Every finding on record at Bright Life Hospice Inc.

Condition of Participation: Patient’s Rights.

Upon observation, there was no evidence that during the initial assessment visit in advance of furnishing care, the hospice provided the patient and/or family with verbal (meaning spoken) and written notice of the Patient's Rights and Responsibilities in a language and manner that the patient understands. Patient #2, 15: Patient admission consents/election signed by "Bioethics Committee", with no evidence of legal representative for authorization of service.

Upon patient record review, 2 of 15 (Patient #2, 15) did not have evidence that the hospice informed and provided written information to the patient concerning its policies on advance directives, including a description of applicable state law. Patient #2, 15: Patient admission consents/election signed by "Bioethics Committee", with no evidence of legal representative for authorization of service.

Upon patient record review, 2 of 15 (Patient #2, 15) did not have evidence that the hospice obtained the patient's or representative's signature confirming that they received a copy of the Patient's Rights and Responsibilities. Patient #2, 15: Patient admission consents/election signed by "Bioethics Committee", with no evidence of legal representative for authorization of service.

Upon observation, there was no evidence the patient has the right to voice grievances/complaints regarding treatment or care that is (or fails to be) furnished and lack of respect of property by anyone who is furnishing care/service on behalf of the hospice. Patient #2, 15: Patient admission consents/election signed by "Bioethics Committee", with no evidence of legal representative for authorization of service.

Upon patient record review, 2 of 15 (Patient #2, 15) did not have evidence that if a state court has not adjudged a patient incompetent, any legal representative designated by the patient in accordance with state law may exercise the patient's rights to the extent allowed by state law. Patient #2, 15: Patient admission consents/election signed by "Bioethics Committee", with no evidence of legal representative for authorization of service.

Upon client record review, 2 of 15 (Patient #2,15) did not have evidence that the plan of care included IDG's documentation of the patient's or families level of understanding, involvement and agreement with the plan of care. Patient #2, 15: Patient admission consents/election signed by "Bioethics Committee", with no evidence of legal representative for authorization of service.

Upon patient record review, 2 of 15 (Patient #2, 15) did not have evidence that the patient chooses a health care provider, including an attending physician.

Upon patient record review, 2 of 15 (Patient #2, 15) did not have evidence of the appropriate documentation for release of confidential information. Patient #2, 15: Patient admission consents/election signed by "Bioethics Committee", with no evidence of legal representative for authorization of service.

Upon patient record review, 2 of 15 (Patient # #2, 15) did not have evidence that the patient received information about the services covered under the hospice benefit. Patient #2, 15: Patient admission consents/election signed by "Bioethics Committee", with no evidence of legal representative for authorization of service.

Upon patient record review, 2 of 15 (Patient #2, 15) did not have evidence that the patient received information about the scope of services that the hospice will provide and specific limitations on those services. Patient #2, 15: Patient admission consents/election signed by "Bioethics Committee", with no evidence of legal representative for authorization of service.

Upon patient record review 1 of 15 (Patient #5) 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 #5: There is no documented evidence of a spiritual assessment by RN, SC or MSW. SC frequency is declined.

Upon patient record review, 1 of 15 (Patient #2) 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: There is documentation the patient has no family or friends, but there is no related psychosocial problems, goals, interventions.

Upon client record review, 1 of 15 (Patient #1) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1: MSW and SC frequency order as 1 every recertification and 1 prn. There were no SC or MSW visits made beyond start of care including at time of recertification period 6/7/25.

Upon patient record review, 4 of 15 (Patient #1, 2, 11, 14) did not have evidence that the IDG shares information on a on-going basis with non-hospice healthcare providers furnishing services unrelated to the terminal illness and related conditions. Patient #1: ALF resident with Foley catheter and no specified accountability for Foley maintenance including changes. Interview with RN during visit stated "a nurse from the skilled side goes" to ALF to change as needed. Patient #1, 2, 11, 14: ALF residents with existing wounds and contracted specialized wound care services. Wound care contracts reference coordination, and copies of notes are provided. Orders are consistent, but Hospice Plan of Care does not specify accountability/coordination regarding wound care provider services and agency communications with provider are note documented in IDG/Plan of Care.

Upon observation, there was no evidence the hospice is in compliance with accepted professional standards and principles for all core services which includes nursing services, medical social services and counseling services. interview, 1 of 13 (Personnel #1) was not able to describe the process of disposing of controlled drugs when the drugs are no longer needed by the patient. Patient visits made with Administrator/DPCS. When questioned regarding disposal, she appropriately stated process for destroying medications to be discarded, but she added that sometimes she just takes the meds home and does it herself because she isn't sure the caregiver will do it. Surveyor questioned if that is agency's policy/process and her response was no, but she doesn't know they all will do it correctly. During policy review, surveyor noted Policy No 4-4054.1 clearly states "Hospice personnel will not dispose of any patient medications." In addition, this is not in compliance with accepted professional standards, specifically PUBLIC LAW 115–271, CHAPTER 3—SAFE DISPOSAL OF UNUSED MEDICATION, SEC. 3222. DISPOSAL OF CONTROLLED SUBSTANCES OF A HOSPICE PATIENT BY EMPLOYEES OF A QUALIFIED HOSPICE PROGRAM. (a) IN GENERAL.—Subsection (g) of section 302 of the Controlled Substances Act (21 U.S.C. 822) is amended by adding at the end the following: ‘‘(5)(A) In the case of a person receiving hospice care, an employee of a qualified hospice program, acting within the scope of employment, may handle, without being registered under this section, any controlled substance that was lawfully dispensed to the person receiving hospice care, for the purpose of disposal of the controlled substance so long as such disposal occurs onsite in accordance with all applicable Federal, State, Tribal, and local law..."

Upon personnel record review, 1 of 13 (Personnel #5) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) ·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. Personnel #5: Hospice Aide competency form utilized by agency does not include all 3 types of shampoos, therefore, competency cannot be verified.

Upon patient record review, 1 of 15 (Patient #2) 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 diagnosis of seizures and medications prescribed for seizure disorder. Seizure precautions is blank on hospice aide care plan assignment.

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 as evidenced by the Administrator not following acceptable standards of practice or agency policy for proper medication disposal, specifically narcotics. In addition, the agency is not following state guidelines for patients who are unable to consent to the election of hospice and understand their rights and responsibilities.

Upon contract review, 2 of 6 (Allcare and Omni Wound Care contracts) did not have evidence the agreement to furnish any services under arrangement included that the hospice must retain administrative and financial management, and oversight of staff and services for all arranged services, to ensure the provision of quality care. Arranged care/services are supported by written contract/agreement that requires all care/services are: • Authorized by the hospice • Furnished in a safe and effective manner by qualified personnel • Delivered in accordance with the patient's plan of care Contracts do not clearly state services to be authorized by hospice.

Upon patient record review, 2 of 15 (Patient #7, 12) 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 Patients #7, 12: There is no documented narrative to support prognosis for initial certifications, the allocated space includes certification statement only. Patient #7 has a documented Face-to-Face encounter, but there is no information transcribed or specifically referenced in certification narrative.

Upon patient client record review, 3 of 15 (Patient #2, 3, 15) 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 #2, 15: Patient admission consents/election signed by "Bioethics Committee", with no evidence of legal representative for authorization of service. Patient #3: Patient chose to receive Notification of Non-Covered Items and Services, but there was no evidence that a completed form was provided.

Upon patient client record review, 2 of 15 (Patient #11,14) 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 #11: 5/23/25 SN noted documented wound care provided with no specifics of treatment performed. Patient #14: 3/4/25 initial RN assessment documentation includes skin assessed and wound care done with no specifics of treatment performed.

Upon client record review, 1 of 15 (Patient #5) did not have evidence that the discharge summary includes all required information. Patient #5: Patient revoked participation in hospice. DC Summary included details of services provided that were inaccurate.

Upon client record review, 2 of 15 (Patient #2, 15) did not have evidence that the written policies and procedures for managing controlled drugs was provided and discussed. Patient #2, 15: Patient admission consents/election signed by "Bioethics Committee", with no evidence of legal representative for authorization of service.

Upon client record review, 2 of 15 (Patient #4, 7) did not have evidence that a written hospice plan of care is established and maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided is in accordance with this hospice plan of care. Patient #4: During patient visit, noted SNF resident had Foley discontinued (reportedly in recent days) with no update to Plan of Care and no clear accountability/explanation or specific date or order from either facility or hospice, at time of survey. SNF resident admitted with indwelling catheter, but there were no related problem, goals, interventions. Patient #7: The SNF resident has Heparin subcutaneous injections ordered every 8 hours. The related problems goals and interventions include teaching to caregiver. There is no evidence the teaching occurred, but the patient is resident of facility and interventions should be more focused on coordination, compliance with administration.

Upon client record review, 3 of 15 (Patient #4, 5, 12) did not have evidence that the hospice plan of care identifies the care and services that are needed and specifically identify which provider (nursing facility or hospice) is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care. Patients #4, 5, 12: SNF residents with indwelling Foley catheters and orders for prn changes. The Plan of Care does not specify accountability/coordination related to catheter changes.

Upon observation, there was no evidence the organizational chart matches the hospice's information submitted to CMS and/or State licensing agencies for ownership and management personnel. Administrator/DPCS date of hire 12/01/24 and Alt Admin/Alt DPCS date of hire is 03/01/25. There was no evidence of enrollment addendum by end of survey. CA 215 presented, but no evidence of date submitted.

Upon patient record review, 5 of 5 (Patient's #1, #2, #3, #4 and #5) 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. Patient #1: This patient had a walker. This item was not included on the Plan of Care. Patient #2: This patient had a walker. This item was not included on the Plan of Care. Patient #3: This patient had a cane. This item was not included on the Plan of Care. Patient #4: The record reflected that this patient had a walker. This item was not included on the Plan of Care. Patient #5: The record reflected that this patient had a walker and cane. These were not included on the Plan of Care.