Every finding on record at Devoted Hearts Hospice Corp

Based on interview and record review, the Hospice Agency (HA) failed to ensure one of 14 sampled patients (Patient 11) was aware of all Medicare covered hospice services. This failure resulted in out-of-pocket expenses for medications that should have been covered under the hospice service. --- A review of Patient 11s record titled, ";Personal Information", indicated a start of care date on 10/23/2023, with a primary diagnosis of COPD (Chronic Obstructive Pulmonary Disease- a lung disease that makes breathing difficult). During an interview on 4/24/2024, at 12:09 p.m., Patient 11s caregiver (CG 4) stated the HA was not covering some medications. CG 4 stated Patient 11 was seeing a lung specialist, for treatment of his lung cancer. CG 4 stated caregiver 5 (CG 5) should be called also because she cared for Patient 11 all the time and CG 5 dealt with the HA most of the time. During an interview on 4/24/2024, at 12:45 p.m., Patient 11s CG 5 stated she had to pay for most of the medications out of pocket because whenever she called the HA for a refill, the HA told her they do not cover the cost of the medication. CG 5 stated the expenses for the medications were from $16 to $20 per medication refill. CG 5 stated the out-of-pocket expenses for medications were the lung cancer medications and others which she did not remember the name of. During a concurrent interview and record review on 4/26/2024, at 10:47 a.m., the Administrator Designee (AD) stated the HA was supposed to cover the cost of medications that are associated with Patient 11s diagnosis. The AD stated the lung cancer medication should be covered. During a concurrent interview and record review on 4/26/2024, at 11:41 a.m., the AD reviewed Patient 11s record titled, ";POC Summary", dated 4/25/2024. The record indicated, ";8. Medication...Order date 10/13/2023 Alecensa (to treat non-small cell lung cancer that has spread to other parts of the body) 150 mg (mg-milligram, unit of measurement) 1 capsule oral (by mouth) twice daily. The AD stated the medication had not been refilled because the HA had not received a request to refill. The AD stated the medication was a daily medication and a refill should have been needed by now. The AD stated she did not know who had told Patient 11s CG 4 and CG 5 that this medication was not covered. The AD stated the nurse was supposed to review medications every visit for the need. The AD stated the SN was visiting Patient 11 twice a week. During a concurrent interview and record review on 4/26/2024, at 11:41 a.m., the AD reviewed Patient 11s record titled, ";POC Summary", dated 4/25/2024. The AD stated the following medications had not been refilled by the HA because a refill had not been requested. These medications were daily doses, and a refill should have been needed by now: Tizanidine Hydrocholoride (muscle relaxant), order date 10/13/2023 Citalopram Hydrobromide (depression), order date 10/13/2023 Donepezil Hydrochloride (Alzheimers), order date 10/13/2023 Finasteride (BPH), order date 10/13/2023. A record review of the HAs policy and procedure titled, ";Medication Profile", dated April 2019, indicated, ";Procedure: 1..., the nurse will review the medications with the patient or their representative and determine the relationship of the medication to the patients terminal illness and related conditions that contribute to the terminal prognosis. The nurse will designate medications as follows: A. Related to terminal illness or related conditions (hospice pays for medication).

Based on interview and record review the Hospice Agency (HA) failed to ensure one of fourteen sample patients (Patient 3) had an initial Spiritual Assessment conducted within five days of start of care. This failure resulted in Patient 3s husband not be aware of the resources the HA had to offer and not being offered spiritual counseling services. --- During a review of Patient 3s medical record form titled ";Personal Information" indicated a start of care date of 1/5/2024 with a primary diagnosis of senile degeneration of brain (mental decline). During a review on 4/26/2024 at 11:56 a.m., of Patient 3s Electronic Medical Record (EMR) section ";History of Spiritual Assessment" indicated there was one entry dated 4/5/2024. During a review of Patient 3s medical record form titled ";Spiritual Assessment" dated 4/5/2024, indicated under section Care Provided & Narrative indicated the chaplain placed a spiritual care call to the patient's husband. The chaplain provided active listening and explored the patient's husbands concerns. The patient and patient's husband did not have any concerns or any distress. The patient's family was aware and accepted the patient's physical decline and passing. During a telephone interview on 4/26/2024 at 9:30 a.m., with Patient 3s husband stated he was not aware the HA offered Medical Social Worker and Spiritual Counselor (SC) services. During a concurrent telephone interview and record review on 4/26/2004 at 11:51 a.m., with the SC of Patient 3s EMR, SC stated he spoke with Patient 3s husband and that he did not voice any concerns or grief at that time. Patient 3s audit log form was explained to SC. SC stated he did not speak to Patient 3s. SC stated he documented Patient 3s initial Spiritual Assessment on 4/5/2024 and the initial Bereavement Assessment on 4/26/2024. SC apologized for ";being dishonest". A record review of the HAs policy and procedure titled, ";Spiritual Assessment", dated April 2019, indicated, ";Procedure...The in-depth spiritual assessment will be performed by the Hospice Chaplain."

Based on observation, interview and record review, the Hospice Agency (HA) staff failed to review and reconcile four of fourteen sample patients (Patient 1, Patient 2, Patient 8, Patient 9) medications with their medication profiles. This failure had the potential to place patients at risk for medication errors and adverse drug reactions. --- a. During a review of Patient 1s medical record form titled ";Personal Information" indicated a start of care date of 11/26/2023 with a primary diagnosis of chronic (long term) systolic congestive heart failure (heart unable to pump enough blood). During a review of Patient 1s medical record form titled ";Current Treatment / Medication / DME List" indicated ";Omeprazole (acid reflux medication) 40 mg (milligrams) oral daily; Medi honey (topical wound treatment medication) apply to wound back every 1-2 days." During a joint visit on 4/24/2024 at 11 a.m., with Registered Nurse 1 (RN1) to Patient 1s home, RN1 reconciled Patient 1s medications with the medication profile. Patient 1s Care giver (CG1) stated Patient 1 was no longer receiving wound treatments because his wounds healed 2-3 weeks ago. Patient 1s Omeprazoles medication label indicated ";Omeprazole 40 mg take 1 capsule by mouth before meal." RN1 stated Patient 1s medication list should have been updated to show his current medications to prevent administering the wrong medication. b. During a review of Patient 2s medical record form titled ";Personal Information" indicated a start of care date of 8/15/2023 with a primary diagnosis of cerebral atherosclerosis (buildup of plaque inside the brains arterys wall). During a review of Patient 2s medical record form titled ";Current Treatment / Medication / DME List" indicated ";Atorvastatin (cholesterol medication) 40mg take 1 tab daily at bedtime; Ativan (anti-anxiety medication) 1mg 1 tab, 1 after breakfast and after dinner; Dulcolax (stool softener) 10mg rectal suppository 1 supp twice daily until good BM." During a joint visit on 4/24/2024 at 9:45 a.m. with Registered Nurse 1 (RN1) at Patient 2s residence at the B&C, RN1 reconciled Patient 2s medications with the medication profile. Patient 2s Care Giver 2 (CG2) provided Patient 2s B&C medication list that was followed by their staff. B&C medication list indicated Atorvastatin had not been administered for the month of April 2024. CG2 stated Ativan was given as needed, not routinely. RN1 stated patients and their care givers need to be provided with a current medication list to prevent medication errors and to be align with the patients medication regimen. During a review of Patient 2s medications at the Board and Care (B&C) indicated ";Atorvastatin 40mg take 1 tab daily 8pm; Lorazepam (Ativan) 1mg take 1-tab 2x daily; Bisacodyl (Dulcolax) take 1 tab daily as needed. c. A review of Patient 8s record titled, ";Personal Information", indicated a start of care date on 9/18/2023, with a diagnosis of Parkinsons disease (a brain disease that causes uncontrollable movements). During the home visit, on 4/25/2024, at 9:52 a.m., it was observed Licensed Vocational Nurse 1 (LVN 1) reviewed the medication Patient 8 was taking, using undated record titled, ";Current Treatment/Medication/DME list". During an interview, LVN 1 stated the wrong dose was listed on the record for the following medications: For Melatonin (treat sleep disorder) medications, LVN 1 stated the record should reflect that Patient 8 was taking 2 tablets daily because that was what Patient 8s caregiver (CG 6) reported. For Tylenol (pain/fever), LVN 1 stated the record should reflect the dose of 500 mg (mg-milligrams, unit of measurement) because that was what was taken at home. For Vitamin D 3 (supplement), LVN 1 stated the record should reflect the dose of 125 mcg (mcg-micrograms, unit of measurement) because that was what was at home. For Systane Lubricant (eyedrops), LVN 1 stated the concentration at home was 0.6%, not 0.3% as indicated in the record. The following medications were observed at the home; however, they were not listed in the record: Omega 3500 mg 1 capsule a day. Lisinopril 10 mg 1 tablet by mouth twice a day. Clonidine hydrochloride 5 mg. Lidocaine/Prilocaine 2.5%-2.5% topical cream Chloraseptic 1.4% throat spray Chloraseptic Sore 10 mg Lozenge Vitamin A&D topical ointment Levsin 0.125 mg Zofran 4 mg Donepezil Hydrochloride 5 mg The following medication had two dosages listed in the record: Milk of Magnesia. The dosage at the home was 1200mg/15 ml (ml-milliliter, unit of measurement), as indicated in the record. The other dose listed in the record was 400 mg/5ml. This medication dosage was not at home. During the continued review of the medications, there was two medication bottles for Ativan (a mediation used to treat anxiety), and two doses listed in the profile. The first bottle of Ativan was a tablet form. LVN 1 stated the label and profile indicated Ativan 1 mg tablet, take 1 tablet three times a day as needed. The second bottled was a liquid form. LVN 1 stated the label and profile indicated Ativan 2mg/ml 0.25 ml (0.5 mg) every 6 hours as needed. During an interview on 4/25/2024, at 10:30 a.m., Patient 8s CG 6 stated she gave the liquid Ativan when Patient 8 was really agitated. CG 6 stated she did not like to give the oral tablet because it made her so sleepy. During an interview on 4/25/2024, at 11:05 a.m., LVN 1 stated medication review should occur every visit and any discrepancy between the record and what the patient is taking should be reported to the case manager. LVN 1 stated Patient 8 should only have 1 dose of Ativan prescribed so she does not overdose. Patient 8 was already sleepy; more Ativan could put her at increased risk of falls. LVN 1 stated the importance of medication review was to make sure everyone was on the same page and to check for effectiveness of the medication in the patients treatment plan. d. A review of Patient 9s record titled, ";Personal Information", indicated a start of care date on 11/5/2023, with a diagnosis of Alzheimers disease (a brain disorder that affects activities of daily living). During a concurrent interview and record review on 4/25/2024, at 2:10 p.m., the AD reviewed Patient 9s undated record titled, ";Current Treatment/Medication/DME List". The record indicated, ";Order Date 11/5/2023, Haloperidol Lactate 2mg/ml Solution, 0.5s ml-1 mg solution, every 6 hours as needed, indication anxiety". The record also indicted, ";Order Date 4/19/2024, Ativan 2mg/dl, 0.5 ml, every 2 hours as needed for anxiety/ agitation/ restlessness". The AD stated the Haloperidol had not been refilled, so that meant the patient was no longer taking it. The AD stated the medication profile should reflect the medications patients are taking. If the patient was no longer using Haloperidol, it should have taken off the active list. The AD stated the Ativan was prescribed on 4/19/2024 because the Patient 8 had a change of condition. AD was asked if patient was administered both Haloperidol and Ativan, what can happen to the patient, AD stated patient can overdose and patient can get groggy (dopey). During a review of HAs and procedure titled ";Medication Profile" revised 4/2019, indicated ";The medication profiles will be updated for each change to reflect current medications, and new and/or discontinued medications.

Based on interview and record review the Hospice Agency (HA) failed to ensure one of fourteen sample patients (Patient 3) had an initial bereavement assessment within five days of admission. This failure resulted in Patient 3s husband not being aware of the resources the HA had to offer and not being offered bereavement services. --- During a review of Patient 3s medical record form titled ";Personal Information" indicated a start of care date of 1/5/2024 with a primary diagnosis of senile degeneration of brain (mental decline). During a telephone interview on 4/26/2024 at 9:30 a.m. with Patient 3s husband stated he was not aware the HA offered Medical Social Worker and Spiritual Counselor services. Patient's husband stated he was having a difficult time taking care of himself. During a review on 4/26/2024 at 9:42 a.m. of Patient 3s Electronic Medical Record (EMR) section ";History of Bereavement Assessment" indicated there was an entry dated 1/8/2024. Further review of the form dated 1/8/2024 indicated it was left blank and not completed. During a review of Patient 3s medical record form titled ";Bereavement Assessment" dated 1/8/2024, indicated the form was left blank. During a review of Patient 3s medical record form titled ";Audit Log" dated from 4/23/2024 to 4/26/2024, form indicated SC created Patient 3s Bereavement Assessment document on 4/26/2024 at 10:07 a.m. During a concurrent interview and record review on 4/26/2024 at 11:30 a.m. with the Director of Patient Care Services (DPCS) of Patient 3s EMR section ";History of Bereavement Assessment", DPCS stated there were two entries made. One documented by the Medical Social Worker (MSW) on 1/8/2024 and another documented by the Spiritual Counselor (SC)on 1/6/2024. DPCS was requested to call the MSW and the SC. MSW and SC did not answer. DPCS left messages to return phone call. DPCS stated patients initial bereavement assessment should be completed within five days of admission by the SC or MSW. DPCS stated bereavement assessments are done to identify if patients or their families have any issues. During a concurrent telephone interview and record review on 4/26/2004 at 11:51 a.m. with the SC of Patient 3s EMR, SC stated he spoke with Patient 3s husband and that he did not voice any concerns or grief at that time. Patient 3s audit log form was explained to SC. SC stated he did not speak to Patient 3s. SC stated he documented Patient 3s initial Spiritual Assessment on 4/5/2024 and the initial Bereavement Assessment on 4/26/2024. SC apologized for ";being dishonest". A record review of the HAs policy and procedure titled, ";Bereavement Assessment", dated April 2019, indicated, ";Procedure: 1. On admission, the social worker or hospice registered nurse will complete a bereavement risk assessment that is given to the Bereavement Coordinator."

Based on interview and record review the Hospice Agency (HA) failed to ensure all care services furnished followed an individualize plan of care established by the interdisciplinary team (IDT) by not providing Ensure (meal supplement) as ordered to one of fourteen sample patients (Patient 2). This failure had the potential to result in placing the patient at risk for decline in health due to weight loss. --- During a review of Patient 2s medical record form titled ";Personal Information" indicated a start of care date of 8/15/2023 with a primary diagnosis of cerebral atherosclerosis (buildup of plaque inside the brains arterys wall). During a review of Patient 2's medical record form titled ";Current Treatment / Medication / DME List" indicated ";Ensure 1:1 Kcal/ml 1 can oral one daily as tolerated." During a joint visit on 4/24/2024 at 9:45 a.m. with Registered Nurse 1 (RN1) to Patient 2s home, Patient 2s care giver 2 (CG2) stated the HA did not provide Patient 2 with Ensure. CG2 stated she buys Ensure for other patients and gives Patient 2 at times because she knows she likes it. RN1 stated she did not know about the Ensure and would follow up with the HA. During a concurrent interview and record review on 4/26/2024 at 11:30 a.m. with the Director of Patient Care Services (DPCS) or Patient 2s Electronic Medical Record (EMR) medical record form titled ";POC (plan of care) Summary" dated 4/26/2024, DPCS stated one can of Ensure daily was ordered for Patient 2. DPCS stated Ensure was prescribed for Patient 2 due to her poor appetite. DPCS stated that the HA did not have any evidence that Ensure was being delivered to Patient 2. Patient 2s POC Summary indicated ";Ensure 1:1 k Cal/ml 1 can oral one daily as tolerated." During an interview on 4/26/2024 at 2 p.m. with the DPCS, DPCS stated the HA did not have anything documented that indicates Patient 2 received the Ensure. DPCS stated, ";I dont know if she got them or not." A review of HAs policy and procedure titled ";The Plan of Care" revised 4/2019, indicated ";Care provided to the patient must be in accordance with the plan of care. Any change in the patients condition must result in a change in the plan of care, prior to implementation of the new service."

Based on interview and record review, the Hospice Agency (HA) failed to ensure one of 14 sampled patients (Patient 8) received education about the medications being prescribed. This deficient practice place Patient 8 at risk of overdosing due to having access to two medications for the same purpose, with two different doses. --- A review of Patient 8s record titled, ";Personal Information", indicated a start of care date on 9/18/2023, with a diagnosis of Parkinsons disease (a brain disease that causes uncontrollable movements). During a concurrent observation, interview, and record review, during the home visit, on 4/25/2024, at 9:52 a.m., Licensed Vocational Nurse 1 (LVN 1) reviewed the medication Patient 8 was taking, using undated record titled, ";Current Treatment/Medication/DME list". There were two medication bottles for Ativan (a mediation used to treat anxiety), and two doses listed in the profile. The first bottle of Ativan was a tablet form. LVN 1 stated the label and profile indicated Ativan 1 mg tablet, take 1 tablet three times a day as needed. The second bottled was a liquid form. LVN 1 stated the label and profile indicated Ativan 2mg/ml 0.25 ml (0.5 mg) every 6 hours as needed. During an interview on 4/25/2024, at 10:30 a.m., Patient 8s caregiver (CG 6) stated she gave the liquid Ativan when Patient 8 was really agitated. CG 6 stated she did not like to give the oral tablet because it made her so sleepy. During an interview on 4/25/2024, at 11:05 a.m., LVN 1 stated Patient 8 should only have 1 dose of Ativan prescribed so she does not overdose. Patient 8 was already sleepy; more Ativan could put her at increased risk of falls. LVN 1 stated the importance of medication review was to make sure everyone was on the same page and to check for effectiveness of the medication in the patients treatment plan. During a concurrent interview and record review on 4/25/2024, at 1:28 p.m., the Administrator Designee (AD) reviewed Patient 8s record titled, undated record titled, ";Current Treatment/Medication/DME list". The AD stated there was two doses listed for Ativan and the risk of overdosing was there because there were two doses of the same medication. The AD stated there was no documentation in Patient 8s medical record to indicate the nurse educated CG 6 about the Ativan. The AD stated the nurse should have documented in the medical record that verbal education was given during the visit. A record review of Patient 8s document titled, ";Plan of Care", dated 4/23/2024, indicated, ";Respiratory...instruct pt/pcg regarding new medication/treatment order and side effects. Monitor/assess effectiveness of current and new medication/treatment."

Based on interview and record review the Hospice Agency (HA) failed to ensure the medical director and/or physician designee conducted a review and verify the patients clinical information to determine patient needs of recertification of terminal illness for continued hospice care and services for one of fourteen sample selected patients (Patient 11). This deficient practice resulted in the hospice providing services without the physician's assessment to recertify the patient for continued provision of the hospice benefits. --- A review of Patient 11s record titled, ";Personal Information", indicated a start of care date on 10/23/2023, with a primary diagnosis of COPD (Chronic Obstructive Pulmonary Disease- a lung disease that makes breathing difficult). During a record review on 4/23/2024, at 1:20 p.m., Patient 11s record titled, ";Physicians Certification for Hospice Benefit", dated 4/10/24 to 6/8/2024, indicated this was the 3rd recertification for hospice care. Further review of the record did not indicate a doctors narrative and signature explaining why Patient 11 should continue with hospice care. The record also indicated a check mark was placed in section ";Certification is based on: Face to Face Encounter". During an interview on 4/24/2024, at 12:09 p.m., Patient 11s caregiver (CG 4) stated Patient 11 was being seeing by his lung specialist because he had lung cancer. CG 4 stated Patient 11 was doing a lot better. CG stated Patient 11 was also seeing his primary care doctor, psychiatrist, and dentist. CG 4 stated caregiver 5 (CG 5) should be called also because she cares for Patient 11 all the time and CG 5 dealt with the Hospice Agency most of the time. During an interview on 4/24/2024, at 12:45 p.m., Patient 11s CG 5 stated she cared for Patient 11, 24 hours a day, 7 days a week. CG 5 stated she had never spoken to or seen a doctor come and visit Patient 11. CG 5 stated she had not had a phone call or video call with a doctor for Patient 11. CG 5 stated she had not heard of the Medical Directors (MD) name. During an interview on 4/26/2024, at 10:05 a.m., MD stated he offered telemedicine (using an electronic device to speak and see patients remotely) to patients in lieu of physical visits because he does not want to transfer illnesses between patients. MD stated he told the patients about the potential for infection with an in-person visit. MD stated most patients preferred to go with the telemedicine option. MD stated he used ";Facetime" (an audio-visual program owned by Apple) to go over the physical assessment with the nurse. MD stated telemedicine for hospice visits was allowed by Centers of Medicaid Services (CMS) until December 2024. During an interview on 4/26/2024, at 10:25 a.m., the Medical Director stated recertifying a patient for hospice care involved discussion with the IDG (IDG – meeting where the Registered Nurse {RN}, Medical Social Worker {MSW}, Chaplain, and Physicians come together to discuss patients plan of care to be able to provide the best individualized care and support to patients and families) to discuss what had been happening with the patient in the last 2 months, to determine if patient had declined. During an interview on 4/26/2024, at 10:32 a.m., MD 1 stated the date on form ";History and Physical", dated 3/21/2024, indicted his visit with Patient 11. MD was informed the form indicated ";Telemedicine". When MD was asked if he remembered who he had spoken to or who was involved in the telemedicine, MD stated ";I dont write who I spoke to, or who is involved. The Administrator Designee (AD) could tell you who was there. Sometimes family forgets of who they talk to. That happens often." The MD stated he did not know Patient 11 was seeing a lung specialist. The MD stated that some family did not communicate that information to the HA. The MD stated he was clear that if a patient wants to seek treatment, they needed to be discharged from hospice care. The MD stated he did not recall having conversation with Patient 11s family about the patient seeing a lung specialist. During a concurrent interview and record review on 4/26/2024, at 12 p.m., the AD reviewed Patient 11s record titled, ";Audit Log", dated 1013/2024 to 4/26/2024. The record indicated the MD entered the narrative for the 3rd recertification period beginning on 4/10/2024 on 4/24/2024. The AD stated the MD had entered the note on 4/24/2024, the first day the survey began. The AD stated the MD had recertified Patient 11 on 3/21/2024 as indicated in the form ";History and Physical", dated 3/21/2024. During a concurrent interview and record review on 4/26/2024, at 12:00 p.m., the AD reviewed the HAs policy and procedure titled, ";Certification of Terminal Illness", dated April 2019. The policy indicated, ";Procedure...5. At recertification, the hospice Medical Director must compose and sign the narrative based on a review of the patients medical record or, if applicable, examination of the patient. A verbal or written certification statement must be obtained from the Medical Director or the attending physician no more than fifteen (15) calendar days prior or two (2) calendar days after the first day of each period." The AD stated the MD had recertified Patient 11 too early and he had entered the note electronically too late. During a concurrent interview and record review on 4/26/20224, at 12:04 p.m., the AD reviewed Patient 11s record titled, ";History and Physical", dated 3/21/2024. The AD stated MD probably did the visit by himself. The AD stated sometimes the nurse is there and sometimes not. The AD stated the form was the face-to-face visit for the 3rd recertification period. The AD reviewed Patient 11s medical records and stated there was no documented nursing visit for 3/21/2024. The AD stated there was a nursing visit note for 3/20/2024 and 3/22/2024. Neither of those notes indicated a telemedicine visit had occurred with the doctor. A review of the HAs document titled, ";National Hospice and Palliative Care Organization", dated 3/16/2023, indicated, ";The statutory requirement for the hospice face to face encounter specifies that when an encounter is conducted via telehealth it MUST be performed via audio-visual communication technology. The definition of telehealth that applies to the hospice face-to-face encounter is: Two-way audio video telecommunication technology that allows for real-time interaction between the hospice physician/hospice nurse practitioner and the patient. The hospice face to face encounter may NOT be conducted using audio-only technology.... Under this Notification, covered health care providers may use popular application that allow for video chats, including Apple FaceTime...b...The allowance to use non-HIPAA compliant devices is set to end at the end of the PHE (Public Health Emergency) on May 11, 2023." A review of the HAs policy and procedure titled, ";Face-To-Face Encounter", dated April 2019, indicated, ";Policy: A face-to-face encounter will be performed for patients entering the third and all subsequent benefit periods."

Based on interview and record review the hospice agency (HA) failed to ensure any amendments, correction or late entries within their electronic health record clearly identify the original content, the modified content, date, and authorship of each record modification for one of 19 sampled patients (Patient 8). This failure had the potential to result in an unauthorized and inaccurate patient information or assessment will be entered in the patient's clinical record that could affect the patients quality of care and well-being. --- A review of Patient 8s record titled, ";Personal Information", indicated a start of care date on 9/18/2023, with a diagnosis of Parkinsons disease (a brain disease that causes uncontrollable movements). A record review of Patient 8s record titled, ";POC/IDG Review", dated 4/18/2024, did not indicate a signature for the MSW, RN, and Chaplain. A record review of Patient 8s record titled, ";POC/IDG Review", dated 4/4/2024, did not indicate a signature for the MSW, RN, and Chaplain. A record review of Patient 8s record titled, ";POC/IDG Review", dated 3/21/2024, did not indicate a signature for the MSW, RN, and Chaplain. A record review of Patient 8s record titled, ";POC/IDG Review", dated 3/7/2024, did not indicate a signature for the MSW and Chaplain. During an interview on 4/26/2024, at 11:15 a.m., the Administrator Designee (AD) stated she transcribed what was discussed in the IDG (IDG – meeting where the Registered Nurse {RN}, Medical Social Worker {MSW}, Chaplain, and Physicians come together to discuss patients plan of care to be able to provide the best individualized care and support to patients and families) meetings and entered it into the medical record. The AD stated each discipline was supposed to sign the document to show they attended and had input in the meeting. The AD stated she should have signed the IDG documents as well to indicate she was present in the meetings.

Upon patient record review, 1 of 14 (Patient #9) 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 #9: SOC 5/12/23. Initial MSW frequency of 1 as needed.

Upon patient record review, 1 of 14 (Patient #10) 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 #10: MSW frequency is MSW evaluate and assess within 5 days of admission, once a month and as needed for emotional and psychosocial support. 6/10 and 6/15/23 IDG notes by MSW that patient declined MSW. Actual POC frequency was not updated to reflect updated assessment.

Upon client record review, 2 of 14 (Patient #1, 5) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1: SOC 2/1/22, Initial SC frequency of within 5 days. Patient declined until 6/6/22, when SC first saw patient. 6/16/22 IDG updated SC to spiritual care coordinator for spiritual assessment to identify spiritual needs/support and 1 as needed visit for any changes in spiritual care needs. Patient visits occurred once per month, but actual frequency listed is not updated in IDG POC. Patient #5: SOC 8/15/23 Initial IDG/POC states patient declined SC and MSW. SC documented 1 PRN-spiritual care offered but declined by patient and family at this time. Will remain available. Narrative 9/7/23 IDG says SC provided to and received by patient on regular or PRN basis. SC Visit documented 9/15/23. Initial MSW frequency of declined. 9/7/23 IDG - MSW documents patient declined MSW; however, there is 9/9/23 MSW visit provided/documented without update to POC frequency.

Upon personnel record review, 1 of 15 (Personnel #5 ) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) ·(C) Shampoo, sink, tub, and bed Personnel #6: The aide competency form utilized by agency does not specify types of shampoo demonstrated, but simply states "shampoo", therefore, competency is not verified.

Upon patient record review, 3 of 14 (Patient #4, 5, 8) 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: SOC hospice aide assignment sheet has oxygen 2L/NC but does not specify prn or continuous. Patient #5: SOC 8/15/23 hospice aide assignment sheet says frequency of once the first week. Orders for once the first week and 2x/wk after, but assignment hospice aide assignment sheet is not updated to 2x/wk frequency. (The HA provided visits 2x/wk.) Patient #8: SOC 2/2/23. Initial aide frequency is HA 1/wk, then 2x/wk. The hospice aide assignment sheet says once first week. It is not updated to reflect 2xwk, as ordered after week 1.

Upon patient record review 1 of 14 (Patient #4) 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 • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #4: 7/17/23 Hospice aide care plan assignment for HA 2/wk. Only received visits 1x/wk weeks of Aug 21, Aug 28, Sept 11, Sept 18, Sept 29. No updated assignment or orders

Upon patient record review, 4 of 14 (Patient #1, 2, 3, 8) 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 #1: SOC 2/1/22. "Certifying Physician Summary" form is blank for recertification benefit period #10 9/24-11/22/23. There is no documented evidence of verbal certification (no check). Narrative is blank. No written/signed certification of terminal illness. Patient #2: SOC 4/16/22, benefit period #8 8/9-10/7/23 form is blank. There is no documented evidence of verbal certification. Narrative is blank. No written/signed certification of terminal illness. Patient #3: SOC 9/15/22, benefit period #5 7/12-9/9/23 form is blank. No documented evidence of verbal certification. Narrative is blank. No signed certification of terminal illness. Patient #8: SOC 2/2/23, benefit period #4 9/30-11/28/23 form is blank. No documented evidence of verbal certification. Narrative is blank. No signed certification of terminal illness.

Upon patient client record review, 1 of 14 (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: MSW Comprehensive describes patients living environment as with his daughter in her home. SC and RN describe as board and care facility. EMR Demographic page identifies as B/C. Staff interview confirms patient resides in B/C facility. Staff inquiry offers no explanation.

Upon personnel record review, 3 of 15 (Personnel # 11, 12, 13) did not have evidence the hospice obtained a criminal background check on all contracted individuals who have direct patient care and access to patient records. Personnel #11, 12, 13 for PT, OT, ST did not have evidence of Criminal Background Check. The agency was unable to obtain copies from contractor prior to end of survey.