Every finding on record at Citizens Palliative Care LLC

Upon patient record review, 2 of 5 (Patient #2, #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: • Drug therapy currently associated with laboratory monitoring Patient #2:The RN visit note dated 10-16-24, the RN indicated the patient was using Oxygen at 2L per NC. In addition, oxygen education and use was documented on the care plan dated 11-13-24. Oxygen was not listed on the medication profile. COS Patient #5: The CTI dated 09-19-24 indicated the patient was using oxygen at 3L per NC. In addition, the care plan dated 11-13-24 indicated the patient was using Oxygen. Oxygen was not listed on the medication profile. COS.

Upon patient record review 1 of 5 (Patient #1) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs. Patient #1: The RN conducted a supervisory visit on 10-16-24 and there was no evidence of a supervisory visit being completed through visits dated to 11-15-24.

Upon patient client record review, 1 of 5 (Patient #1) 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: On admission note dated 10-09-24, RN documented "none" on need for hospice aide. On 10-31-24 visit note, the RN documented "Pt doesn't have a CNA." The chart contained a CNA care Plan dated 10-09-24 and the CNA was visiting 3 x weekly since 10-10-24.

Upon patient record review, 1 of 5 (Patient # 1) did not have evidence in the patient record that the interdisciplinary group, as part of the review of the plan of care, determines the ability of the patient and/or family to safely self-administer drugs and biologicals to the patient in his or her home. If the patient and/or family are not capable of safely administering drugs and biologicals in the home, the hospice must address this issue in the patient's plan of care. Patient #1: On the admission documentation dated 10-09-24, the RN left blank both assessment questions related to the patient and the caregivers ability to administer medications.

Upon patient record review, 1 of 14 records reviewed (Patient #2) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient #2: The record indicated the patient did not choose an attending physician. The patient's choice and physician name on the Notice of Election was left blank. COS.

Upon patient record review 2 of 14 records reviewed (Patient #2,4) 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 #2: The record indicated the start of care date was 03/08/24. There was no initial assessment within 48 hours after the election of hospice care. COS. Patient #4: The record indicated the start of care date was 07/03/24. There was no initial assessment within 48 hours after the election of hospice care.

Upon patient record review 1 of 14 records reviewed (Patient #10) 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 #10: The record indicated the patients start of care was 06/24/24. The spiritual comprehensive assessment was completed on 07/07/24.

Upon patient record review 2 of 14 records reviewed (Patient #1,2) 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 record indicated the start of care was 09/19/24. There was no evidence of the spiritual comprehensive assessment being completed at the time of the survey. Patient #2: The record indicated the start of care was 03/08/24. There was no evidence of the spiritual comprehensive assessment being completed at the time of the survey.

Upon patient record review, 10 of 14 medical records reviewed (Patient #1-10) 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- #10: The record indicated the patient had a medication administration record. There was no evidence the medication list was being monitored for actual or potential drug interactions, duplicate drug therapy, and or drug therapy currently associated with laboratory monitoring. Patient #1: The record indicated on the medication profile Atropine Care 1% Ophthalmic Solution 5ml 3 drops in the eye Q2hours prn secretions. There was no evidence the route of administration was correct as this medication is used SL in end of life care for secretion control. COS. Patient #3: The record indicated on the medication profile Eliquis 5mg po BID for blood pressure. This medication is a blood thinner. COS. Upon home visit, the hospice medication profile did not match facility MAR. The following medications were on the board and care MAR but not on the Hospice medication profile: Magnesium 400mg po daily, Fexofenadine 180mg po daily, Insulin Glargine (U-100) 100 units/ml 20U SC daily, Oxycodone 5mg 0.5 tab po Q6hours prn pain score 4-6, Ativan 0.5mg 1.5 tabs as needed for sleep. In addition this patient stated, "I take my own Mucinex." This was not on the hospice medication profile or the board and care MAR. The following medications were on the hospice medication profile but not on the board and care MAR: Jardiance 10mg one tab po daily, Gabapentin 100mg capsule TID and Acetaminophen 650mg PR every 8 hours prn fever. Also there were two acetaminophen orders on the facility MAR with multiple strengths available, acetaminophen 325 mg 2 tabs po Q4hours and Acetaminophen 500mg one tab TID. COS. Patient #4: The record indicated on the medication profile Atropine Care 1% Ophthalmic Solution 5ml 3 drops in the eye Q2hours prn secretions. There was no evidence the route of administration was correct as this medication is used SL in end of life care for secretion control. COS. Upon home visit, the patient had a filled prescription for Metoprolol 100mg po BID that was filled on 09/09/24. This medication was not listed on the hospice medication profile. COS. In addition, there were 3 different pills loose in the bottom of the box the bottles and Medi planner was stored in. COS. Patient #9: The record indicated on the medication profile Atropine Care 1% Ophthalmic Solution 5ml 3 drops in the eye Q2hours prn secretions. There was no evidence the route of administration was correct as this medication is used SL in end of life care for secretion control. COS. Patient #10: The record indicated on the medication profile Atropine Care 1% Ophthalmic Solution 5ml 3 drops in the eye Q2hours prn secretions. There was no evidence the route of administration was correct as this medication is used SL in end of life care for secretion control. COS.

Upon patient record review, 2 of 14 (Patient #1,9) 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: The record indicated the start of care was on 09/19/24 There was no evidence of the Bereavement Risk assessment being completed at the time of the survey. Patient #9: The record indicated the start of care was on 07/02/24. There was no evidence of the Bereavement Risk assessment being completed at the time of the survey.

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

Upon patient record review, 4 of 14 records reviewed (Patient #1,3,5,6) 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 indicated the patient was Xarelto 10mg po QHS. There was no evidence of a care plan for bleeding precautions that reflected the patient/family goals and interventions based on the problem. COS. Patient #3: The home visit revealed the patient was receiving physical therapy. There was no evidence of a care plan for the physical therapy that reflected the patient/family goals and interventions based on the problem and or need for the physical therapy. COS. Patient #5: The record indicated the patient was on Plavix 75mg po Qday. There was no evidence of a care plan for bleeding precautions that reflected the patient/family goals and interventions based on the problem. COS. Patient #6: The record indicated the patient was on Xarelto 20mg po Qday for CVA prophylaxis. There was no evidence of a care plan for bleeding precautions that reflected patient/family goals and interventions based on the problem. COS

Upon patient record review, 4 of 14 records reviewed (Patient #1, #4, #9, #10) 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: The record indicated an MD order for Atropine Care 1% Ophthalmic Solution 5ml 3 drops in the eye Q2hours prn secretions. There was no evidence the route of administration was correct as this medication is used SL in end of life care for secretion control. COS. Patient #4: The record indicated an MD order for Atropine Care 1% Ophthalmic Solution 5ml 3 drops in the eye Q2hours prn secretions. There was no evidence the route of administration was correct as this medication is used SL in end of life care for secretion control. COS. Patient #9: The record indicated an MD order for Atropine Care 1% Ophthalmic Solution 5ml 3 drops in the eye Q2hours prn secretions. There was no evidence the route of administration was correct as this medication is used SL in end of life care for secretion control. COS. Patient #10: The record indicated an MD order for Atropine Care 1% Ophthalmic Solution 5ml 3 drops in the eye Q2hours prn secretions. There was no evidence the route of administration was correct as this medication is used SL in end of life care for secretion control. COS.

Upon client record review 5 of 14 charts reviewed (Patient #2,3,4,6,7) did not have evidence that the IDG in collaboration with the attending physician reviewed, revised and documents the individualized plan as frequently as the patient's condition requires but no less frequently then every 15 calendar days. Patient #2: The record indicated the IDG meeting was held on 8/7/24. There was no IDG meeting on 8/21/24. Patient #3: The record indicated the start of care date was 07/03/24. The first IDG meeting was held on 7/24/24, 21 days after the SOC. Patient #4: The record indicated an IDG meeting was due on 9/18/24. There was no evidence this meeting was held on 09/18/24 at the time of the survey. COS. Patient #6: The record indicated the start of care was on 03/19/24. There was no evidence of IDG meetings starting from 03/19/24 - 06/25/24 at the time of the survey. Patient #7: The record indicated the start of care was on 08/27/24. There was no evidence of IDG meeting after 09/04/24 up until the time of the survey. COS.

Upon patient record review, 4 of 14 records reviewed (Patient #2,6,8,10) 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 #2: The record indicated the patient had care plans based off the comprehensive assessments. There was no evidence of the patient's progress towards outcome/goals from the plan of care on 6/26/24, 7/10/24, 7/24/24 and 08/08/24. Patient #6: The record indicated the patient had care plans based off the comprehensive assessments. There was no evidence of the patient's progress towards outcome/goals from the plan of care on 06/26/24, 07/10/24, 07/24/24 and 08/07/24. Patient #8: The record indicated the hospice medical director made a face to face on 08/29/24 @7:15 a.m. he noted a skin tear to the left forearm that occurred during routine positioning. The tear measures approximate (size) and exhibits minimal bleeding. The surrounding skin is fragile. The wound was cleansed with saline and a non adherent dressing was applied to protect the area and promote healing. There was no evidence of a revised plan of care to include the progress towards outcomes and or goals on the plan of care. COS. Patient #10: The record indicated the patient had care plans based off the comprehensive assessment. There was no evidence of the patient's progress towards outcome/goals from the plan of care on 06/26/24, 07/10/24 and 07/24/24.

Upon client record review, 2 of 14 records reviewed (Patient #1,2) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1: The record indicated the patient was receiving nurse, social worker and aide visits. There were no MD Orders for these visit frequencies and/or no visit frequencies documented in the IDG meetings for these disciplines. Patient #2: The record indicated the patient had frequency orders for the social worker to visit 1 X M and the chaplain to visit 1 X M. There was no visit made in the month of September by the social worker and/or chaplain.

Upon observation, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient #3: During the home visit the RN placed the pulse ox back in the case after use on the patient without disinfecting the pulse ox. Policy No. 6-013.2 #5 states when the visit is completed, reusable equipment will be cleaned using alcohol, soap and water, or other appropriate solutions, hands will be washed and equipment and supplies will be returned to the bag. Patient #5: During the home visit with the patient the CNA placed her bag on the patients bed without a barrier.

Upon patient record review, 3 of 14 records reviewed (Patient #1,5,6) 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 record indicated the patient was on Xarelto 10mg po QHS. There was no bleeding precautions on the Aide Plan of Care. COS. Patient #5: The record indicated the patient was on Plavix 75mg po QDay. There was no bleeding precautions on the Aide Plan of Care. COS. Patient #6. The record indicated the patient was on Xarelto 20mg po QDay. There was no bleeding precautions on the Aide Plan of Care. COS.

Upon patient record review 1 of 14 (Patient #1) 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 indicated the aide made a visit on 8/30/24, 9/11/24, 9/13/24 and 9/16/24. The visit note was not marked for the task completed, the task were blank.

Upon personnel record review, 3 of 15 records reviewed (Personnel #8,9,10) did not have evidence that a skills competency assessment, specific to each discipline had been conducted for all personnel including volunteers initially during orientation. Personnel record #8, #9, #10: There was no evidence of a skills checklist in the HR file at the time of the survey.

Upon patient record review, 4 of 14 (Patient #6,7,8,10) 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 #6: The patients start of care was 03/19/24 and the first benefit period was 03/19/24 to 06/16/24. There was no evidence of a verbal order by the RN and the MD signed on 06/13/24. Also there was no evidence of a composed narrative by the certifying physician.

Upon patient record review, 3 of 14 (Patient #7,8,10) 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: The patients start of care was 08/27/24 and the 3rd benefit period was 08/27/24 to 10/25/24. There was no evidence the narrative was composed by the certifying physician, the MD wrote "n/a" in the narrative section. There was no evidence of a verbal order by the RN and the MD signed on 09/03/24. Patient #8: The patients start of care was 08/24/24 and the 2nd Benefit period was 08/24/24 to 11/21/24. There was no evidence of a written narrative the narrative section was in bullet points and not written in a narrative format. There was no evidence of a verbal order by the RN and the MD signed on 08/29/24. Patient #10: The patients start of care was 06/24/24 and the 2nd Benefit period was 09/22/24 to 12/20/24. There was no evidence of a verbal order by the RN and the MD signed on 09/26/24.

Upon patient client record review, 2 of 14 records reviewed (Patient #1,2) 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 #1: The record indicated the patient was admitted on 09/19/24. There was no evidence of the non covered items list being provided within 5 days. Patient #2: The record indicated the patient did not choose an attending physician. This was left blank on the Notice of Election for hospice services. In addition, the record indicated the patient was admitted on 03/08/24. There was no evidence of the non covered items list being elected or declined on the notice of election for hospice services. Also, there was no name of the hospice listed on the Notice of Election for hospice services.

Upon patient client record review, 1 of 14 records reviewed (Patient #5) did not have evidence that each patient record contains Advance Directives. Patient #5: The record indicated on 07/17/24 the patient had advance directives and would provide a copy to the hospice. There was no evidence of this on the record at the time of the survey. COS.

Upon patient client record review, 3 of 14 record reviewed (Patient #2,10,12) 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 indicated IDG was held on 6/26/24, 7/10/24 and 7/24/24. The IDG note was not signed by the RN or the chaplain at the time of the survey. COS. Patient #10: The record indicated IDG was held on 07/24/24. The IDG note was not signed by the chaplain at the time of the survey. COS. Patient #12: The signed revocation on file was dated with the signature date 04/10/24 with no effective date on the form. There was a discharge order with the effective date 04/22/24 to discharge the patient due to the patient no longer wanted hospice. The last date of service was 04/22/24.