Every finding on record at Connolly Care Hospice LLC

Upon patient record review, 7 of 10 (Patient #1,2,3,4,5,7,8) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual's attending physician, if any) • Changes that have taken place since the initial assessment • Information on the patient's progress toward desired outcomes • Reassessment of the patient's response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days Patient 1: No evidence that a comprehensive assessment has been completed every 15 days. Agency currently completing IDG every 30 days and assessments were updated at that time. The record shows that the assessments occurred on 06/14/2024 and 07/14/2024. Patient 2: No evidence that a comprehensive assessment has been completed every 15 days. Agency currently completing IDG every 30 days and assessments were updated at that time. The record shows that the assessments occurred on 06/04/2024 and 07/04/2024. Patient 3: No evidence that a comprehensive assessment has been completed every 15 days. Agency currently completing IDG every 30 days and assessments were updated at that time. The record shows that the assessments occurred on 06/04/2024 and 07/04/2024. Patient 4: No evidence that a comprehensive assessment has been completed every 15 days. Agency currently completing IDG every 30 days and assessments were updated at that time. The record shows that the assessments occurred on 05/20/2024, 06/20/2024 and 07/20/2024. Patient 5: No evidence that a comprehensive assessment has been completed every 15 days. Agency currently completing IDG every 30 days and assessments were updated at that time. The record shows that the assessments occurred on 04/02/204, 05/02/2024, and 07/04/2024. Patient 7: No evidence that a comprehensive assessment was completed every 15 days during time on service. Occurred once on 06/04/2024. Patient 8: No evidence that a comprehensive assessment was completed every 15 days during time on service. Occurred once on 12/30/2023.

Upon client record review, 9 of 10 (Patient #1,2,3,4,5,7,8, 9, 10) 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 1: No evidence that an IDG was completed every 15 days. Agency currently completing IDG every 30 days. The record shows that IDG has occurred on 06/14/2024 and 07/14/2024. Patient 2: No evidence that an IDG was completed every 15 days. Agency currently completing IDG every 30 days. The record shows that IDG has occurred on 06/04/2024 and 07/04/2024. Patient 3: No evidence that an IDG was completed every 15 days. Agency currently completing IDG every 30 days. The record shows that IDG occurred on 06/04/2024 and 07/04/2024. Patient 4: No evidence that an IDG was completed every 15 days. Agency currently completing IDG every 30 days. The record shows that IDG occurred on 05/20/2024, 06/20/2024 and 07/20/2024. Patient 5: No evidence that an IDG was completed every 15 days. Agency currently completing IDG every 30 days. The record shows that IDG occurred on 04/02/204, 05/02/2024, and 07/04/2024. Patient 7: No evidence that an IDG was completed every 15 days during time on service. Occurred once on 06/04/2024. Patient 8: No evidence that an IDG was completed every 15 days during time on service. Occurred once on 12/30/2023. Patient 9: No evidence that an IDG was in collaboration and completed during time on service. Patient 10: No evidence that an IDG was in collaboration and completed during time on service.

Upon patient record review, 10 of 10 (Patient #1,2,3,4,5,6,7,8,9,10) 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 1: No evidence that written certification was received at the time of survey. No evidence that a narrative was completed at the time of survey. COS. Patient 2: No evidence that written certification was received at the time of survey. No evidence that a narrative was completed at the time of survey. COS. Patient 3: No evidence that written certification was received at the time of survey. No evidence that a narrative was completed at the time of survey. COS. Patient 4: No evidence that written certification was received at the time of survey. No evidence that a narrative was completed at the time of survey. RN signed to certify illness statement for the first benefit period. Corrected during survey. Patient 5: No evidence that written certification was received at the time of survey. No evidence that a narrative was completed at the time of survey. Corrected during survey. RN signed to certify illness statement for the first benefit period. Corrected during survey. Patient 6: No evidence that written certification was received at the time of survey. No evidence that a narrative was completed at the time of survey. Patient 7: No evidence that written certification was received or updated at the time of survey. No evidence that a narrative was completed at the time of survey. Patient 8: No evidence that written certification was received or updated at the time of survey. No evidence that a narrative was completed at the time of survey. RN signed to certify illness statement. Patient 9: No evidence that written certification was received or updated at the time of survey. No evidence that a narrative was completed at the time of survey. RN signed to certify illness statement. Patient 10: No evidence that written certification was received or updated at the time of survey. No evidence that a narrative was completed at the time of survey.

Upon patient record review, 4 of 10 (Patient #2,3,4,5) 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 2: No evidence that written certification was received for the second benefit period at the time of survey. No evidence that a narrative was completed at the time of survey. COS. Patient 3: No evidence that written certification was received for the second benefit at the time of survey. No evidence that a narrative was completed at the time of survey. COS. Patient 4: No evidence that written certification was received for the second benefit at the time of survey. No evidence that a narrative was completed at the time of survey. COS. Patient 5: No evidence that written certification was received for the second benefit at the time of survey. No evidence that a narrative was completed at the time of survey. COS.

Upon patient record review, 3 of 10 (Patient #3, 7, 9) 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 3: Hospice election statement missing effective date. Patient 7: Hospice election statement missing effective date. Patient 9: Hospice election statement missing effective date. Only has month and year listed.

Upon patient record review, 5 of 10 (Patient #1,2,3,4,5) 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 1,2,3,4,5: The record shows that CTI's/narratives that were corrected during survey were backdated to reflect a signature date as the day of admission instead of the actual date that it was signed which was 08/06/2024.