Every finding on record at Central Hospice Care Inc

Upon patient record review, 3 of 14 (Patients #2, #3, #12) 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 Patients #2, #3, #12: Did not include oxygen on medication profile as required. Corrected on Site.

Upon patient record review, 1 of 15 (Patient #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 #4: Bereavement Risk Assessment was not completed within 5 days of electing hospice. Start of care was 5/8/24. The Bereavement Risk Assessment was completed on 5/15/24.

Upon patient record review, 7 of 14 (Patients #1, #3, #4, #5, #6, #9, #10) 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 Patients# 1, #3, #4, #9: The Plan of Care Indicated MSW and SC Services as PRN. This frequency did not include any baseline visits. Corrected on Site. Patient #5: The Plan of Care Indicated MSW and SC Services as PRN. This frequency did not include any baseline visits. Patient #6: The Plan of Care Indicated MSW and SC Services as PRN. This frequency did not include any baseline visits. Patient #10: The Plan of Care Indicated SN Services as PRN. This frequency did not include any baseline visit. Corrected on Site.

Upon patient record review, 3 of 14 (Patients #2, #3, #12) 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. Patients #2, #3, #12: Did not include oxygen orders on Plan of Care. Corrected on Site.

Upon patient record review, 3 of 14 (Patients #2, #3, #12) 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 #2: This patient had an oxygen concentrator and a Hoyer Lift. These were not included on the Plan of Care. Corrected on Site. Patient #3: This patient had an oxygen concentrator and a walker. These were not included on the Plan of Care. Corrected on Site. Patient #12: The record reflected that this patient had Oxygen 2L/Min via NC. Oxygen equipment was not included on the Plan of Care. Corrected on Site.

Upon client record review, 1 of 14 (Patient #13) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #13: The POC listed Spiritual Counselor (SC) visit frequency of, 1 X's per month (5/5/22). The SC did not visit the patient in August, September or November. The visit frequency was not met.

Upon observation, there was no evidence the hospice is in compliance with accepted professional standards and principles for all core services. The agency is using Omni Wound Physician company and had been using MSW and SC/BC as contracted services. • The wound care company provided excisional debridement and routine assessment for patient #8. The Wound Care Company submits billing claims to patient insurance. The agency nor the patient are billed directly. • This agency had a contracted MSW and SC/BC personnel (1099). Both disciplines have been providing initial assessments and routine visits as ordered. The agency hired both the MSW and SC/BC as W-2 employees during this survey with start date of 7/23/24.

Upon patient record review, 2 of 14 (Patients #13, #14) did not have evidence the hospice offers bereavement counseling that includes: • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery. Patients #13, #14: The Electronic Medical Record does not have Bereavement Plan of Care in chart. The Bereavement Coordinator has an excel spreadsheet he uses to send cards and letters to the bereaved.

Upon personnel record review, 1 of 14 (Personnel #10 ) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient or pseudo patient: Personnel #10: The Aide Initial Competency did not include observed/demonstrated verification for: ·Normal range of motion ·Shampoo, sink, tub, and bed ·Nail and skin care ·Oral hygiene

Upon patient record review 5 of 14 (Patients #1, #3, #4, #7, #11) 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 (POC) Patients #1, #4: The POC listed Aide visit frequency of, 2 X's per week. The first Benefit Week there were no visits made by the Aide. Patients #3, #11: The POC listed Aide visit frequency of, 3 X's per week. The first Benefit Week there were no visits made by the Aide. Patient # 7: The POC listed Aide visit frequency of, 3 X's per week (1/7/24). There were no visits made by the Aide until 3/21/24.

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. The governing body did not have evidence of assuming responsibility for services related to patient needs with core staff as well as providing core services with employees. • The wound care company provided excisional debridement and routine assessment for patient #8. The Wound Care Company submits billing claims to patient insurance. The agency nor the patient are billed directly. • This agency had a contracted MSW and SC/BC personnel (1099). Both disciplines have been providing initial assessments and routine visits as ordered. The agency hired both the MSW and SC/BC as W-2 employees during this survey with start date of 7/23/24.

Upon patient client record review, 14 of 14 (Patients #1 through #14) did not have evidence that each patient record contains: • Signed election statement in accordance with 418.24 Patients #1,#4,#10,#11,#12, #13, #14: The Election Statements does not include contact information for BFCC-QIO. Patients #2, #3, #5, #7, #8: The Election Statements does not include contact information for BFCC-QIO. Additionally, does not have Start of Care/Effective Date indicated in space provided on form. Patient #6: The Election Statements does not include contact information for BFCC-QIO. The Start of Care is 1/7/24 per EMR and 1/8/24 per Election Statement. Patient #9: The Election Statements does not include contact information for BFCC-QIO. The Start of Care is 12/28/23 per EMR and 12/29/24 per Election Statement. Hospice did not receive payment for 12/28/23 service date.

Upon patient client record review, 2 of 14 (Patient #5,6) 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 #5: Plan of Care (4/23/24) indicated conflicting information for Aide Visit Frequency. In one area of the POC, Aide Services are Declined. In another area, of same POC Aide services are 3 x per week. Patient #6: Plan of Care (1/7/24) indicated conflicting information for Aide Visit Frequency. In one area of the POC, Aide Services are Declined. In another area, of same POC Aide services are 2 x per week.

Upon client record review, 1 of 14 (Patient #12) did not have evidence that the hospice forwarded a summary and a copy of the patient record, if requested, to a facility when transferring the patient to that facility. Patient #12: The discharge/transfer summary did not indicate form was sent to receiving hospice.