Every finding on record at Curo Health Services, LLC

Upon patient record review 1 of 14 (Patient #7) 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 7: Patient admitted on 01/09/2025. Chaplain services were declined. There is no evidence that the RN or the SW completed this part of the assessment. RN completed HIS questions in comprehensive assessment. No evidence that the assessment has been completed at the time of survey. Mini spiritual assessment completed on day 2 of the survey.

Upon patient record review, 2 of 14 (Patient #4,6) 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 4: No evidence that the bereavement risk assessment was completed within 5 days of the election of hospice. Patient admitted on 01/03/2025, assessment completed on 02/20/2025. Patient 6: No evidence that the bereavement risk assessment was completed within 5 days of the election of hospice. Patient admitted on 02/08/2025, assessment completed on 04/08/2025.

Upon patient record review, 2 of 14 (Patient #5,9) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient 5: The record indicates that patient developed a wound to the right buttock on 04/25/2025. No evidence that the wound has been measured since the wound was identified. Wound remains active in the wound chapter, the plan of care has active wound care orders. Gentiva policy is for wounds to be measured weekly. Patient 9: The record indicates that patient developed a wound to the coccyx on 02/17/2025. No evidence that the wound had been measured since the week the wound was identified, 02/17/2025. The documentation reflects that the wound was active from 02/17/2025 - 03/20/2025. Gentiva policy is for wounds to be measured weekly.

Upon patient record review, 3 of 14 (Patient #2,4,10) 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 2: The medical record indicated that the patient has a history of depression and has an active diagnosis of depression. Currently takes Zoloft for depression. No evidence of problems, goals, and interventions related to risk for depression included in the plan of care. Patient 4: The medical record indicated that the patient has a history of depression and has an active diagnosis of depression. Clinical documentation indicates that patient continues to have active signs and symptoms of depression. No evidence of problems, goals, and interventions related to risk for depression included in the plan of care. Patient 10: The medical record indicated that the patient has a history of dysphagia. No evidence of problems, goals, and interventions related to risk for aspiration included in the plan of care.

Upon patient record review, 2 of 14 (Patient #7,8) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient 7: The initial visit frequency for both the social worker and the spiritual care counselor was ordered as 1 prn. Patient 8: The initial visit frequency for both the social worker and the spiritual care counselor was ordered as 1 prn.

Upon client record review, 2 of 14 (Patient #7,8) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 7: The plan of care has MSW frequency ordered as monthly. No evidence that a visit occurred for the month of March 2025. No evidence that the visit were missed at the request of the family or that an order was received to change the visit frequency for the month. Patient 8: The plan of care has MSW and volunteer frequency ordered as twice monthly. No evidence that the MSW visited the patient twice for the month of May 2025. The medical record shows documentation for one visit in the month of May that occurred on 05/30/25. No evidence that the volunteer visited the patient twice for months of April and May. The medical record shows documentation for one visit in April that occurred on 04//04/25 and one visit for the month of May that occurred on 05/30/25. No evidence that the visits were missed at the request of the family or that an order was received to change the visit frequency for the month.

Upon observation, there was no evidence the annual report documents the use of volunteers providing day to day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract personnel. Agency volunteer percentage for 2024 was 2.5%.

Upon patient client record review, 1 of 14 (Patient #9) 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 9: The medical record included a POST form that was uploaded on that was missing a signature date for the representative.

Upon client record review, 1 of 14 (Patient #11) did not have evidence that if a patient revokes the election of hospice care or is discharged from hospice in accordance with §418.26, the hospice must forward to the patient's attending physician: • A copy of the hospice discharge summary • The patient's clinical record, if requested Patient 11: There is no evidence in the medical record that a discharge summary was sent to the patient’s identified attending physician when the patient revoked services on 01/15/2025.

Upon client record review, 4 of 14 (Patient #11,12,13,14) did not have evidence that the discharge summary includes all required information.. Patients 11,12,13,14: There is no evidence in the medical record that a discharge summary was completed at the time of discharge.

Upon client record review, 1 of 14 (Patient #1) did not have evidence that a written hospice plan of care is established and maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided is in accordance with this hospice plan of care. Patient 1: The plan of care has volunteer frequency ordered as 2 visits a month. No evidence that patient received 2 visits for the month May. The clinical documentation indicated that only one visit occurred for the month of May (05/30/25). No evidence that the visit were missed at the request of the family or that an order was received to change the visit frequency for the month

Upon patient record review, 5 of 11 (Patients #1, 2, 6, 7, 11) 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 6/14/22 physician order reads Peg care daily & prn. The 6/14/22 physician order reads cg to suction patient prn with no qualifier. Patient #2 The 6/18/22 and 6/24/22 physician order for wound care contains instructions for hospice nurse to perform prn with no qualifier. The plan of care contains an order for medihoney application 3xweek and prn with no qualifier. Patient #6 The 5/26/22 physician order for wound care contains instructions for dressing change frequency of daily and prn with no qualifier. Patient #7 The 5/24/22 and 6/7/22 physician order for wound care contains frequency of dressing change by hospice nurse as prn with no qualifier. Patient #11 The 4/29/22 physician order digital impaction prn with no qualifier.

Upon patient client record review, 11 of 11 (Patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11) 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 #1-11 The aide signature to all visits to date are missing credentials with the associated signature. Also all orders signed by Clinical Management and Consultant contain no associated credentials to date.

Upon patient record review, 4 of 11 records (Patients #3,#5,#7,#9) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications. Patient 3: The medication profile contained Bactrim with start date of 3-10-22 that was still active. There was an order 3-11-22 to discontinue the Bactrim. The medication profile also contained oxygen without a frequency of continuous or as needed. Corrected on site. Patient 5: The medication profile contained oxygen with no defined delivery method. The order stated per nasal cannula. Patient 7: The medication profile contained oxygen with no defined delivery method. Patient 9: The medical record contained nursing documentation upon admission identifying patient use of oxygen. There was no evidence of oxygen listed on the medication profile.

Upon patient record review, 4 of 11 records (Patients #2,#5,#6,#8) 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 2: The medical record contained an initial bereavement assessment completed 1-4-22. Patient admitted 12-9-21. Patient 5: The medical record contained an initial bereavement assessment completed 7-26-21. Patient admitted 7-16-21. Patient 6: The medical record contained an initial bereavement assessment completed 12-21-21. Patient admitted 11-22-21. Patient 8: The medical record contained an initial bereavement assessment completed 11-5-21. Patient admitted 10-10-21 and expired 10-30-21.

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

Upon patient record review, 3 of 11 records (Patients #1,#6,#9) 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 plan of care contained an active need for spiritual care and social work services. The patient declined services upon initial psychosocial and spiritual evaluations. Corrected on site. Patient 6: The medical record contained evidence the patient received spiritual care services. There was no evidence of problems, goals, and interventions related to spiritual care needs. Patient 9: The medical record contained nursing documentation upon admission identifying patient use of catheter. There was no evidence of problems, goals, and interventions related to altered genitourinary function and catheter use included on the plan of care.

Upon patient record review, 3 of 11 records (Patients #3,#7,#9) 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 3: The medical record contained an order for oxygen with no evidence of a defined frequency of continuous or as needed. Corrected on site. Patient 7: The medical record contained an order for oxygen with no defined delivery method. Patient 9: The medical record contained nursing documentation identifying patient use of indwelling catheter and oxygen. There was no evidence of a treatment order for catheter size and maintenance and no evidence of an order for oxygen dosage, frequency, and delivery method.

Upon patient record review, 4 of 11 records (Patients #1,#5,#7,#8) 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 equipment and supply needs. Patient 1: The medical record contained nursing documentation identifying patient use of an air mattress. There was no evidence of an air mattress listed for DME included on the plan of care. Corrected on site. Patient 5: The medical record contained nursing documentation upon admission identifying patient use of APP mattress. There was no evidence of the mattress included as DME on the plan of care. Patient 7: The medical record contained nursing documentation 7-14-21 identifying patient use of commode. There was no evidence of the commode included as DME on the plan of care. Patient 8: The medical record contained nursing documentation 10-14-21 identifying patient use of a low air mattress. There was no evidence of the mattress included as DME on the plan of care.

Upon client record review, 2 of 11 records (Patient #1, 11) 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 medical record contained an ordered nursing frequency of twice weekly. There was evidence of one scheduled visit and two prn visits completed the week of 3-13-22. There was no evidence of documentation or order change for frequency not met. Corrected on site. Patient 11: The medical record contained an ordered frequency for social work of 3 PRN visits and for spiritual care of 7 PRN visits on the recertification plan of care update. Scheduled visits were completed by social worker on 10-26-21, 11-17-21, and 12-16-21. Scheduled visits were completed by chaplain 10-11-21, 10-25-21, 11-18-21, 11-22-21, 12-10-21, and 12-20-21. There was no evidence any of an order for scheduled visits.

Upon patient client record review, 1 of 11 records (Patient #4) 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 4: The medical record contained nursing documentation identifying patient use of oxygen. There was no evidence of order, medication on profile, or DME in the profile and leadership clarified with nurse that oxygen use was error in documentation. Corrected on site with notation of error documented.