Every finding on record at Blue Sky Hospice Inc

Upon personnel record review, 1 of 8 (Personnel #8 ) did not have evidence that all Speech Therapy Services are provided by a qualified licensed Speech-Language Pathologist (SLP) or Audiologist in accordance with the state's Speech-Language Pathology Practice Act and the hospice's policies and procedures and/or job descriptions. Personnel #8 ST personnel file not available to review and did not show evidence of appropriate certification

Upon personnel record review, 1 of 8 (Personnel #7 ) did not have evidence all Occupational Therapy Services are provided by a qualified licensed Occupational Therapist (OT) in accordance with the state's Occupational Therapy Practice Act and the hospice's policies and procedures and/or job descriptions. Personnel #7 OT personnel file did not contain evidence of education and credentials

Upon personnel record review, 2 of 8 (Personnel #7 and #8) did not have evidence the hospice obtained a criminal background check on all contracted individuals who have direct patient care and access to patient records.

Upon personnel record review, 2 of 8 (Personnel # 7 & #8) did not have evidence that all personnel have been fully vaccinated for COVID-19.

Upon personnel record review, 9 of 9 (Personnel #1,2,3,4,5,6,7,8,9) did not have evidence Emergency Preparedness training including: • Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles • Demonstrate staff knowledge of emergency procedures • Provide emergency preparedness training at least annually • Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others • Maintain documentation of all emergency preparedness training Personnel #1,2,3,4,5,6,7,8,9 There is no evidence in the employee records of Emergency Preparedness training.

Upon patient record review, 11 of 11 (Patient #1,2,3,4,5,6,7,8,9,10,11) did not have evidence of the appropriate documentation for release of confidential information. Patient #1,2,3,4,5,6,7,8,9,10,11 There is no evidence in the patient record of signed agreement for release of confidential information.

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

Upon patient record review 1 of 11 (Patient #1) did not have evidence in the patient record that the hospice conducted and documented in writing a patient-specific comprehensive assessment that identifies the patient's need for hospice care and services, and the patient's need for physical, psychosocial, emotional, and spiritual care. This assessment includes all areas of hospice care related to the palliation and management of the terminal illness and related conditions. Patient #1 admitted 12/29/22 no evidence of an initial nursing assessment or initial spiritual assessment and no evidence of a medication profile.

Upon patient record review 9 of 11 (Patients #2,3,4,5,6,7,8,10,11) 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. Patient #2, 5 There is no evidence of a spiritual care assessment completed at the time of admit and to date. Patient #3, 4, 6, 7, 8, 10, 11 There is no evidence of a spiritual care assessment or psychosocial assessment completed.

Upon patient record review, 1 of 11 (Patient #3) 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 #3 The patient resides in an assisted living facility and received furosemide 20 mg PO daily, that is not included in the plan of care and has not been reviewed. The patient also has PRN orders for hydrocodone/acetaminophen 5-325mg Q6hours, Lorazepam 2mg/ml conc 0.5ml every 6 hours and prochlorperazine 10mg 1 tab every 8 hours that have not been reviewed or added to the plan of care. There are 9 medications listed in the hospice plan of care that are not included in the active orders at the assisted living facility. There is no evidence of a medication reconciliation between the ALF and the hospice agency.

Upon patient record review, 7 of 11 (Patient #2, 3, 6, 7, 8, 10, 11) 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 #3, 4, 6, 7, 8, 10, 11 There is no evidence in the patient records of a completed bereavement assessment within 5 days or to date.

Upon patient record review, 6 of 11 (Patient #3, 4, 7, 11) 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 #3 The patient was treated for an infection to the left lower extremity on 8/15/22 with doxycycline 1 PO BID x 7 days. There is no reassessment of the patient response to care or evidence of progress toward the desired outcome. Patient #4 The patient plan of care has not been updated to reflect the current status of pain management for the patients. The goal was set that the patient would report her pain level as 4 or less within 24 hours of admit on 11/25/22. Patient #7 There is evidence in the patient record that the patient was treated for a wound infection on 7/22/22 with Bactrim 800/160 BID x 10 days, there is no reassessment or evidence of the patient response to care or progress toward desired outcomes. Patient #11 There is evidence in the patient record that the patient was treated with Bactrim DS PO BID x 7 days starting on 9/1/22 for UTI, there is no reassessment or evidence of the patient response to treatment or progress toward the desired outcome.

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

Upon client record review, 1 of 11 (Patient #1) did not have evidence that the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions as identified in the comprehensive assessment. Patient #1 admitted 12/29/22 no evidence of a plan of care to include orders, medications (present on home visit with RN), visit frequencies, problems/goals/interventions, and RN and SW completed visits without orders.

Upon patient record review, 2 of 11 (Patient #2 and 6) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient #2 The patient began treatment on 12/27/22 with Keflex 500mg TID x 7 days for a wound infection. There is no reassessment of the patient response to care. Patient #6 There is evidence in the patient record that the patient was treated for "pink eye" with neomycin-polymycin-dexamethasone opth solution x 5 days starting on 12/26/22, there is no evidence of reassessment of the patient response to care.

Upon patient record review, 7 of 11 (Patient #2, 3, 5, 6, 7, 8, 11) 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 #2 The patient began treatment on 12/27/22 with Keflex 500mg TID x 7 days for a wound infection. There is no identified problem statement with interventions and goals. The patient has problem statements entered for spiritual care, but there are no orders for spiritual care services and no assessment has been completed for patient/family needs. Patient #3 There is evidence in the patient record that the patient has a wound to the coccyx and an additional wound to the LLE, there is no identified problem statement with goals or interventions. The patient was treated for an infection to the left lower extremity on 8/15/22 with doxycyline 1 PO BID x 7 days. There is no problem statement with interventions and goals entered into the plan of care. The patient has problem statements entered for spiritual care and psychosocial needs, but there are no orders for spiritual care or social work services and no assessment has been completed for patient/family needs. Patient #5 The patient has problem statements entered for spiritual care, but there are no orders for spiritual care services and no assessment has been completed for patient/family needs. Patient #6 There is evidence in the patient record that the patient was treated for "pink eye" with neomycin - polymycin-dexamethasone opth solution x 5 days starting on 12/26/22, there is no problem statement with interventions or goals. The patient has problem statements entered for spiritual care and psychosocial needs, but there are no orders for spiritual care or social work services and no assessment has been completed for patient/family needs. Patient #7 There is evidence in the patient record that the patient was treated for a wound infection on 7/22/22 with Bactrim 800/160 BID x 10 days. There is no problem statement added to the plan of care to address the interventions or goals for the treatment. Patient #8 There is evidence in the patient record that the patient had wounds to the LLE and to the coccyx at the time of admission. The plan of care does not establish treatment orders or a problem statement with interventions and goals for treatment. Patient #11 There is evidence in the patient record that the patient was treated with Bactrim DS PO BID x 7 days starting on 9/1/22 for UTI. There is no problem statement for interventions or goals included in the plan of care.

Upon patient record review, 2 of 11 (Patient #3, 8) 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 #3 The plan of care does not include orders for furosemide 20 mg PO daily, hydrocodone/acetaminophen 5-325mg PO Q6hours PRN pain, Lorazepam 2mg/ml conc 0.5ml Q6 hours PRN anxiety and prochlorperazine 10mg 1 tab every 8 hours PRN nausea/vomiting. The patient has a wound to the coccyx requiring wound care. The plan of care does not contain wound care orders for treatment. Patient #8 The patient record identifies wounds to the coccyx and the left lower extremity. The plan of care does not include wound care orders for treatment.

Upon client record review, 3 of 11 (Patient #1, 2 and 4) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1 RN visit completed on 1/4/23, no evidence of frequency orders for this patient and SW visit at admission without an order. Patient #2 There is evidence in the patient record that the patient was treated for a wound to the left lower extremity, there are no wound care orders included in the plan of care. Patient #4 The plan of care includes orders for spiritual care 1 x per month, there is no evidence in the patient record of a SC visit for December.

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. Home Visit #3 The RN did not place a barrier between her bag and the patients over bed table. The RN failed to wash or sanitize her hands prior to providing patient care. The RN wore a pair of gloves while providing wound care and did not change the gloves after removing soiled dressing and prior to placing clean dressings. The RN picked up her ink pen while providing wound care and entered documentation with her gloves on and then continued to complete her wound care with the gloved hands. The RN did not clean or sanitize any of her assessment tools (stethoscope, thermometer, blood pressure cuff, oxygen sensor or ink pen) before or after use. The RN removed her assessment tools from her nursing bag and returned them to the same bag without cleaning or sanitizing. Upon removal of soiled wound dressings, the RN placed them onto a bed of another person assigned to the patient room instead of into a garbage bag.

Upon patient record review, 2 of 11 (Patient #7, 8) did not have evidence the hospice offers bereavement counseling that includes: • Making bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. Bereavement counseling also extends to residents of a SNF/NF or ICF/IID when appropriate and identified in the bereavement plan of care • Ensuring that bereavement services reflect the needs of the bereaved • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery Patient #7 & #8 There is no evidence that bereavement services were offered at the time of death, a bereavement assessment was not completed at the time of death.

Condition of Participation: Physical Therapy, Occupational Therapy, and Speech-Language Pathology.

Upon observation, there was no evidence the hospice ensures that non-core services are provided to hospice patients and their families according to applicable laws and regulations. Non-core services include Physical Therapy, Occupational Therapy and Speech-Language Pathology. The hospice agency is unable to provide non-core services, there is no evidence of a valid therapy contract for PT/OT/SP services.

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. There is no evidence of oversight of the agency as evidence by the following: Agency has a functioning medical director however no evidence of a signed contract for the medical director. No evidence of a contract or person identified to fulfill the role of alternate medical director. No evidence of the ability to provide non-core services such as PT, OT, ST as evidence by no contract for therapy services. Personnel records did not have evidence of background check, completion of orientation, job description, competency, orientation to hospice philosophy, I-9 documents, or emergency preparedness training. One recent admission on service for 6 days did not have evidence of a current plan of care, no orders, no evidence of initial comprehensive assessment, no medication profile, and visits completed without orders. In addition, Upon personnel record review, 1 of 9 (Personnel #3) 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 #3 The employee file does not include evidence of education, experience or orientation to the role, there is no signed job description in the employee file.

Upon personnel record review, 9 of 9 (Personnel #1,2,3,4,5,6,7,8,9) did not have evidence the hospice employees and contract employees have received orientation on the hospice philosophy. Personnel #1,2,3,4,5,6,7,8,9 There is no evidence in the employee record that the employee has received orientation to the hospice philosophy.

Upon personnel record review, 9 of 9 (Personnel #1,2,3,4,5,6,7,8,9 ) did not have evidence that the hospice employees have received orientation on their specific job requirements. Personnel #1,2,3,4,5,6,7,8,9 There is no evidence in the personnel file that the employee has received orientation on their specific job requirements.

Upon personnel record review, 8 of 9 (Personnel #1,2,3,4,5,6,7,8) did not have evidence that a skills competency assessment, specific to each discipline had been conducted for all personnel including volunteers initially during orientation. Personnel #1,2,3,4,5,6,7,8 There is no evidence in the employee record that a skills competency was completed during orientation or to date.

Condition of Participation: Medical Director.

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 hospice agency is unable to provide evidence of a designated (alternate) Medical Director.

Upon contract review, 1 of 4 (Medical Director and Alternate Medical Director) did not have evidence of a contract to fulfill the role of medical director or alternate medical director.

Upon patient record review, 1 of 11 (Patient #5) did not have evidence that the medical director or physician designee provides written certification that it is anticipated that the patient's life expectancy is 6 months or less if the illness runs its normal course. The physician must consider the following when making this determination: • The primary terminal condition • Related diagnosis • Current subjective and objective medical findings • Current medication and treatment orders • Information about the medical management of any of the patient's conditions unrelated to the terminal illness Patient #5 The patient was admitted on 12/15/22, the patient record does not contain a written certification of terminal illness for benefit period #1.

Upon patient record review, 1 of 11 (Patient #11) did not have evidence that if a drug order is verbal or given via an electronic transmission, it is given to a Registered Nurse, Nurse Practitioner, pharmacist, physician or other licensed individuals as designated by state regulations. The person receiving the order records and signs it immediately and has the prescribing person sign it in accordance with state and federal regulations. Patient #11 A verbal order for Bactrim DS PO BID x 7 days was received by the RN on 9/1/22. The order was not signed by the RN or the physician.

Upon personnel record review, 1 of 9 (Personnel #9) did not have evidence the hospice obtained a criminal background check on all contracted individuals who have direct patient care and access to patient records. Personnel #9 There is no evidence in the personnel record that a background check was completed on the contracted individual.

Upon personnel record review, 8 of 9 (Personnel #1,2,3,4,5,6,7,8) 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 #1,2,3,4,5,6,7,8 There is no evidence in the personnel files of a background check completed.