Every finding on record at Capu Health Care LLC

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

Upon patient record review, 1 of 14 (Patient #7) 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 #7: no evidence of Plan of Care for 10/3/21-12/1/21.

Upon client record review, 5 of 14 (Patient #9,10,11,12,13) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #9: POC dated 12/24/20: SN ordered 1xwk, visits documented 12/28/20, 1/5, 1/12 and 1/20/21. No evidence of SNV for first week of episode. POC- SW ordered 1x mo, no visits documented, nor missed visits or order to change frequency. CH also ordered 1xmo, no visits documented, nor missed visits or order to change frequency. Patient #10 POC starting 11/7/21 SW ordered 1xmo, no evidence of visits documented. no visits documented, nor missed visits or order to change frequency. Patient #11: Plan of care dated 2/17/21 to 5/17/21: SW ordered 1xmo, CH ordered 1xmo, all for duration of episode. There is no evidence of notes for any discipline during that time period in the written or electronic record, nor missed visits or order to change frequency Patient #12: Plan of care dated 11/18/20-2/15/21: SW 1xmo, 1 prn, CH 1xmo, 1 prn. There is no evidence of notes for any discipline during that time period in the written or electronic record. nor missed visits or order to change frequency Patient #13: Plan of care dated 7/29/21-10/26/21 MSW ordered 1x mo, 2 prns. No evidence of visits for Sept, Oct. No missed visits documented or order to change frequency.

Condition of Participation: Core Services.

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. No evidence of current active employees for nursing, social worker, chaplain, or aide services.

Upon observation, there was no evidence the hospice provides medical social services as a core service. The agency does not have a social worker.

Upon observation, there was no evidence Bereavement counseling services, no evidence of spiritual services, or dietary services available to the patient and family to assist the patient and family in minimizing the stress and problems that arise from the terminal illness, related conditions and the dying process. No evidence of current active employees for these services.

Upon patient record review, 1 of 8 applicable (Patient #13) 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 #13:Aide assignment did not include functional limitations or activities permitted. Patient was assigned a shower and patient wheelchair bound.

Upon patient record review 6 of 8 applicable (Patient #8,9,10,11,12,14) 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 #8 No aide order listed on plan of care dated 1/15/21. Aide performed visits on 1/18/21, 1/20, 1/25, 1/27, 2/1 and 2/3. Patient #9 Aide ordered 3xwk on cert period 12/24/20. No evidence of visits in written or electronic medical record, no evidence of missed visits or order to change freq. Patient # 10 Aide ordered 3xwk on 11/7/21 plan of care: aide performed visits 11/20, 11/22, 11/24, 11/27 and 11/29. No additional visits for the final part of episode. no missed visits in evidence. no order to change frequency Patient #11 Aide ordered 3xwk on POC dated 2/17/21-5/17/21. No evidence of any notes for visits during that time. No evidence of missed visits or order to correct frequency. Patient #12 Aide ordered 3x wk for POC dated 11/18/20-2/15/21. No evidence of documented visits in this period, No evidence of missed visits. No evidence of order to correct frequency Patient #14 Aide ordered 3xwk for POC dated 10/1-10/13/21. Visits documented 10/1, 10/2, 10/4, 10/6, 10/8, 10/11, and 10/13. There are only 2 calendar days in the first week of POC so aide could not do 3 visits in week one. No order to correct frequency in evidence.

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. No evidence of an appointed Administrator or Alternate Administrator. No evidence of any current employees for these roles. No evidence the agency would be able to accept a referral as there are no current active employees and no administrative or clinical oversight is provided.

Upon observation, there was no evidence the hospice is primarily engaged in providing the following care and services: • Nursing services • Medical social services • Counseling services, including spiritual counseling, dietary counseling and bereavement counseling • Hospice aide, volunteer, homemaker services No evidence of any current employees to provide these services.

Upon observation, there was no evidence that the following services are made routinely available on a 24-hour basis 7 days a week. • Nursing services • Drugs and biologicals • Other covered services must be available on a 24-hour basis when reasonable and necessary to meet the needs of the patient and family.

Upon patient record review, 1 of 14 (Patient #7) 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 #7: No evidence of CTI for period 4/6/21-7/4/21.

Upon patient record review, 1 of 14 (Patient #7) did not have evidence that before the recertification period for each patient, the medical director or physician designee must review the patient's clinical information and provide written documentation that it is anticipated that the patient's life expectancy is 6 months or less. Patient #7: No evidence of CTI for 7/5/21-10/2/21 and 10/3/21-12/1/21 recertification periods.

Upon client record review, 14 of 14 (Patient ##1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14) 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 Patients 1-14: No evidence in the patient's medical record that discharge summary was completed and forwarded to the physician.

Condition of Participation: Compliance with Federal, State, and Local Laws and Regulations Related to the Health and Safety of Patients.

Upon observation, there was no evidence the hospice has the appropriate licenses/permits required by state or local rules and regulations. The hospice and its staff must operate and furnish services in compliance with all applicable Federal, State, and local laws and regulations related to the health and safety of patients. The agency terminated all employees including administrator, clinical director, and all core staff. The agency moved the location of the office and did not notify CMS or ACHC of these changes. The agency does not have a working phone available to accept referrals or the staff to provide services to any referrals. The agency has not maintained access to the electronic medical record although they did pay for one day of access in order for the surveyor to review the medical records. There is no administrative or clinical oversight being provided.