Every finding on record at Buena Vida Hospice LLC

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. Corrected on site.

Upon patient record review 1 of 14 (Patient #11) 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 #11: SOC 2/15/2023, the psychosocial assessment was completed on 4/13/23.

Upon patient record review 2 of 14 (Patient #3 and 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 #3: SOC 7/8/2021, there was no evidence of a psychosocial assessment. Patient #5: SOC 6/2/2023, there was no evidence of a psychosocial assessment.

Upon patient record review, 10 of 14 (Patient #1, #2, #3, #5, #6, #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 #1: An order dated 7/27/2023 included O2, there was no evidence of O2 on the medication profile. Corrected on site. Patient #2: The medication profile dated 11/2/2023 included Miralax 17GM/scoop, admin 2x day po for constipation. There was no evidence of a diluent. There is an order for O2 8/15/2022, there was no O2 on the medication profile. Corrected on site. Patient #3: The medication profile dated 7/13/2021 included Miralax 17GM/scoop, admin QD prn po for constipation. There was no evidence of a diluent. There is an order for O2 dated 7/8/2021, there was no O2 on the medication profile. Corrected on site. Patient #5: There is an order for O2 dated 6/2/2023, there was no o2 on the medication profile. Corrected on site. Patient #6: The medication profile date 3/4/2023 included Nitroglycerin SL 0.4mg one tab as needed for angina, there was no evidence of a limit or timing of the medication. Corrected on site. Patient #10: The medication profile dated 7/10/2023 included Miralax 17GM/scoop, admin 2x day po for constipation. There was no evidence of a diluent. An order for O2 dated 2/16/2023 exists, there was no o2 on the medication profile. Corrected on site. Patient #11: There is an order for O2 dated 2/15/2023, there was no evidence of O2 on the medication profile. Patient #12: There is an order for O2 dated 6/5/2023, there was no evidence of O2 on the medication profile. Patient #13: There is an order for O2 dated 2/21/2023, there was no evidence of O2 on the medication profile. Patient #14: There is an order for O2 dated 2/14/2023, there was no evidence of O2 on the medication profile.

Upon patient record review, 2 of 14 (Patient #3, #5) 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: There was no evidence of a bereavement assessment within 5 days in the comprehensive assessment. Patient #5: There was no evidence of a bereavement assessment within 5 days in the comprehensive assessment.

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

Upon patient record review, 10 of 14 (Patient #1, #2, #3, #5, #6, #7, #9, #10, #12, #13) 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: Pt SOC diagnosis is Alzheimer's and CHF. Pt has order for O2 and warfarin, there was no evidence of any problems/interventions for O2 safety, fall risk, and Bleeding precautions. Corrected on site. Patient #2: SOC diagnosis Parkinsons Ds, ASHD, DMll. Pt ordered O2, fall risk identified at SOC, new wound 7/29/2023. There was no evidence on the POC of problems/interventions for Neuro, Cardio/resp/O2, Endocrine/diet, or wound/integumentary. Corrected on site. Patient #3: SN SOC assess identifies fall risk 8>4, and pts takes Eloquis for anticoagulant. There was no evidence of Safety/Fall risk/bleeding precautions of the POC. Corrected on site. Patient #5: Order exists for O2, there was no evidence in the POC of a problem/interventions for O2. Corrected on site. Patient #6: SOC diagnosis was CHF, ASHD, PVD, and has an order for 02. There was no evidence of a problem/intervention for Cardio/Resp., along with O2 admin. Corrected on site. Patient #7: SOC diagnosis is Degenerative disorder of neuro system with Fall, fx hip, Pulmonary Embolism. Pt has order for O2. There was no evidence in the POC of a problem/interventions for Cardio/Resp. along with O2. Corrected on site. Patient #9: SOC diagnosis Senile degeneration of brain, CVA, Falls, has order for O2 There was no evidence of problem/interventions for safety/falls, neuro, or skin integrity related to incontinence and Respiratory for O2. Corrected on site. Patient #10: SOC diagnosis Cirrhosis Liver, Heart disease, on NP notes documented ascites of abdomen, has order for O2. There was no evidence on the POC of problem interventions for Cardio/Vascular/Fluid overload along with O2, or GI/Nutrition. Corrected on site. Patient #12: SOC SN assessment identified fall risk 6>4, pt has order for O2. There was no evidence on the POC of a problem/interventions for Fall risk or Oxygen. Patient #13: SOC diagnosis ASHD/Heart failure, pt has order for O2. There was no evidence on the POC of a problem interventions for Cardio/Respiratory along with O2.

Upon patient record review, 1 of 14 (Patient #5) 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 #5: There was an order for SN frequency on POC dated 7/24/2023, SN visits 1x week with 23 PRN visits (excessive). Corrected on site.

Upon patient record review, 4 of 14 (Patient #2, #3, #6, #10) 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: There is an order dated 11/2/2023 included Miralax 17GM/scoop, admin 2x day po for constipation. There was no evidence of a diluent. Corrected on site. Patient #3: There is an order dated 7/13/2021 included Miralax 17GM/scoop, admin QD po PRN for constipation. There was no evidence of a diluent. Corrected on site. Patient #6: There was an order for Nitroglycerin SL 0.4mg one tab as needed for angina, there was no evidence of a limit or timing of the medication. Corrected on site. Patient #10: There is an order dated 7/10/2023 included Miralax 17GM/scoop, admin 2x day po for constipation. There was no evidence of a diluent. An order for O2 dated 2/16/2023 included 02 2lpm via nc for SOB, no specification of continuous or PRN. Corrected on site.

Upon patient record review, 7 of 14 (Patient #2, #4, #5, #6, #8, #10, #13) 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 #2: Original POC at SOC dated 8/15/2022. There was no evidence of documentation of patients progress towards goals and outcomes, last documented on POC 10/5/2022. Patient #4: Original POC dated 11/3/2022. There was no evidence of documentation of patients progress towards goals and outcomes, last documented on POC 11/3/2022. Patient #5: Original POC dated 6/2/2023. There was no evidence of documentation of patients progress towards goals and outcomes, last documented on POC 6/2/2023. Patient #6: Original POC dated 3/4/2023. there was no evidence of documentation of patients progress towards goals and outcomes, last documented on POC 3/4/2023. Patient #8: Original POC dated 7/13/2023. there was no evidence of documentation of patients progress towards goals and outcomes, last documented on POC 7/13/2023. Patient #10: Original POC dated 2/16/2023. there was no evidence of documentation of patients progress towards goals and outcomes, last documented on POC 2/16/2023. Patient #13: Original POC dated 2/21/2023. there was no evidence of documentation of patients progress towards goals and outcomes, last documented on POC 2/21/2023.

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: RN placed all item from clean bag onto clean surface, used all items and placed back on same surface. RN cleansed all items and placed back on now dirty surface prior to returning to clean bag.

Upon observation, there was no evidence the hospice that is using contract personnel for core services met the following exception: The hospice may use contracted personnel, if necessary, to supplement hospice personnel in order to meet the needs of patients under extraordinary or other non-routine circumstances. A hospice may also enter into a written arrangement with another Medicare certified hospice program for the provision of core services to supplement hospice personnel to meet the needs of patients. Circumstances under which a hospice may enter into a written arrangement for the provision of core services include: unanticipated periods of high patient loads, staffing shortages due to illness or other short-term temporary situations that interrupt patient care; and temporary travel of a patient outside of the hospice's service area. Contracted RN carrying a case load of 8 patients on a routine basis. Corrected on site.

Upon patient record review, 1 of 14 (Patient #13) 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 #13: There was no evidence of a bereavement assessment following death or services offered for bereavement, with no development of a bereavement plan.

Condition of Participation: Hospice Aide and Homemaker Services. L607

Upon personnel record review, 1 of 13 (Personnel #6) 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 #6: Hired 8/18/2022. There was no evidence competency assessment was performed with a patient or pseudo patient.

Upon personnel record review, 1 of 13 (Personnel #5) did not have evidence that the RN who supervises classroom and practical training possesses a minimum of 2 years nursing experience, at least 1 year of which must be in home care. Personnel #5: Employee obtained RN in December of 2022.

Upon patient record review, 6 of 14 (Patient #1, #2, #3, #11, #13, #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 #1: SOC SN assessment included high risk of falls score 7 > 4. Patient takes Warfarin. Has order for O2. There was no evidence of fall precautions, O2 precautions or bleeding precautions on the HHA POC/Assignment sheet. Corrected on site. Patient #2: SOC SN assessment included high risk of falls score 5 > 4. Has order for O2. There was no evidence of fall precautions or O2 precautions on the HHA POC/Assignment sheet. Corrected on site. Patient #3: SOC SN assessment included high risk of falls score 7 > 4. Has order for O2. There was no evidence of fall precautions or O2 precautions on the HHA POC/Assignment sheet. Corrected on site. Patient #11: SOC SN assessment included high risk of falls score 5 > 4. Has order for O2. There was no evidence of fall precautions or O2 precautions on the HHA POC/Assignment sheet. Patient #13: SOC SN assessment included high risk of falls score 5 > 4. Has order for O2. There was no evidence of fall precautions or O2 precautions on the HHA POC/Assignment sheet. Patient #14: SOC SN assessment included high risk of falls score 5 > 4. Has order for O2. There was no evidence of fall precautions or O2 precautions on the HHA POC/Assignment sheet.

Upon patient record review 1 of 14 (Patient #1) 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 #1: Order dated 7/27/2023 included HHA visits 1x week x 8. There was no evidence of a visit or missed visit the SOC week 7/27/2023, or the week of 8/6/2023.

Upon patient record review 2 of 14 (Patient #2, #9) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs. Patient #2: Aide supervision performed on 7/17/2023 and 8/2/2023- 16 days apart. Patient #9: No evidence of aide supervision from 7/17/2023 first aide visit and 8/6/2023 last aide visit.

Upon observation, there was no evidence the hospice documents and demonstrates viable and ongoing efforts to recruit volunteers. Last documented recruitment efforts occurred in 2020.

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: Trained as CNA, Current Office Manager, signed JD 7/18/2023, does not meet the JD signed: There was no evidence the alternate administrator met the job description requirements (per resume provided) that include: (B) have a high school diploma or a general equivalency degree (GED) with at least two years of management or supervisory experience in a health-related setting, such as: (i) a home and community support services agency; (ii) a hospital; (iii) a nursing facility; (iv) a hospice; (v) an outpatient rehabilitation center; (vi) a psychiatric facility; (vii) an intermediate care facility for persons with mental retardation or related conditions; or (viii) a licensed health care delivery setting providing services for individuals with functional disabilities.io

Upon personnel record review, 1 of 13 (Personnel #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 #8: There was no evidence of a skills competency assessment.