Every finding on record at C&W Investments 2020

Upon patient record review, 3 of 14 (Patient #2,#4,#7) 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 record indicates patient oxygen dependent. There is no oxygen on medication profile. Corrected on site. Patient#4: The record indicates patient was ordered Oxygen 2-5 lpm NC PRN. At group home patient has lidocaine 4% patches that the caregiver indicates patient is using. There is no evidence of these items on the medication profile. Corrected on site. Patient #7: The record indicates alogliptine benzoate 25mg 1 daily on the agency medication profile. These are not listed on medication list in group home. Group home states patient is not receiving these. Ondensetron 4mg 1 daily is listed on the the group home but is not on the agency medication profile. Group home states patient refuses this medication daily. Agency discontinued this item. Diltiazem 24hr ER 1 by mouth daily is listed on the group home MAR but is not listed on agency medication profile. The patient is receiving this medication. All items were corrected on site.

Upon patient record review, 5 of 14 (Patient #1,#4,#6,#7.#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: The record indicates patient has been ordered oxygen 2-5lpm PRN NC. The record also indicates patient has needs regarding incontinence, fall prevention, dyspnea with exertion, and fluid retention. There is no evidence of interventions or goals for these items on the plan of care. Corrected on site. Patient#4: The record indicates the patient was ordered oxygen 2-5lpm PRN NC. The record also indicates per nurse documentation that patient is taking levetiracetam for seizures, has shortness of breathe with activity, and incontinence. There is no evidence of interventions or goals related to these items. Corrected on site. Patient#6: The record indicates the patient is at risk for falls per nursing documentation however, no interventions or goals related to this. Corrected on site. Patient #7: The record indicates that the patient is ordered oxygen and requires treatment for constipation according to nurses documentation. There is no evidence of interventions or goals related to these needs. Corrected on site Patient #10: The record indicates that the patient is at risk for skin impairment according to nurses documentation. There is no evidence of interventions or goals related to this issue. Corrected on site.

Upon patient record review, 3 of 14 (Patient #5,#7,#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#5: The record indicated for MiraLAX 17grams powder daily PRN. There is no evidence of dilutant information. The record indicated for Nystatin cream 1000000 apply topically two times a day. There is no evidence of a specified area of application. The record indicated for miconazole powder apply twice a day. There is no evidence of a specified area of application. Corrected on site Patient#7: The record indicated for Voltaren 1% 2gm apply 4 times a day as needed for pain. There is no evidence of a specific area of application. The record indicated for MiraLAX 17grams powder daily. There is no evidence of dilutant information. Corrected on site Patient#8: The record indicated for Diclofenac sodium 1% 4gm topical every 6 hours PRN for pain. There is no evidence of specified area of application. The record indicated for Lidocaine 4% patch one time a day for pain. There is no evidence of instructions for application of patch. Corrected on site.

Upon patient record review, 4 of 14 (Patient #1,#2,#4,#9) 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 and supply needs. Patient#1: The record indicates patient having over the bed table, hospital bed, oxygen concentrator and supplies, half rails, walker, motorized wheelchair, shower chair, incontinence supplies, hygiene supplies, and low air loss mattress. There is no evidence of equipment or supplies on plan of care. Corrected on site. Patient#2: The record indicates patient having bed, wheelchair, over the bed table, oxygen concentrator and supplies, nebulizer, bed rails, hygiene and incontinence supplies. There is no evidence of equipment or supplies on plan of care. Corrected on site. Patient#4: The record indicates patient having oxygen concentrator and supplies, wheelchair, shower chair, incontinence and hygiene supplies. There is no evidence of equipment or supplies on plan of care. Corrected on site. Patient #9: The record indicates patient having electric wheelchair, transport wheelchair, hygiene and incontinence supplies. There is no evidence of equipment or supplies on plan of care. Corrected on site.

Upon client record review, 4 of 14 (Patient #2,#4,#7,#10) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient#2: The record indicates frequency for spiritual and social work is 2 times a month. There is only one visit documented each of these disciplines for July 2024. Corrected on site Patient#4: The record indicates the frequency for spiritual care is 2 times per month. The record indicates spiritual visits were made on 9/2/24, 9/6, 9/18. There is no indication that one of these visits were PRN. The record indicates the frequency for social worker is 2 times per month. The record indicates social worker visits were made on 9/2/24, 9/11, 9/25. There is no indication that one of these visits were PRN. Corrected on site. Patient#7: The record indicates the frequency for spiritual care is 2 times per month. There is evidence of 3 visits documented in October on 10/2/24, 10/9, 10/16. There is no evidence that one of these visits is PRN. Corrected on site. Patient#10: The record indicates the frequency for spiritual care is 2 times per month. There is only evidence of one visit for August on 8/9/24. There is no evidence of missed visit documented. Corrected on site.

Upon patient record review 3 of 14 (Patient #1,#4,#7) 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: The record indicates the aide frequency is ordered at 2 times per week. There is evidence of only one visit being made on the week of 10/10/24. There is no evidence of missed visit documented for that week. Corrected on site. Patient#4: The record indicates the aide frequency is ordered at 2 times per week. There is evidence of only one visit made the week of 9/1/24. There is no evidence of a missed visit documented for that week. There are no evidence of visits documented for the week of 10/14 or 10/21. Corrected on site Patient#7: The record indicates the aide frequency is ordered at 2 times per week. There was only evidence of one visit made the weeks of 7/7/24 and week of 9/20. There was no evidence of missed visits documented for either of these weeks. Corrected on site.

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. Upon review, evidence shows agency volunteer services is at 0.3% of the total patient care hours for 2023.

Upon patient client record review, 1 of 14 (Patient #2) 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#2: The record indicates on 10/24/24 nurse documented for the care giver at residential home to call Country care hospice for questions or needs. Patient is under care of compassion within hospice. Corrected on site

Upon observation, there was no evidence the Emergency Plan communication plan must includes alternate means for communicating with hospice's employees and Federal, state, tribal, regional, and local emergency management agencies. Review of the staff communication plan, listed the staff's phone number as the primary source, however, there was no alternate means listed for communicating with staff or other agencies.

Upon patient record review 4 of 6 (Patients #1, #2, #4 and #5) did not have documentation in the patient record that a hospice aide provided services that were ordered by the IDG and included in the plan of care. Patient #1: Aide assignment 12/8/2021 directed the Aide to provide mouth care at every visit. There was no mouth care provided on the visits conducted on 12/20/2021, 12/22/2021, 12/24/2021, 12/30/2021 and 12/31/2021. Patient #2: Aide assignment 11/9/2021 directed the Aide to provide skin care, nail care and foot care on every visit. On the visits conducted on 11/17/2021 and 11/20/2021, there was no skin care provided. On the visit conducted on 11/27/2021 and 12/22/2021, there was no skin care, nail care or foot care provided and on the visit conducted on 12/8/2021, there was no nail or foot care provided. Patient #4: Aide assignment 12/9/2021, directed the Aide to provide nail care, foot care, peri care, mouth care and hair care on every visit. On the visit conducted on 12/22/2021, there was no nail care or foot care provided. On the visit conducted on 12/23/2021, there was no peri care, hair care, mouth care, nail care and foot care provided. Patient #5: Aide assignment sheet dated 11/10/2021, directed the Aide to provide a weekly shampoo to the patient. There was no shampoo provided during the weeks of 11/28/2021 and 12/5/2021.

Upon observation, there was not evidence of a contract/agreement with other Facilities/Agencies/Hospices to receive Compassion Within Hospice's patients in the event that Compassion Within Hospice cannot provide care/services to their patients during an emergency.

Upon patient record review, 2 of 5 (Patients #3 and 4) did not contain evidence that the Comprehensive Assessment included a Bereavement Risk Assessment component. Patients #3 and 4 there was not documented evidence of an initial Bereavement Risk Assessment having been conducted.

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

Upon patient record review, 4 of 5 (Patient #1, 2, 3, 4) 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. Patients #1, 2, 3, and 4: The plan of care dated 09/30/21 did not include any Spiritual interventions.

Upon patient record review, 1 of 5 (Patient #1) did not contain a Plan of Care which included all services necessary for the palliation and management of the terminal illness and related conditions, including Equipment and Supply needs. Patient #1- During the home visit on 10/12/21, a wheelchair was observed. The wheelchair was not included on the plan of care.

Upon patient record review, 1 of 5 (Patient #2) did not contain evidence that the IDG had documented the sharing of information between all disciplines providing care and services. The record reflected that the patient had experienced an ALF-staff-witnessed fall on 10/07/21, with the ALF notifying the on-call Hospice RN that same evening. The ALF reported bruising and swelling of the left temple area, with no opened areas of skin. ALF reported the patient 'seemed to be alright'. The Hospice RN called ALF later in the evening to check on patient status, and it was determined that a home visit that night was not indicated. The Hospice RN made a home visit the following day. There was no documented evidence that the Hospice had notified the the Physician of this incident and resultant injury.

Upon personnel record review, 2 of 5 applicable (Personnel #6 and 9) did not contain evidence that a Skills Competency Assessment, specific to each discipline, had been conducted for all personnel, including Volunteers, initially during orientation, prior to their providing independent care/services to a patient: Personnel #6: Provided independent care/services to a patient on 07/27/21. Skills Competency Assessment was not documented until 08/30/21. Personnel #9: Provided independent care/services to a patient on 07/26/21. Skills Competency Assessment was not documented until 08/30/21.

Condition of Participation: Clinical Records.

Upon patient record review, 5 of 5 (Patients #1, 2, 3, 4, 5) did not contain evidence that all entries were appropriately authenticated: Patient #1, 2, 3, 4, 5: Clinical entries entered by Aide did not have credentials attached to signature.

Upon patient record review, 1 of 1 applicable (Patient #5), did not contain evidence that the Hospice had forwarded a Transfer Summary, to the facility when transferring the patient to a Medicare/ Medicaid-certified facility. Patient #5 was was transferred to the hospital on 08/25/21. There was no evidence of a Transfer Summary having been forwarded to the hospital.

Upon patient record review, 1 of 1 applicable (Patient #5) did not contain evidence that if a patient has revoked their Election of Hospice Benefit, or is discharged from the Hospice in accordance with §418.26, that the Hospice must forward a copy of the Discharge Summary to the patient's Attending Physician, if any. Patient #5 revoked on 08/25/21. There was no evidence that the DC Summary was forwarded to the Attending Physician.

Upon patient record review, 5 of 5 (Patients #1, 2, 3, 4, 5) did not contain evidence that the Interdisciplinary Group, as part of the review of the Plan of Care, had determined the ability of the patient and/or family to safely self-administer drugs and biologicals to the patient in his or her home.

Upon personnel record review, 1 of 4 applicable (Personnel #8) did not contain evidence that the Hospice had obtained a Criminal Background Check (CBC) on all contracted individuals who have direct patient care, and access to patient records. Personnel #8- Contract date of 06/03/21. The Hospice was not able to locate evidence of a completed CBC.