Every finding on record at Commonwealth Healthcare, LLC

Upon patient record review 4 of 19 (Patient #6, #9, #11, #13) 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 #6 The clinical record indicated an admission date of 7/21/23. The psychosocial assessment was not completed until 8/30/23. Patient #9 The clinical record indicated an admission date of 8/22/23. The psychosocial assessment was not completed until 8/29/23. Patient #11 The clinical record indicated an admission date of 4/25/23. The spiritual care counselor completed the spiritual assessment on 5/1/23. Patient #13 The clinical record indicated an admission date of 8/1/23. The spiritual care counselor completed the spiritual assessment on 8/9/23 and the psychosocial assessment was completed on 8/8/23.

Upon patient record review 1 of 19 (Patient #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 #4 No evidence of a spiritual assessment

Upon patient record review, 3 of 19 (Patient #8, #13, and #14) 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 #8 The medication profile indicate acetaminophen 500mg po as directed for pain or fever. No evidence of a fever parameter or frequency. -Corrected on site Patient #13 The medication profile indicated Acetaminophen 500mg po 2 tabs po Q8H and Acetaminophen 650mg 1 supp PRN every 4 hrs PRN pain/fever. No evidence of a fever parameter or maximum allowable dose in a 24 hour period, was found. In addition the IDG log from 9/21/23 indicted the patient was on Augmentin for a urinary tract infection which was changed to Bactrim. No evidence of either medication was found on the medication profile. Patient #14 The medication profile indicated Advil 200mg 2 tablets PRN every 8 hrs po pain. Oxycodone HCI 5mg po 1-2 tablets every 4-6 hrs prn pain. No evidence of pain parameters along with limited dose and usage specificity, was found.

Upon patient record review, 4 of 19 (Patient #1, #3, #4, and #11) 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, #3, #4, #11 the record did not contain a bereavement assessment.

Upon patient record review, 1 of 19 (Patient #13) 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 #13 No care plan with patient/family goals and interventions was found in the clinical record related to the urinary catheter. In addition no care plan was completed for infection related to an urinary tract infection.

Upon patient record review, 3 of 19 (Patient #8, #13, and #14) 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 #8 medication order indicated acetaminophen 500mg po as directed for pain or fever. No evidence of a fever parameter or frequency. corrected on site Patient #13 Physician orders stated Insert Catheter and as prescribed (specify cath and balloon size, type, and frequency) Monthly or PRN. No evidence of Catheter size, type for frequency was found. The medication profile indicated Acetaminophen 500mg po 2 tabs po Q8H and Acetaminophen 650mg 1 supp PRN every 4 hrs PRN pain/fever. No evidence of a fever parameter or maximum allowable dose in a 24 hour period. In addition the IDG log from 9/21/23 indicted the patient was on Augmentin for a urinary tract infection which was changed to Bactrim. No evidence of orders for either antibiotic were found. Patient #14 The medication profile indicated Advil 200mg 2 tablets PRN every 8 hrs po pain. Oxycodone HCI 5mg po 1-2 tablets every 4-6 hrs prn pain. No evidence of pain parameters along with limited dose and usage specificity, was found.

Upon client record review, 3 of 19 (Patient #8, #9, and #13) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #8 the clinical record indicated a skilled nurse (SN) frequency of two times a week for eight weeks. The SN completed visits once a week on the following weeks; 8/13/23, 9/10/23, 9/17/23, and 10/4/23. In addition the spiritual care provider frequency was two times per month. The record indicated the spiritual care counselor provided visits only one time in the months of August and September. The Social Worker frequency was one time a month, and two routine visits were completed in July on the 11th and 12th. Patient #9 SW ordered as 1x/month. The social worker completed prn visits on 8/25/23 and 8/29/23 without prn orders and no evidence of the routine monthly visit for August. Patient #13 the clinical record indicated a SN frequency of two times a week for two weeks. The SN visited on 8/1/23, 8/2/23, 8/4/23 for 3 visits in one week. Then again on 9/9/23, for only one visit the week of 9/6/23. In addition the social worker had a frequency of once a month. No evidence of a social worker visit for the month of September.

Upon patient record review, 2 of 19 (Patient #1, #2) did not have evidence in the patient record that hospice aide assignments and duties are • There is evidence in the patient record that the plan of care specifically 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 had a diagnosis of seizures and the aide care plan did not include seizure precautions. Corrected on site Patient #2 The aide care plan indicated to perform a shower at every visit, may do bed bath if unable to tolerate shower, in addition shampoo was indicated as weekly and PRN, turn and reposition PRN, and to assist with ambulation PRN. Corrected on site

Upon patient record review 1 of 19 (Patient #13) 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 Patient #13 The clinical record revealed an aide frequency of two times a week, however during the week of 9/17/23 the aide went only once on the following date 9/19/23.

Upon patient record review 6 of 19 (Patient #1, #6, #7, #10, #12 and #13) 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 clinical record indicated supervisory visits were conducted on 9/5/23 and 9/27/23, No evidence of a supervisory visit the week of 9/17/23. Patient #6 The clinical record indicated an admission date of 7/21/23. It further indicated only one supervisory visit that was completed on 9/14/23. Patient #7 The clinical record indicated an admission date of 8/12/22. Supervisory visits were completed on 8/30/23, and 9/21/23. Patient #10 The clinical record indicated an admission date of 8/24/23. No evidence of any supervisory visits. Patient #12 The clinical record indicated an admission date of 8/17/23. The first supervisory visit was completed on 9/11/23. Patient #13 The clinical record indicated an admission date of 8/1/23. No evidence of supervisory visits.

Upon observation, there was no evidence that the hospice did not provide services from a branch (multiple) location until receiving a CMS approval letter. The agency is describing these 3 additional “branches” as drop sites; however these locations are manned, staff are a mix of shared and some dedicated to these locations, they have a patient census and unduplicated admissions for these locations, they are billing through the parent for them, and they hold IDG at these locations as well (physicians attends in person at times).

Upon patient record review, 1 of 19 (Patient #4) did not have evidence that the hospice provided the following information: • Hospice election form and any Advance Directives specific to each patient • Physician certification and recertification of the terminal illness specific to each patient Patient #4, the SNF record did not include evidence of the hospice election form or certification of terminal illness and it was not documented by the hospice that it was provided to the SNF.

Upon observation, there was no evidence the hospice has a CMS approval letter for all branch additions. The agency provided an unduplicated admission number and a current census for each of these branches which they have labeled as drop sites. These sites are: Louden, Winchester, Fredericksburg