Every finding on record at Comforting Hands Hospice LLC.

Observed in HR File Review. In 1 of 8 HR files reviewed, it was noted the organization failed to ensure that the initial training in emergency preparedness policies and procedures to all new and existing hospice employees consistent with their expected roles. For example in HR#8 Volunteer personnel file review, the surveyor noted that the staff had not attended an emergency management training during orientation. This finding was reviewed and confirmed by the Volunteer Coordinator.

Observed in Record Review. it was noted the organization failed to ensure that the patient was informed in advance about the expected outcomes of care and services. For example in review of record of HOSRRDC#18, the notice of Medicare non-coverage (NOMNC) was signed by the patient 11 days late from the date patient was discharged from hospice services. In HOSRRDC#20, there was no evidence that patient had received NOMNC from the date patient was discharged from hospice services. This finding was discussed and validated by the hospice Administrator and Patient Care Coordinator (PCC).

Observed in Patient Home. In 2 of 4 home visits conducted, it was noted the organization failed to conduct to reconcile medications in order to assess potential medication-related problems, including effectiveness of drug therapy. For example during home visit of HOSRRHV#2, the hospice registered nurse (RN) did not reconcile medications. Also observed during home visit of HOSRRHV#3, wherein the hospice registered nurse (RN) did not reconcile medications as well. This finding was discussed and validated by the hospice Administrator who was present during the visit.

Observed in Record Review. In 14 of 14 active patient records, it was noted the organization had failed to ensure that the written plan of care was developed in accordance with the patient's identified goals with defined timeframes for achieving those goals. For example, HOSRRHV#1: MSW: Patient will maintain optimal coping through hospice care. HOSRRHV#2: SN Patient will pain free or verbalize an acceptable pain level with current pain management regimen. HOSRRHV#3: SN: Measured arm circumference will not decrease by more than 1 cm per month. HOSRRHV#4: MSW: Patient will demonstrate ability to cope with limitation. HOSRRNHV#5: HOSRRNHV#6: SC: Patient/Caregiver will feel needs are being met as they have defined; SN: Anxiety/agitation controlled through course of care. HOSRRNHV#7: Patient/Caregiver will verbalize appropriate interventions for stress/anxiety management. HOSRRNHV#8, HOSRRNHV#9: SC: Family/Caregiver will minimize effects of abnormal grief.(SN): Skin will remain intact. HOSRRNHV#10: Maintenance of respiratory baseline as evidenced by breathing at optimal level within disease parameters. HOSRRNHV#11: Aide: Patient's personal care needs will be met. HOSRRNHV#12: SN: Family/caregiver maintain and modify environment according to patient's cognitive and comfort status. HOSRRNHV#13: SC: Patient/Caregiver will feel needs are being met as they have defined. HOSRRNHV#14: SN: Patient/Caregiver will verbalize understanding of falls/injury prevention and home safety measures. This finding was discussed and validated by the Hospice Administrator and Patient Care Coordinator.

Observed in Record Review. In 2 of 14 active patient records reviewed, it was noted the organization failed to ensure that the hospice plan of care plan includes all services needed for the palliation and management of the terminal illness and related conditions, including medications and treatment necessary to meet the patient’s needs. For example, on review of record HOSRRHV#2, SN was ordered to perform wound care/dressing change. apply thin layer of barrier cream. However, it did not indicate how often the wound dressing change and what kind of wound barrier cream; In record of HOSRRHV#4, an order for Oxygen 3 LPM via NC to maintain oxygen saturation above 90% and comfort, however, it did not specify frequency (continuously or intermittent). This finding was discussed and validated by the hospice Administrator and patient care coordinator (PCC).

Observed in Record Review. In 14 of 14 active hospice patient records reviewed, it was noted the organization failed to ensure that a revised plan of care must include information from the patient's updated comprehensive assessment and must note the patient's progress toward outcomes and goals specified in the plan of care. For example on review of records HOSRRHV#1, HOSRRHV#2, HOSRRHV#3, HOSRRHV#4, HOSRRNHV#5,HOSRRNHV#6,HOSRRNHV#7,HOSRRNHV#8,HOSRRNHV#9,HOSRRNHV#10,HOSRRNHV#11,HOSRRNHV#12,HOSRRNHV#13,HOSRRNHV#14, The plan of care goals and interventions remained the same and not updated from admission and continued IDT to IDT meeting. This finding was discussed and validated by the Administrator and Patient Care Coordinator.

Observed in Record Review. In 14 of 14 active patient records with hospice aide services, it was noted the organization had failed to ensure that the 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. For example, HOSRRHV#1, HOSRRHV#2, HOSRRHV#3, HOSRRHV#4, HOSRRNHV#5,HOSRRNHV#6,HOSRRNHV#7,HOSRRNHV#8,HOSRRNHV#9,HOSRRNHV#10,HOSRRNHV#11,HOSRRNHV#12,HOSRRNHV#13,HOSRRNHV#14, the aide care plan did not include a frequency for each of the task assigned. Also noted in other records, HOSRRNHV#5 Patient takes Aspirin 81 mg 1 tablet PO once a day. No instructions related to bleeding precaution or not use razor blade when shaving. This finding was discussed with and validated by the Administrator and Patient Care Coordinator.

Observed in Record Review. In 2 of 14 active patient records with hospice aide services reviewed, it was noted the organization failed to ensure that hospice aide supervision was conducted at the patient's home no less than every 14 days as required. For example in HOSRRHV#4, there was a gap of 15 days hospice aide supervision between the 2nd week and 4rth week of March (certification benefit period 1). Another example, in HOSRRHV#8, there was a gap of 15 days hospice aide supervision between 2nd week and 4rth week of March and also noted between the 1st and 3rd week of April (certification benefit period 4). This finding was discussed and validated by the hospice administrator and patient care coordinator (PCC).

Observed in Record Review. In 3 of 3 Live discharge hospice records reviewed, it was noted the organization failed to ensure that the hospice discharge summary includes a summary of the patient’s stay, including treatments, symptoms, and pain management. For example in review of record of HOSRRDC#18, HOSRRDC#19, and HOSRRDC#20, the discharge summary sections such as reason for admission, discharge condition, summary of care, post-dc goals left were left blank. This finding was discussed and validated by the hospice Administrator and Patient Care Coordinator (PCC).

Observed in Patient Home. In 1 of 1 hospice patient with home oxygen observed, it was noted the organization failed to provide patient education and training related to storage, handling, and access of home oxygen. For example, during home visit of HHRRHV#4 , the hospice nurse surveyor had noticed 1 oxygen cylinder stored in the living room, although in upright position, but unsecured and also found another oxygen cylinder stored in the garage. The clinical staff had not re-educated patient the proper storage and safety nor taking action during the entire home visit. This finding was discussed and validated by hospice Administrator (RN), who was present during the visit.

Observed in Record Review. In 1 of 5 patient records reviewed, the plan of care failed to include all services needed for the palliation and management of the terminal illness and related conditions, including treatments necessary to meet the patient’s needs. For RRNHV #3 who had been admitted to the hospice program 9 weeks ago the initial assessment documented a pressure ulcer to the patient's coccyx, and left ankle but there were no physician orders for wound care in the medical record. On subsequent visits the nursing staff documented measurements of the ankle wound and reported that the wound bed had granulating tissue and also documented performing dressing changes to the left outer ankle however there was no evidence of physician orders for wound care. The Administrator and Patient Care Coordinator confirmed that an physician order for wound care had not been obtained.

Observed in Record Review. In 2 of 5 patient records reviewed, goals were not identified for all problems identified on patient assessments. Examples include: MR 2 plan of care did not include an HHA goal for services being provided and MR 5 did not include a goal for the MSW providing services. This was verified by the Administrator and PCC.

Observed in Record Review. In 3 of 5 patient records reviewed, all problems identified on assessments were not included on the plan of care. Examples include: MR 1: the plan of care did not include the heart disease primary problem, pain or caregiver for moderate risk assessment during bereavement; MR 2: no plan of care for the HHA providing services, heart disease/edema (CHF was primary diagnosis) or fall risk; MR 5 plan of care did not include an update when the patient was placed on oxygen, which was noted on the IDT note. This was verified by the Administrator and PCC.

Observed in Record Review. The organization did not complete the Certificate of Terminal Illness by the Medical Director in MR 3 (1 of 5 CTIs reviewed); specific reference to the content of the assessment being present, however it was not signed or dated due to a glitch in the electronic medical record at the time of entry. This was verified by the Administrator.

Observed in Record Review. In 5 of 5 patient records reviewed, the organization did not develop plans of care that were based on patient’s goals and the time frames, settings, and services required to meet those goals. In every record reviewed goals were not specific, measurable, and individualized. For example: Personal care needs will be met; respirations will not be labored as evidenced by respirations will be at or below 24 at each visit; patients personal care needs will be met as evidenced by skin clean, dry, intact and free from odors; patient achieves feelings of spiritual comfort by evidence of face expressions or body movement; patient will complete oral antibiotics as disease will allow as evidence by patient able to swallow medication. This RFI was confirmed by the Administrator and Patient Care Coordinator.

Observed in Record Review. In 5 of 5 patient records reviewed, the organization did not ensure that the plan of care included all services needed for the palliation and management of the terminal illness and related conditions, including the scope and frequency of the services necessary to meet the patient’s and family’s needs. For example, in comprehensive assessments and re-assessments of RRNHV#1 it was identified that the patient was at risk for skin breakdown; had sluggish perfusion; was saturating at 91% at 4 lpm of oxygen without dyspnea or shortness of breath; had an indwelling foley catheter; bowel incontinence; and a high risk for falls. None of these problems were addressed in the plan of care. Similar omissions were found in the records of RRHV#1, RRNHV#2, RRBR#1, and RRBR#2. This RFI was confirmed by the Administrator and Patient Care Coordinator.

Observed in Record Review. In 5 of 5 patient records reviewed, the organization failed to document its review and revision of the patient's plan of care. Interdisciplinary meeting notes did not document decline, updates to the plan of care, and progress toward goals in the records of RRHV#1, RRNHV#1, RRNHV#2, RRBR#1, and RRBR#2. This RFI was confirmed by the Administrator and Patient Care Coordinator.

Observed in Tracer Activities. The organization's written infection prevention and control plan continued not to address prioritized risks as they had not been identified. This RFI was confirmed by the Administrator and Patient Care Coordinator.

Observed in Record Review. In 2 of 2 patient records reviewed, where patients died, the organization did not develop a bereavement plan of care that specified the type and frequency of services. In the records of RRBR#1 and RRBR#2 no bereavement plans of care were created. This RFI was confirmed by the Administrator and Patient Care Coordinator.

Observed in Tracer Activities. There was no evidence that the governing body and leadership had established processes to support patient care, treatment, and services through sustained compliance as evidenced by repeat and condition level requirements for improvement at §418.56, §418.100, and §418.102. This RFI was reviewed with the Administrator and Patient Care Coordinator.

Observed in Record Review. In 5 of 5 patient records reviewed, the organization did not ensure that written certifications documented primary terminal conditions, and current subjective and objective medical findings. In the record of RRHV#1 the terminal diagnosis was identified as chronic respiratory failure in some CTIs and COPD in other CTIs. These were intermingled and there was nothing in the record to indicate that the terminal diagnosis was changed. In the records of RRHV#1, RRNHV#1, RRNHV#2, RRBR#1, and RRBR#2 subjective and objective documentation to support on-going appropriateness for hospice services was minimal or absent. This RFI was confirmed by the Administrator and Patient Care Coordinator.

Observed in Tracer Activities. Contracts with therapy services were not revised to include a stipulation that criminal background checks would be completed on employees providing direct patient care or having access to patient records. This RFI was reviewed with the Administrator and Patient Care Coordinator.

Observed in Record Review. In 1 of 6 patient records reviewed, the interdisciplinary group, in collaboration with the physician, did not document the review and revision of the patient's plan of care at least every 15 days. In RR#1, the first Interdisciplinary Group (IDG) meeting and plan of care review/revision was documented 21 days of the patient's admission to hospice care. This was reveiwed and verified with the Administrator.

Observed in Record Review. In 3 of 10 patient records reviewed, the plan of care did not include all services for the palliation and management of the terminal illness and related conditions, including interventions to manage pain and symptoms. In RR#1, the patient's primary diagnosis was Alzheimer's Disease; and the patient was discharged to the hospital for treatment related to behavioral manifestations that could not be managed by the staff at the memory care unit. Problems, interventions, and goals related to the patient's behavior were not noted on the hospice POC. In reviewed of the record for HV#2 and RR#6, the patient was assessed at high risk for falls. Interventions related to fall prevention/reduction was not reflected in the hospice plan of care. This was reviewed and verified with the Administrator.

Observed in Record Review. In 1 of 10 patient records reviewed, the organization did not plan the patient's care by including all services needed for the palliation and management of the terminal illness and related conditions in the hospice plan of care, including drugs and treatments. In review of the record for HV#2, the current plan of care included nutrition/hydration, and blood sugar management, but the only interventions noted in the plan of care was for skilled nursing assessments. It was also noted the Certificate of Terminal Illness (CTI) indicated the patient had a stage 1 pressure ulcer to the coccyx. The patient's plan of care did not include the alteration and risks related to skin integrity and the barrier cream implemented. This was reviewed and verified with the Administrator.

Observed in Record Review. In 2 of 2 bereavement records reviewed, the bereavement plan of care did not specify the type of bereavement services to be offered and the frequency of service to be provided. In BR#1 and BR#2, the Bereavement Plan of Care did not outline the specific services (mailings) to be provided and the frequency of the mailings/communications to the low and moderate risk family members. This was reviewed and verified with the Bereavement Coordinator and Administrator.

Observed in Record Review. In 2 of 9 patient records reviewed with hospice aide services, the registered nurse did not perform/document aide supervision at least every 14 days. In review of the record for HV#1, aide supervision was not performed/documented for 37 days. In RR#7, an aide supervisory visit was completed/documented after 17 days. This was reviewed and verified with the Administrator.

Observed in Record Review. In 1 of 4 patient records reviewed on recent admissions, the organization did not accept the patient for care, treatment, or services based on its ability to meet the patient's needs. In RR#5, the hospice physician's narrative note for the determination of the patient's life expectancy on the Certificate of Terminal Illness (CTI) indicated the patient was admitted to hospice for the primary diagnosis of Chronic Anemia. The patient's primary hospice diagnosis was determined to be Arteriosclerotic Heart Disease of the Native Coronary Artery. This was reviewed and verified with the Administrator.

Observed in Record Review. In 3 of 3 active patient record review, During RR# 1, RR# 2, and RR# 3's patient records review it was noted the organization had not ensured the written plan of care goals were individualized and measurable. For example: review of RR# 1's plan of care revealed the goal Optimal cardiac status within disease limitations, as evidenced by ability to resume and maintain adapted lifestyle without distress or complications. Review of RR# 1, RR# 2, and RR# 3's plans of care revealed the same goal Patient/Caregiver will feel needs are being met as they have defined. The goals were not individualized or measurable. This was reviewed, discussed, and validated with the Patient Care Coordinator and the Administrator.

Observed in Record Review. In 3 of 3 active patient records reviewed, During RR# 1, RR# 2, and RR# 3's patient record review it was noted the organization had not ensured the plan of care included interventions to manage symptoms. For example: review of RR# 1's patient record reveald RR# 1 had a diagnosis of diabetes mellitus and was receiving insulin and Metformin daily. However, review of the plan of care revealed no interventions for diabetes mellitus or hypo/hyperglycemia precautions. Review of RR# 2's patient record revealed RR# 2 had an ostomy. Further review of the plan of care revealed no interventions or coordination of care regarding the ostomy, such as who manages the ostomy. Review of RR# 3's patient record revealed RR# 3 had a diagnosis of dysphagia and a mechanical soft diet. Review of the plan of care revealed no interventions or aspiration precaution. This was reviewed, discussed, and validated with the Patient Care Coordinator and the Administrator.

Observed in Record Review. In 2 of 3 active patient records reviewed, During RR# 2 and RR# 3's patient record review it was noted the organization had failed to document its review and revision of the patient's plan of care. For example: review of RR# 1's Interdisciplinary Group Meeting/Plan of Care Update notes on 3/9/23 revealed no Chaplain and on 3/23/2023 revealed no MSW or Chaplain documentation. Review of RR# 3's Interdisciplinary Group Meeting/Plan of Care Update notes revealed no Chaplain documentation on 3/23/2023. This was reviewed, discussed, and validated with the Patient Care Coordinator and Administrator.

Observed in Record Review. No evidence that the governing body and leadership had established processes to support patient care treatment and services through sustained compliance as evidenced by repeat findings at the condition level deficiencies at 418.102, 418.116, 418.56, 418.104 and 418.100. In addition, to new condition level deficiencies at 418.108. This was confirmed by the Administrator and Patient Care Coordinator. Observed in Record Review. There was no evidence that the governing body and leadership had established requirements to support patient care treatment and services as evidenced by the HCO did not implement the policies and procedures related to IDG meeting documentation, authentication of documents, not providing, in writing to the patient/family information on hospice services covered or non-covered, not having GIP care available, and not ensuring the Medical Director or physician designee reviewed the clinical record prior to recertification. In addition, there were conditional level findings at 418.100, 418.102, 418.116, 418.56, and 418.104. This was confirmed by the Administrator and Patient Care Coordinator.

Observed in Record Review. HCO did not have a general contract to provide short term general inpatient. Email from hospital to owner stating the contract is still in the legal department and had not been approved. This was confirmed by the Administrator.

Observed in Record Review. In 2 of 2 patient records reviewed with recertification., During RR# 2 and RR# '3s patient records review it was noted the organization had not ensured the Medical Director or physician designee reviewed the patient's clinical information before the recertification period. For example: review of RR# 2's patient record revealed a recertification dated approximately five days prior to the surveyor review of the record. Further review of RR# 2's patient record revealed a blank recertification CTI with no signature with a typed in date and name of a RN. Review of RR# 3's patient record revealed a recertification dated approximately three days prior to the surveyor review of the record. Further review of RR# 3's patient record revealed a blank recertification CTI with no signature with a typed in date and name of a RN. This was reviewed, discussed, and validated with the Patient Care Coordinator and the Administrator.

Observed in Record Review. In 3 of 3 active patient records reviewed, Interdisciplinary Group Meeting/Plan of Care Update notes are not authenticated. IDG/POC Update notes do not contain signature and title of participants or of primary author. In addition review of RR# 2 and RR# 3's patient record revealed blank recertification CTIs that were dated the same day with a typed in name of a RN. The Administrator shared it was not a verbal order and not sure why it had a date or a typed in name of a RN. This was reviewed, discussed, and validated with the Patient Care Coordinator and the Administrator.

Observed in Record Review. In 2 of 2 patient records reviewed with start of care after 3/8/23, During review of RR# 1 and RR# 5's patient records it was noted the organization had not ensured patients were informed verbally and in writing of the covered and non-covered items, services, or drugs. For example: review of RR# 1's patient record revealed a start of care dated 23 days prior to the surveyor review of the record, and RR# 5's patient record review revealed a start of care dated two days prior to the surveyor review of the record with no documentation of covered and non-covered items, services, or drugs. This was discussed with the Administrator that shared the organization had created a new form to be included in the admission packet and was not aware it had not been implemented on the clinician's laptops. This was reviewed, discussed, and validated with the Patient Care Coordinator and Administrator.

Observed in Emergency Management Session. HCO did not document potential risks in the community that could impact the organization's ability to provide care for its patients. Upon review of Hazard Vulnerability Analysis, the organization had not identified technological and human cause hazards. This was confirmed by the Administrator and Patient Care Coordinator.

Observed in HR File Review. In 1 of 9 HR files reviewed, staff had not been provided emergency management training at least every 2 years. In HR#1 and HR#4 personnel file review, the surveyor noted that the staff had not attended an emergency management training in the last 2 years. This was confirmed by the Administrator.

Observed in Record Review. In 13 of 13 patient records reviewed, Organization did not provide patients with the option the to choose attending physician. Upon review of a sample admission packet, the surveyor noted that the Hospice Medicare Benefit Election Form has the Medical Director's name and NPI number preprinted on the form under designated physician. This was confirmed with the Administrator.

Observed in Record Review. In 2 of 13 patient records reviewed, The medical social worker failed to complete their initial assessments within five days after the election of hospice. In HV#1/RR#1, the medical social worker completed the initial assessment on Day 10. In HV#2/RR#2, the medical social worker completed the initial assessment on Day 7. This was confirmed by the Administrator.

Observed in Record Review. In 1 of 13 patient records reviewed, Initial bereavement assessment not completed to determine the needs of the patient's family and how a death may impact their ability to cope. In RR#5, the initial bereavement assessment was not completed. This was confirmed by the Administrator.

Observed in Tracer Activities. During survey, physician left the IDG meeting prior to discussing all patients. After discussion with Leadership Team, it seems to be a common occurrence. This was confirmed by the Administrator.

Observed in Record Review. In 1 of 13 patient records reviewed, plan of care goals were not measurable. For example, in HV#2/RR#2 the surveyor noted that there were no measurable goals for a specific outcome as evidenced by patient will maintain optimal cardiac function and goals were not individualized patient will be able to verbalize/demonstrate appropriate coping behaviors. This was confirmed by the Administrator.

Observed in Record Review. In 1 of 13 patient records reviewed, Plan of care did not include all services needed for palliation and management of the terminal illness and related conditions. In RR#4, patient identified as having a bilateral foot plantar area pressure ulcer, stage III; but the plan of care did not address wound care. This was confirmed by the Administrator. Observed in Record Review. In 1 of 13 patient records reviewed, HCO had not obtained an order for use of oxygen. In HV#3/RR#3, the surveyor noted that the patient had an oxygen concentrator. Caregiver stated that patient uses oxygen to sleep. RN Case Manager notes reference the intermittent use of oxygen @ 2 lpm via nasal cannula, but no written order found. This was confirmed by the Administrator.

Observed in Record Review. In 13 of 13 patient records reviewed, HCO failed to document its review and revision of the patient's plan of care. Interdisciplinary Group Meeting/Plan of Care Update notes does not capture team discussion about specific patient needs, potential issues, or long-term care strategies. This was confirmed by the Administrator.

Observed in Infection Control System Tracer. HCO did not include goals to minimize the spread of infection as evidenced by the organization was unable to provide this documentation at the time of survey. Observed in Infection Control System Tracer. HCO did not include goals to minimize the spread of infection by improving compliance with hand hygiene guidelines as evidenced by the organization was unable to provide this documentation at the time of survey. Observed in Infection Control System Tracer. HCO did not include goals to minimize the spread of infection associated with procedures as evidenced by the organization was unable to provide this documentation at the time of survey. Observed in Infection Control System Tracer. HCO did not include goals to minimize the spread of infection associated with the use of medical equipment, devices, and supplies as evidenced by the organization was unable to provide this documentation at the time of survey. Observed in Infection Control Tracer. HCO's written infection prevention and control goals did not include how it would address prioritized risks. This was confirmed by the Administrator and Patient Care Coordinator.

Observed in Record Review. In 2 of 2 patient records reviewed, A bereavement plan of care was not developed. In RR#10 and RR#11, the surveyor noted that a bereavement plan of care was not developed to reflect family needs, as well as delineate the services to be provided and the frequency of service delivery. This was confirmed by the Administrator.

Observed in HR File Review. Organization failed to provide ongoing 12-hours of hospice aide in-service training. In HR#9 personnel file review, there were no in-service education hours documented for 2020-2022. This was confirmed by the administrator.

Observed in Record Review. In 1 of 12 patient records reviewed, receiving aide services, Hospice aide supervision not completed every 14 days. In HV#3/RR#3, the surveyor noted that the aide was not supervised in November and only once in the month of December. This was confirmed by the Administrator.

Observed in Tracer Activities. There was no evidence that the governing body and leadership had established requirements to support patient care treatment and services as evidenced by the HCO did not implement the policies and procedures related to IDG meeting documentation and core members participating, authentication of documents, not doing the addendum, not having GIP/Respite care available. In addition, there were conditional level findings at 418.100, 418.102, 418.116, and 418.104. This was confirmed by the Administrator and Patient Care Coordinator. Observed in Tracer Activities. No evidence that the governing body and leadership had established processes to support patient care treatment and services through sustained compliance as evidenced by repeat findings from previous surveys in the areas of Infection Control, Emergency Management, and Plan of Care issues. In addition, there were repeat condition level deficiencies at 418.60 and 418.113. This was confirmed by the Administrator and Patient Care Coordinator.

Observed in Tracer Activities. HCO did not have a general contract to provide short term general inpatient or respite care. A one-time contract is signed at the time a patient is in need of respite care. This was confirmed by the Administrator.

Observed in Record Review. In 5 of 13 patient records reviewed, The CTI did not consider all of the required elements. In HV#3/RR#3, RR#4, RR#5, RR#6, RR#9 the Initial CTI failed to include current subjective and objective medical findings, current medication and treatment orders, and information about the medical management of the patient's conditions unrelated to the terminal condition. For example, in RR#5, physician's narrative stated, Patient has shown continued decline in his weight. Dx concurrent CHF & dementia are aggravating his decline. He qualifies for hospice services. This was confirmed by the Administrator.

Observed in Record Review. In 5 of 13 patient records reviewed, Medical Director did not address how the patient continues to meet the criteria for terminal status. In HV#1/RR#1, 2 out of 4 CTIs the Medical Director/Hospice Physician wrote, Reviewed F2F encounter and agree that patient qualifies for continued hospice services. This was also found in HV#2/RR#2, RR#5, RR#6, RR#13. This was confirmed by the Administrator.

Observed in Record Review. In 13 of 13 patient records reviewed, Interdisciplinary Group Meeting/Plan of Care Update notes are not authenticated. IDG/POC Update notes do not contain signature and title of participants or of primary author. This was confirmed by the Administrator.

Observed in Tracer Activities. Contractual agreement for Pharmacy, Durable Medical Equipment, and Therapy did not stipulate that contractor conducts criminal background checks on all employees who have direct patient contact or access to patient records. This was confirmed by the Administrator.

Observed in Record Review. In 13 of 13 patient records reviewed, organization did not inform patients verbally and in writing of the covered and non-covered items, services, or drugs. This was confirmed by the Administrator.