily PRN, apply to affected area. There was no indication of an area to apply. Corrected on site. Patient #8: The med. profile dated 3/29/2023 included both Morphine and hydrocodone for pain control, no evidence of parameters on how to dispense, dated 3/9/2023 02 2L/M PRN SOB, may increase to 3L if 2L insufficient. There was no evidence of a route. Patient #9: The med. profile dated 3/5/3034 included Warfarin sodium oral tab 2.5mg, 1 tab as directed by anticoag. clinic. No evidence how to dispense. Patient #10: The med. profile dated 12/22/2022 included 02 2L/M PRN SOB, may increase to 3L if 2 L insufficient. There was no evidence of a route. Patient #11: The med. profile dated 12/1/2023 included both MS 5mg 1 tab PO for pain and Tylenol for mild or moderate pain, no clear direction for when to dispense MS, 02 2L/M PRN SOB may increase 3-6L if 2L insufficient, no route identified and no parameters for titration. Patient #12: The med. profile included two entries for MS, dated 4/4/2023 MS 10mg/5ml give 5ml Q 4 hrs PO PRN Pain or SOB. Order dated 4/18/2023 MS oral sol. 100mg/5ml, 0.25 ml Q 4hrs PRN Pain SOB, no parameter as to how to dispense. Patient #13: The med. profile dated 3/28/2023 included Hydromorphone oral liq.1mg/ml, 1 ml PO Q 4 hr PRN Pain/dyspnea, and MS concentrate 100mg/5ml, give 0.5 ml PO Q 4hr PRN pain, no evidence of parameters for dispensing. Patient #14: Order dated 3/14/2023 included 02 2L/M via N/C for SOB, may increase 3-5L if ineffective. No evidence of parameters for titration.

Upon patient record review, 1 of 14 (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: There was no evidence of a bereavement assessment.

Upon patient record review, 1 of 14 (Patient #7) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual's attending physician, if any) • Changes that have taken place since the initial assessment • Information on the patient's progress toward desired outcomes • Reassessment of the patient's response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days Patient #7: No evidence of an updated comprehensive assessment 9/30/2023-10/19/2023, 19 days.

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

Upon patient record review, 9 of 14 (Patient #1, #2, #3, #4, #5, #6, #7, #8, #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: SN/SW on SOC notes "normal anticipatory grief, Pt is sad, no evidence on POC for problems/interventions/goals for anticipatory grief. Corrected on site. Patient #2: SW on SOC notes "daughter experiencing anticipated grief and loss as expected", no evidence on POC for problems/interventions/goals for anticipatory grief. Corrected on site. Patient #3: SN/SW On SOC notes: "Rapid change in condition, normal anticipatory grief" and bereavement assessment identified Hi risk for bereavement, no evidence on POC for problems/interventions/goals for anticipatory grief, or bereavement. Corrected on site. Corrected on site. Patient #4: SW on SOC notes "normal anticipatory grief" and daughter in law quit job to care for patient and is seeking IHSS hours to supplement income, no evidence on POC for problems/interventions/goals for anticipatory grief, or caregiver assistance. SN on SOC patient admit diagnosis is TIA/Dementia, takes Plavix to prevent clotting, no evidence on POC for problems/goals/interventions for neuro or bleeding precautions. Corrected on site. Patient #5: SN/SW on SOC notes "difficulty coping", "normal anticipatory grief", terminal diagnosis is Malignant neoplasm of Brain/Lung, no evidence on POC for problems/interventions/goals for anticipatory grief, or neuro/seizure precautions. Corrected on site. Patient #6: SN/SW notes "normal anticipatory grief', high risk for bereavement, no evidence on POC for problems/interventions/goals for anticipatory grief/bereavement. Corrected on site. Patient #7: SW notes "normal anticipatory grief", high risk for bereavement, no evidence on POC for problems/interventions/goals for anticipatory grief/ bereavement. Terminal diagnosis is kidney failure stage 5, SN notes difficulty chewing and swallowing, pt. is on Heparin Q 12 hours, there was no evidence on the POC for problems/interventions/goals for Aspiration/Fluid overload or bleeding precautions. Corrected on site. Patient #8: SN SOC notes difficulty chewing and swallowing no evidence on POC for problems/interventions/goals for aspirations. Patient #10: SN SOC terminal diagnosis Chronic resp. failure, CHF, COPD. Patient is on a mechanical ventilator with a tracheostomy, has a peg tube and ostomy, history of seizures, at risk of aspiration, takes Eloquis, and 02.The POC has no evidence of problems. interventions/goals for cardio/respiratory, GI/Peg tube/ostomy/Aspiration precautions, Neuro/seizure precautions, and Bleeding precautions/safety.

Upon patient record review, 1 of 14 (Patient #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 #3: Order dated at SOC 2/10/2023 included MSW as needed. No evidence of a specific order for frequency.

Upon patient record review, 10 of 14 (Patient #2, #4, #5, #7, #8, #9, #11, #12, #13, #14) 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 #2: The medication orders dated 8/1/2023 included MS oral sol. 20mg/5ml 0.25ml Q4 hours for pain, and Tylenol ES 500mg Q 6 hours for mild/moderate pain. The MS did not specify when to administer. Corrected on site. Patient #4: Order dated 9/27/2023 included Morphine and Oxycodone for pain, there were no parameters for when to administer MS, Albuteral Sulfate inh. neb. Q 6 hours for "breathing", no evidence of specifics for administration. Corrected on site. Patient #5: Order dated 9/21/2023 included 02 2L/min via N/C for SOB, may increase to 5L if ineffective. There was no evidence of parameters for administration. Corrected on site. Patient #7: Order dated 3/22/2023 included Lidocaine patch transdermal 4% 1 patch daily PRN, apply to affected area. There was no indication of an area to apply. Corrected on site. Patient #8: Order dated 3/29/2023 included both Morphine and hydrocodone for pain control, no evidence of parameters on how to dispense. Patient #9: Order dated 3/5/3034 Warfarin sodium oral tab 2.5mg, 1 tab as directed by anticoag. clinic. No evidence how to dispense. Patient #11: Order dated 12/1/2023 included both MS 5mg 1 tab PO for pain and Tylenol for mild or moderate pain, no clear direction for when to dispense MS, no evidence of orders for 02 (on medication profile). Patient #12: Two orders for MS, dated 4/4/2023 MS 10mg/5ml give 5ml Q 4 hrs PO PRN Pain or SOB. Order dated 4/18/2023 MS oral sol. 100mg/5ml, 0.25 ml Q 4hrs PRN Pain SOB, no parameter as to how to dispense. Patient #13: Orders dated 3/28/2023 included Hydromorphone oral liq.1mg/ml, 1 ml PO Q 4 hsr PRN Pain/dyspnea, and MS concentrate 100mg/5ml, give 0.5 ml PO Q 4hr PRN pain, no evidence of parameters for dispensing. Patient #14: Order dated 3/14/2023 included 02 2L/M via N/C for SOB, may increase 3-5L if ineffective. No evidence of parameters for titration.

Upon patient record review, 3 of 14 (Patient #8, #11, #14) 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 #8: SW initial visit 18 days post SOC, identified need for anticipatory grieving and family assistance for food stamps, and Medicare, there was no evidence of a revised POC for problems/interventions/goals for anticipatory grieving or community/insurance resources. Patient #11: SOC date 12/1/2022. On SN note dated 12/27/2023 the patient was exhibiting a sacral pressure wound. There was no evidence on the update POC to include this wound. Patient #14: SW initial visit 18 days post SOC, identified need for anticipatory grieving, there was no evidence of a revised POC for problems/interventions/goals for anticipatory grieving.

Upon client record review, 1 of 14 (Patient #12) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #12: Order dated at SOC SN 2x week, there was no evidence of a second visit or missed visit week1.

Upon observation, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient #1: Aide reached into clean bag with dirty gloves to retrieve items to obtain vitals, cleansed all items and placed back into bag with dirty gloves. Patient #2: LVN placed bag on barrier on floor (against policy PCl10) and removed clean items from bag reaching in with dirty gloves. Patient #3: LVN used one pair of gloves for all care, not changing after pt care and prior to cleaning items used to obtain vitals.

Upon observation, there was no evidence in QAPI reports that the hospice maintains a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the hospice's Quality Assessment and Performance Improvement program. There was no evidence of surveillance related to employee illnesses.

Upon observation, there was no evidence the hospice is in compliance with accepted professional standards and principles for all non-core services which includes physical therapy, occupational therapy and speech-language pathology. The agency was had a paid "volunteer".

Upon patient record review, 8 of 14 (Patient #2, #4, #5, #7, #8, #10, #11, #14) 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: Patient has 02, there was no evidence on the aide assignment/POC for 02 precautions. Corrected on site. Patient #4: Patient has 02 and takes Plavix, no evidence on aide assignment/POC for 02 and bleeding precautions. Corrected on site. Patient #5: Patient has 02, and diagnosis of brain CA, no evidence on aide assignment/POC for 02 and seizure precautions. Corrected on site. Patient #7: Patient on heparin, known to have chewing and swallowing difficulty, no evidence on aide assignment/POC for bleeding and aspiration precautions. Corrected on site. Patient #8: Patient has 02, aspiration risk identified on SN SOC, patient diagnosis of HIV, no evidence on POC for problems/interventions/goals for 02 precautions, universal precautions, or risk of aspirations. Patient #10: Patient has 02, mechanical vent/trach, ostomy, peg tube, takes Eloquis, and has seizure history. There is no evidence on the aide POC/assignment for Peg/Ostomy/trach/vent, aspiration/bleeding/02/seizure precautions. Patient #11: Identified on SN SOC as high risk for falls, no evidence on aide POC/assignment of pt at risk for falls. Patient #14: Patient has 02, no evidence on aide POC/assignment for 02 precautions.

Upon patient record review 6 of 14 (Patient #4, #5, #6, #7, #10, #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 • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #4: Order dated 9/27/2023 Aide visits 1x week. There was no evidence of a visit or missed visit the first week of care, first visit occurred 10/6/2023. Patient #5: Order dated 9/21/2023 Aide visits 1x week, this order continued in IDG/POC 9/22/2023, 10/6/2023, 10/21/2023. No evidence of HHA visits since start of care. Patient #6: Order dated 8/2/2023 Aide visits 2x week. there was no evidence of visits or missed visits week 1. Patient #7: Order dated 3/22/2023 Aide visits 1x week, no evidence of a visit or missed visit week of 10/15/2023. Patient #10: Order dated 12/22/2022 Aide visits 1x week, no evidence of visit or missed visit week 1. Patient #12: Order dated 4/4/2023 Aide visits 2x week, no evidence of visit or missed visit for week 1.

Upon observation, there was no evidence volunteers are used in day to day administrative and/or direct patient care roles. Corrected on site.

Upon observation, there was no evidence the hospice documents and demonstrates viable and ongoing efforts to recruit and retain volunteers.

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 On the day of survey no volunteer available and agency had used paid "volunteer" in past.

Upon patient client record review, 3 of 14 (Patient #4, #6, #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 #4: There was an EOB, signed, blank area for name of Hospice, date EOB to commence or choice of attending physician. Patients #6, #8: There was no evidence of consents or an EOB.

Upon patient client record review, 3 of 14 (Patient #7, #8, #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 #7: Order dated 3/22/2023, which continues until present day for Cefazolin sodium 1GM IV Q 24 hours, medication was provided in acute care setting and never given in Hospice setting. Corrected on site. Patient #8: Order dated 3/7/2023 transfer to other hospice per patient request. Patient in fact went to ER, revoked care. Patient #10: There is a live discharge note from SN dated 1/4/2023 stated dc for cause. NOMNC form signed for 1/4/2023- dated 12/29/2022. Pt actually revoked service to return to Home Health.

Upon client record review, 1 of 14 (Patient #9) did not have evidence that the hospice forwarded a summary and a copy of the patient record, if requested, to a facility when transferring the patient to that facility. Patient #9: Patient transferred to another hospice. There was no evidence of a transfer summary.

Upon client record review, 2 of 14 (Patient #8, #11) 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 #8, #11: The discharge summary had no evidence of forwarding to attending physician.

Upon client record review, 3 of 14 (Patient #8, #10, #11) did not have evidence that the discharge summary includes all required information. Patients #8, #10, #11: Discharge summaries did not include: a summary of the patient's stay, including treatments, symptoms and pain management, the patient's current plan of care, or the patient's latest physician orders.

Upon observation, there was no evidence the hospice provides orientation to personnel of a SNF/NF or ICF/IID regarding the policies and procedures of the provision of care/service including all required content.