Every finding on record at Community Health Care Hospice Inc

Upon observation, there was no evidence the Emergency Plan communication plan includes contact information for Federal and state emergency preparedness staff or a primary and alternate means for communicating with them. Corrected on site.

Upon patient record review, 13 of 14 (Patient #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #14) 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: On SOC Braden score 8- high risk, SW identified "working on funeral", there was no evidence in the POC for problem/interventions/goals for skin integrity or funeral planning. Corrected on site. Patient #2, #3, #4, #6, #7: SW identified no funeral plans/pending/not finalized, there was no evidence in the POC for problem/interventions/goals for funeral planning. Corrected on site. Patient #5: On SOC Braden score 10- high risk, SW identified no funeral plans/pending, there was no evidence in the POC for problem/interventions/goals for skin integrity or funeral planning. Corrected on site. Patient #8: On SOC Braden score 14- moderate risk, SW identified burial plans without a mortuary chosen, documented through two certifications. There was no evidence in the POC for problem/interventions/goals for skin integrity or funeral planning. Corrected on site. Patient #9: On SOC Braden score 14- moderate risk, SW identified burial plans without a mortuary chosen, documented through two certifications. There was no evidence in the POC for problem/interventions/goals for skin integrity or funeral planning. Corrected on site. Patient #10: On SOC Braden score 11-high, has diagnosis of Parkinson's, there was no evidence in the POC for problems/interventions/goals for skin integrity or neuro. Corrected on site. Patient #11: On SOC Braden score 12-high there was no evidence in the POC for problems/interventions/goals for skin integrity. Patient #12, #14: SW identified no funeral plans/pending/not finalized, there was no evidence in the POC for problem/interventions/goals for funeral planning.

Upon patient record review, 1 of 14 (Patient #4) 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 #4: Order dated 9/27/2023 for Plavix, no evidence on updated POC of problem/intervention/goals for bleeding precautions. Corrected on site.

Upon patient record review, 2 of 14 (Patient #4, #5) 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 #4: Order dated 9/27/2023 included Plavix, there was no instructions added to the Aide assignment/POC for bleeding precautions. Corrected on site. Patient #5: Patient on 02, aide assignment did not include 02 precautions. Corrected on site.

Upon observation, there was no evidence the hospice documents and demonstrates viable and ongoing efforts to recruit and retain volunteers. Per interview VC has not kept any logs of recruitment or retention.

Upon personnel record review, 1 of 11 (Personnel #4) 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 #4: The initial skills checklist had no evidence of skills specific to work with patients marked off as competent, nearly blank.

Upon patient client record review, 1 of 14 (Patient #3) 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 #3: Patient is female, on SN note dated 9/23/2023 refers to patient as his/him.

Upon client record review, 1 of 14 (Patient #7) did not have evidence that the written policies and procedures for managing controlled drugs was provided and discussed. Patient #7: No evidence that policy was provided or discussed.

Upon inpatient contract review, 1 of 2 (Kingsley Manor) did not have evidence that the inpatient facility has identified an individual within the facility who is responsible for the implementation of the provisions of the agreement. Corrected on site.

Upon inpatient contract review, 1 of 2 (Kingsley Manor) did not have evidence of a method for verifying that the requirements for ACHC standard HSP1-8B and CFR 418.108c (1)-418.108c(5)are met. Corrected on site.

Upon SNF/NF contract review, 1 of 2 (Kingsley Manor) did not have evidence of the manner in which the SNF/NF and the hospice are to communicate with each other and how each will document such communications to ensure that the needs of patients are addressed and met 24 hours a day. Corrected on site.

Upon SNF/NF contract review, 1 of 2 (Kingsley Manor) did not have evidence that specifies the provision of hospice services in the facility, including: A provision that the SNF/NF or ICF/IID immediately notifies the hospice if: • A significant change in a patient's physical, mental, social or emotional status occurs • Clinical complications appear that suggest a need to alter the plan of care • When a need to transfer a patient from the SNF/NF or ICF/MR arises, and the hospice makes arrangements for, and remains responsible for, any necessary continuous care or inpatient care necessary related to the terminal illness and related conditions • A patient dies Corrected on site.

Upon SNF/NF contract review, 1 of 2 (Kingsley Manor) did not have evidence of a provision stating that the hospice assumes responsibility for determining the appropriate course of hospice care, including the determination to change the level of services provided. Corrected on site.

Upon SNF/NF contract review, 1 of 2 (Kingsley Manor) did not have evidence that it is the SNF/NF's responsibility to continue to furnish 24 hour room and board care, meeting the personal care and nursing needs at the same level of care that would have been provided by the family at the facility before hospice care was elected. Corrected on site.

Upon SNF/NF contract review, 1 of 2 (Kingsley Manor) did not have a provision that the hospice may use the SNF/NF nursing personnel where permitted by state law and as specified by the SNF/NF to assist in the administration of prescribed therapies included in the plan of care only to the extent that the hospice would routinely use the services of a hospice patient's family in implementing the plan of care. Corrected on site.

Upon SNF/NF contract review, 1 of 2 (Kingsley Manor) did not have a provision stating that the hospice reports all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by anyone unrelated to the hospice to the SNF/NF administrator within 24 hours of the hospice becoming aware of the alleged violation. Corrected on site.