Every finding on record at Citadel & Ivan LLC

Upon patient record review, 1 of 14 (Patient #1) did not contain evidence that the patient had been provided the right/opportunity to choose a health care provider, specifically an Attending Physician: Patient #1: This section of the Election of Hospice Benefit Statement had been left blank.

Upon patient record review, 1 of 14 (Patient #1) did not contain evidence that the patient had been provided/received information about how their Hospice services would be 'covered' under their Hospice benefit: Patient #1: The section of the admission Consent form entitled "The Authorization for Payment/Election of Hospice Care", intended to inform the patient of Hospice services charges, and payment of such care/services, had been left blank/un-checked.

Upon patient record review 2 of 14 (Patients #1 and 3) did not contain documented evidence that the Hospice Interdisciplinary Group, in consultation with the individual's Attending Physician (if any), had completed the Comprehensive Assessment no later than 5 calendar days after the Election of Hospice care: Patient #1: SOC was 11/21/23. The spiritual component of the Comprehensive Assessment was not conducted until 11/27/24 (day 6). Patient #3: SOC was 09/06/24. The SW component of the Comprehensive Assessment was not conducted until 09/20/24.

Upon patient record review, 3 of 14 (Patients #3, 4, and 5) did not contain a current/comprehensive Medication Profile: Patients #3, 4, and 5: These Medication Profile(s) did not include a listing of Allergies, or the absence of such.

Upon patient record review, 2 of 14 (Patients #4 and 9) did not contain evidence that the Plan of Care included all services necessary for the palliation and management of the terminal illness and related conditions, including the following: A detailed statement of both the scope and frequency of services necessary to meet the specific patient and family needs: Patient #4: SOC was 09/11/24, with the Chaplain competing chaplain assessment visit on 09/16/24. The 09/19/24 IDG POC did not include the planned spiritual visit frequency. Patient #9: SOC was 08/13/24, with the Chaplain competing his chaplain assessment visit on 08/16/24, and a subsequent visit on 09/23/24. The 09/19/24 IDG POC did not include the planned spiritual visit frequency.

Upon patient record review, 2 of 14 (Patients #3 and 5) did not contain evidence that the Plan of Care included all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments: Patient #3: During the Surveyor-attended home visit on 10/01/24 the employed in-home caregiver reported the following skin care intervention to the patient's right hip and coccyx area wound(s); with each diaper change. Wash with wound cleanser, pat dry, apply Medi-honey, then border gauze. The current IDG POC only refers to this wound intervention for a Stage II pressure ulcer on the coccyx. The POC does not include this wound intervention to also be completed for the right hip wound. This is not a complete wound order. Patient #5: A verbal order was obtained on 09/09/24 for, "Cleanse redness to coccyx with Normal Saline, pat dry, and apply Calmoseptine B.I.D., and as needed soiling, etc ..." This treatment order did not include 'who' in the home was to provide this wound treatment on such B.I.D. frequency.

Upon patient record review, 4 of 14 (Patients #1, 3, 8, and 10) did not contain documented evidence that the Plan of Care included all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs: Patient #1: During surveyor-attended home visit on 10/01/24 it was noted that the patient had a hospital bed. This was not on the POC. Patient #3: During surveyor-attended home visit on 10/01/24 it was noted that the patient had: 1) hospital bed; 2) overbed table; 3) air mattress; and 4) Oxygen concentrator. These DME were not on the POC. Patient #8: The RN SOC assessment reflected the use of a walker. This DME was not on the POC. Patient #10: The SOC CTI assessment reflected the use of a walker. This DME was not on the POC.

Upon patient record review, 2 of 14 (Patients #2 and 7) did not contain evidence that the revised Plan of Care included information from the patient's updated comprehensive assessment(s): Patient #2: During the 10/01/24 Surveyor-attended home visit, the RN stated that the patient was taking only Ensure and water orally, for approximately the past 1-2 months. The 09/19/24 IDG POC does not reflect this. The POC includes, "Offer food/fluids as tolerated and offer supplements as ordered", and "Teach caregiver on importance of diet in maintenance of adequate bowel function." Ensure was not included on the POC. Patient #7: The RN SOC assessment reflected that the patient had a history of coccyx pressure ulcers. The POC does not include an active Problem/Intervention/Goal for this area of potential concern.

Upon personnel record review, 1 of 11 (Personnel #7) did not contain evidence of a completed Aide Skills Competency Assessment having been conducted, which included all CMS-required tasks. A Skills Competency was conducted on 04/26/2024. However, the following CMS-required tasks were not evaluated for, while the Aide was providing care/services to patient or pseudo-patient: ·Reading and recording temperature, pulse, and respiration were evaluated verbally. ·Appropriate and safe techniques in personal hygiene and grooming that include-- · Bed bath was evaluated verbally. · Shower bath was evaluated verbally. · Sponge and Tub bath were not evaluated for. · Shampoo, sink, tub, and be were evaluated verbally. · Nail care was evaluated verbally. · Skin care was evaluated verbally. · Oral hygiene was evaluated verbally. ·Toileting and elimination was evaluated verbally. ·Normal range of motion was not evaluated for. The other subject area, which may be evaluated through written examination, oral examination, or after observation of a Hospice Aide with a patient; that was not evaluated for was: · The physical, emotional, and developmental needs of and ways to work with the populations served by the Hospice.

Upon patient record review 1 of 14 (Patient #4) did not contain documented evidence that a Hospice Aide had provided services that were: • Ordered by the interdisciplinary group • Included in the plan of care Patient #4: The 09/19/24 IDG POC assigned an Aide visit frequency of 3x per week. An Aide made x5 visits the following week of 09/23, 09/25, 09/26, 09/27, and 09/28/24.

Upon patient record review, 3 of 14 (Patient #1, 4, and 10) did not contain evidence that each patient record contained: Signed Election of Hospice Benefit Statement (EOB) in accordance with 418.24 Patient #1: The EOB did not include: • The effective date of the Hospice Election. This line had been left blank. • Identification of the patient's choice of Attending Physician, if any. This section had been left blank. • The section of the EOB intended for the patient/representative to acknowledge whether they had been informed of their right to request/receive a "Patient Notification of Hospice Non-Covered Items, Services, and Drugs", had been left blank; without any indication that the patient/representative had been informed of this right. Patients #4 and 10: The section of these patients' EOB(s) intended for the patient/representative to acknowledge whether they had been informed of their right to request/receive a "Patient Notification of Hospice Non-Covered Items, Services, and Drugs", had been left blank; without any indication that the patient/representative had been informed of this right.

Upon patient record review, 3 of 14 (Patient #1,2,8) did not contain evidence that all entries were clear and complete: Patient #1: The admission Consent form included a section for the admitting clinician to document whether or not the patient had any Advance Directives. This section of the Consent had been left blank. Patient #2: The 07/17/24 RN SOC assessment noted, "Rash to peri-groin and peri-anal areas. Treating with Nystatin Powder and Triamcinolone Cream. Both the 07/18 and 07/19/24 LVN visits documented incontinent of bowel and bladder, with no skin integrity problem. Patient #8: The RN SOC visit noted that the patient had a pressure ulcer to the coccyx, and that wound care was provided. There was not documentation regarding the detail of such wound care provided.

Upon patient record review, 1 of 14 (Patient #11) did not contain evidence that the Discharge Summary included all CMS-required information: Patient #11: The DC Summary did not include the following required content: • A summary of the patient's stay, including treatments, symptoms and pain management • The patient's current Plan of Care • The patient's latest Physician orders

Upon patient record review 3 of 11 (Patient #2, 3, 9) 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 #2 The record indicates that the initial SW Assessment was completed on day 8 from admit date of 10/12/21. Patient #3 Patient admitted on 12/7/21, Psychosocial assessment completed on 12/15/21, Spiritual assessment completed on 12/14/21. Patient #9 The patient was admitted on 1/21/22, the Spiritual Assessment was completed on 1/28/22.

Upon patient record review 3 of 11 (Patient #1, 2, 8) 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 The patients spiritual care needs were not assessed at the time of admit on 9/11/21 and to date. Patient #2 The patients spiritual care needs were not assessed at the time of admit on 10/12/21 and to date. Patient #8 The patients spiritual care needs were not assessed at the time of admit on 9/3/21 and through discharge on 11/6/21.

Upon patient record review, 3 of 11 (Patient #1, 5, 9) 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 record reflects that the patient was prescribed Levaquin 250mg PO Q7 days on 12/28/22 but this was not included on the medication profile. Patient #5 The patient has oxygen included in the DME but this is not included on the medication profile. Patient #9 The patient has oxygen included in the DME but this is not included on the medication profile.

Upon patient record review, 4 of 11 (Patient #1, 3, 8, 9) 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 There is no evidence in the patient record of bereavement assessment completed at the time of admit on 9/11/21 and to date. Patient #3 Patient admitted on 12/7/21, the bereavement assessment was completed on 12/14/21. Patient #8 There is no evidence in the patient record of a bereavement assessment completed at the time of admit on 9/3/21 through discharge on 11/6/21. Patient #9 Patient admitted on 1/21/22, the bereavement assessment was completed on 1/28/22.

Upon patient record review, 4 of 11 (Patients #3, 4, 6, 7) 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 #3 The POC was not updated to include the treatment, interventions, goals and response to Augmentin started on 12/7/21 for URI. Patient was treated with Doxycycline on 3/5/22 and Keflex on 3/11/22 for cellulitis which was not updated in the POC. Patient #4 There is no update to the POC for wound treatment to the patients sacrum since 11/16/21. Patient #6 The POC was not updated to include the respiratory infection that was treated with Levaquin on 11/9/21. Patient #7 The patients POC reflects that a foley catheter was placed on 12/13/21, with Q30 day changes ordered, there is no update to the POC to reflect catheter changes, care, or management of the foley. The foley was removed on 2/10/22 per nursing note, and the POC was not resolved.

Upon client record review, 1 of 11 (Patient #11) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #11 The POC orders reflect SW visits 1 x per month, but the patient did not have any SW visits from 8/6/21 to 2/4/22.

Upon patient record review 5 of 8 applicable (Patient #1, 2, 3, 6, 9) 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 reflects that the Hospice Aide order is 2x per week starting 9/11/21, but there was only 1 visit made during the week of 10/2/21 and no visits were made from 2/26/22 - 3/9/22. Patient #2 The record reflect that the Hospice Aide order is 1 x per week starting 10/12/21, but the aide made additional visits during the week of 10/17/21, 11/2/21, 11/21/21, and the weeks of 1/9/22 - 2/12/22. Patient #3 Hospice aide visits are ordered for 2x week, but the record shows there are no hospice aide visits from 11/17/21 - 12/01/21 and 1/5/22 - 2/16/22. Patient #6 The hospice aid orders are for 2x week starting 11/11/21 but the patient received 3x week visits from 11/14/21 - 01/01/22 Patient # 9 Hospice aide visits are ordered for 2x week starting 1/21/22, but the record only shows visits on 2/10/22, 2/17/22, 2/22/22 and 2/24/22.

Upon patient client record review, 1 of 11 (Patient #4) did not have evidence that each patient record contains Physician certification and recertification of terminal illness. Patient #4 There is no completed certificate of terminal illness for the 2nd benefit period that started on 2/14/22. (There is no physician narrative or signature)

Upon patient client record review, 2 of 11 (Patient #4, 7) did not have evidence that each patient record contains Advance Directives. Patient #4 The POLST form included in the patient record does not contain a physician signature. Patient #7 The POLST form included in the patient record does not contain a physician signature.