Every finding on record at Caring Help Hospice Agency, Inc.

Upon patient record review, 1 of 5 (Patient #1) did not have evidence the plan of care must includes a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs Patient #1: 4/29/22 physician order for SN 1xwk for changes in condition and symptom management and another 4/29/22 physician order for RN 1q14 days for CHHA supervisory visit. Provided education. Clarification order obtained 6/14/22 with effective date of 4/29/22 for SN 1x weekly (as actual intention of original order received).

Upon patient client record review, 1 of 5 (Patient #2) 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: Patient with SOC of 4/29/22 as evidence by Election of benefit election date of 4/29/22, RN comprehensive assessment dated 4/29/22, benefit period dates of 4/29/22 - 7/27/22, and RN signature on the consent/election form as 4/29/22. However, the patient signature on the consent/EOB is 5/18/22 and the patient signed the acknowledgement of patient rights as of 5/28/22.

Upon patient client record review, 3 of 5 (Patient #1, 4, 5) 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 #1: 5/3/22 MSW Assessment begins with "98 yo.. admitted to hospice services 8/28/21." SOC date / effective date of election is 4/29/22. Patient #4: 5/2/22 MSW Assessment and 5/1/22 SC Assessment narratives end with "Agency will continue to make attempt to provide SC in the event the family and patient decide to change their mind". This is unclear in that the documentation includes no indication that the patient/cg was not receptive/refused care. Ordered frequency is 1x/month for each discipline. Patient #5: 4/29/22 MSW Assessment narrative and 4/30/22 SC Assessment narrative end with "Agency will continue to make attempt to provide SC in the event the family and patient decide to change their mind". This is unclear in that the documentation includes no indication that the patient/cg was not receptive/refused care. Ordered frequency is 1x/month for each discipline.

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

Upon patient record review 1 of 5 (Patient #4) did not have evidence that the hospice Registered Nurse must complete an initial assessment within 48 hours after the election of hospice care in accordance with §418.24. Patient 4 There is no evidence in the patient records of the initial nursing assessment completed within 48 hours of the election of hospice services.

Upon patient record review 4 of 4 applicable (Patient #1, 2, 3, 4) 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 #1, 2, 3, 4 There is no evidence in the patient record of psychosocial or spiritual assessment as part of the comprehensive assessment.

Upon patient record review, 5 of 5 (Patient #1, 2, 3, 4 and 5) 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 The patient has orders for cephalexin on 2/8/22 that are not included in the medication profile. There is evidence in the patient record that the patient is using nystatin powder on his skin, no evidence of Nystatin included on medication profile. Patient #2 There is evidence in the patient record of orders for medications including albuterol, atropine, acetaminophen, morphine, and oxygen that are not included in the medication profile. Patient #3 There is no evidence on the patient medication profile for the use of oxygen which is included in the patient assessment. Patient #4 There is evidence in the patient record of orders for medications Acetaminophen, prochlorperamine, and oxygen that are not included in the medication profile. Patient #5 There is an order in the patient record for oxygen which are not included on the medication profile.

Upon patient record review, 4 of 4 applicable (Patient #1, 2, 3, and 4) 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 #1, 2, 3, 4 There is no evidence in the patient records that an initial bereavement assessment was completed.

Upon patient record review, 3 of 5 (Patient #1, 2, 3) 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 #1 There is evidence in the patient record that the patient is using nystatin powder on his skin, that does not include an order. Patient #2 There is an order for application of diclofenac 1% to affected area, the order does not site specific to the location that the medication should be applied. Patient #3 The nursing note for 2/7/22 indicates that the patient was started on Triamcinolone for itching but there is no order for this medication. On 4/6/22 started on Benadryl 25mg QHS with no evidence of an order.

Upon patient record review, 1 of 5 (Patient #1) 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 There is evidence in the patient record that the patient utilizes a wheelchair and a hoyer lift that are not included in the plan of care.

Upon patient record review, 5 of 5 (Patient #1, 2, 3, 4 and 5) 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 #1 The content of the plan of care was not updated to reflect the needs for antibiotic treatment for a skin infection as noted in 2/28/22 visit notes, or safety issues identified as a result of falls on 3/22/22 and 4/5/22. Patient #2 The content of the plan of care was not updated to reflect the patient changes including increased symptoms of pain and anxiety as noted in the visit notes on 2/16/22, and the need to implement Ensure supplements for nutrition as indicated in 3/30/22 nursing note. Patient #3 The content of the plan of care does not reflect the patient changes for symptom management that included itching/rash as documented on 2/7/22 and sleep disturbances as documented on 4/6/22. Patient #4 The content of the plan of care is not updated to reflect the s/s of approaching death and change in condition leading to the patient death on 2/2/22. Patient #5 The content of the plan of care does not reflect the imminence of death at the time of admit and until death on 1/5/22.

Upon observation, there was no evidence the hospice investigates all adverse events, incidents, accidents, variances or unusual occurrences that involve patient care and develops a plan of correction to prevent the same or similar event from occurring again. Patient #1 There is evidence in the patient record of a fall on 3/22 and a fall on 4/5 that are not documented or included in the occurrence reports.

Upon patient record review, 2 of 2 applicable (Patient #4, 5) 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 #4 & #5 There is no evidence in the patient record of a bereavement plan of care or offerings of bereavement services to the family of either patient after death.

Upon patient record review, 1 of 3 applicable (Patient #1) 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 The hospice aide orders include PRN orders for care.

Upon patient record review, 3 of 5 (Patient #1, 2, 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 #1 The initial certification is missing the physician signature and the physician narrative statement is not directly above the physician signature. Patient #2 The initial certification on file does not include the physician narrative statement directly above the physician signature. Patient #5 The initial certification on file is not signed by the hospice physician.

Upon patient record review, 2 of 2 applicable (Patient #1 and #3) 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 #1 There is no evidence in the record of the patients certification for the 2nd benefit period. Patient #3 The patient record reflects that the certification for benefit period 5 is not signed timely, admitted 2/2/22, and not signed to date. The patients 6th benefit period effective 3/16/22 is not signed and is missing the physician narrative statement.

Upon patient client record review, 5 of 5 (Patient #1, 2, 3, 4, and 5) 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 #1, 2, 3, 4, 5 The election of benefits does not include the hospice election addendum statement that includes the Patient Notification of Hospice Non-covered items, services and drugs.

Upon patient client record review, 1 of 5 (Patient #4) 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 #4 The patient nursing visit notes for 12/23/21, 1/6/22, 1/27/22, and 2/2/22 are not signed/authenticated by the visiting nurse.

Upon client record review, 2 of 2 applicable (Patient #4, 5) did not have evidence that the discharge summary includes all required information. Patient #4 & 5 There is no evidence in the record of a completed patient discharge summary upon death of patient #4 & #5.

Upon patient record review, 1 of 5 (Patient #3) 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 #3 There is evidence in the patient record of verbal orders for medications initiated on 2/7/22 and 4/6/22 that have not been documented and signed by the receiving nurse.