Every finding on record at Dignified Hospice Care

Condition of Participation: Organization and Administration of Services.

Upon personnel record review, 1 of 2 (Personnel #2) did not have evidence the alternate administrator's personnel record verifies that: • The employee has appropriate education and experience requirements • There is a signed job description for this role • The employee has been orientated to this role Personnel #2 Alternate Administrator HR file not complete. No resume or application available to review the appropriate education and experiences. No signed job description as Alternate Administrator on file, No orientation list on file.

Upon observation, there was no evidence the hospice is primarily engaged in providing the following care and services: • Nursing services • Medical social services • Physician services • Counseling services, including spiritual counseling, dietary counseling and bereavement counseling • Hospice aide, volunteer, homemaker services • Physical therapy, occupational therapy, speech-language pathology services • Short-term inpatient care • Medical supplies (including drugs and biologicals) and medical appliance There was no evidence that the agency has established contract for short-term inpatient care.

Upon personnel record review, 1 of 2 (Personnel #2 ) 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 #2 There is no evidence in the HR file that RN competency was completed

Upon patient record review, 6 of 17 (Patient #6,7,12,13,16,17) 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 6: No evidence that an initial bereavement risk assessment was completed at the time of survey. Patient 7: No evidence that an initial bereavement risk assessment was completed at the time of survey. Patient 12: No evidence that an initial bereavement risk assessment was completed at the time of survey. Patient 13: No evidence that an initial bereavement risk assessment was completed at the time of survey. Patient 16: No evidence that an initial bereavement risk assessment was completed at the time of survey. Patient 17: No evidence that an initial bereavement risk assessment was completed at the time of survey.

Upon patient record review, 1 of 17 (Patient #16) 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 16: Plan of care has medical social worker frequency as PRN when the the family request. No evidence that a routine frequency was ordered.

Upon client record review, 5 of 17 (Patient #1,3,8,9,13) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 1: Plan of care has medical social worker frequency ordered at once monthly. No evidence that medical social worker completed a visit for the month of May. No evidence of an order to change visit for that month or miss visit communications from the caregiver to refuse the visit. Patient 3: Plan of care has chaplain frequency ordered at once monthly. No evidence that chaplain completed a visit for the month of July. No evidence of an order to change visit for that month or miss visit communications from the caregiver to refuse the visit. Patient 8: Plan of care has LVN frequency ordered at twice weekly. No evidence that the LVN completed any visit for the first week of benefit period. No evidence of an order to change visit or miss visit communications from the caregiver to refuse the visit. Patient 9: Plan of care has chaplain frequency ordered at once monthly. No evidence that chaplain completed a visit for the month of July. No evidence of an order to change visit for that month or miss visit communications from the caregiver to refuse the visit. Patient 13: Plan of care has medical social worker frequency ordered at once monthly. No evidence that medical social worker completed a visit for the month of March. No evidence of an order to change visit for that month or miss visit communications from the caregiver to refuse the visit.

Upon observation, there was no evidence the hospice ensures that non-core services are provided to hospice patients and their families according to applicable laws and regulations. Non-core services include Physical Therapy, Occupational Therapy and Speech-Language Pathology. Upon observation, no evidence that the agency has an active employee or active contract for speech-language pathology. Contract obtained on day 1 of survey.

Upon patient record review 4 of 17 (Patient #6,7,9,13) 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 • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient 6:Plan of care has aide visit frequency as twice a week. No evidence that aide visits occurred for the first week of the benefit period. Patient 7:Plan of care has aide visit frequency as twice a week. No evidence that aide visits occurred for the first week of the benefit period. Patient 9:Plan of care has aide visit frequency as once a week. No evidence that aide visits occurred during the time that patient was on services. Patient 13:Plan of care has aide visit frequency as twice a week. No evidence that aide visits occurred for the first week of the benefit period. Patient received a total of 3 aide visits during the second week of the benefit period.

Condition of Participation: Organization and Administration of Services.

Upon observation, there was no evidence the hospice is directed by a Board of Directors/governing body which assumes full legal authority and responsibility for the operation of the hospice. The agency was unable to provide evidence of an alternate administrator, alternate DPCS, and ability to provide GIP and Respite levels of care. The agency did not have evidence of alternate medical director or contracted SLP however, the agency was able to obtain these prior to end of survey.

Upon observation, there was no evidence the hospice is primarily engaged in providing the following care and services: • Nursing services • Medical social services • Physician services • Counseling services, including spiritual counseling, dietary counseling and bereavement counseling • Hospice aide, volunteer, homemaker services • Physical therapy, occupational therapy, speech-language pathology services • Short-term inpatient care • Medical supplies (including drugs and biologicals) and medical appliance Upon observation, no evidence provided during survey to show that agency has the ability to provide short-term inpatient care.

Upon observation, there was no evidence the hospice designates a physician to serve as Medical Director which includes: • The Medical Director must be a doctor of medicine or osteopathy who is an employee or is under contract. • When the Medical Director is not available, a physician designated by the hospice assumes the same responsibilities and obligations as the Medical Director. No evidence of current contract or active employee for alternate Medical Director on day 1 of the survey. Agency was able to obtain contract for alternate Medical Director for day 1 of survey.

Upon patient record review, 17 of 17 (Patient #1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17) 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 1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17: No evidence that the Medical Director provided written certification that anticipated patient life expectancy is 6 months or less if the illness runs its normal course. CTI for all patients stated "Based on the summary of NP patient is hospice ready." No other information was provided on the CTIs.

Upon patient record review, 2 of 17 (Patient #1,17) 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. Patients 1: No evidence that the Medical Director provided written documentation that anticipated the patient's life expectancy of 6 months or less within his recertification CTI narrative. CTI stated "Based on the summary of NP patient is hospice ready." No additional information added to the narrative. Patients 17: No evidence that the Medical Director provided written documentation that anticipated the patient's life expectancy of 6 months or less within his recertification CTI narrative. CTI stated "Based on the summary of NP patient is hospice ready." No additional information added to the narrative.

Upon patient client record review, 17 of 17 (Patient #1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17) 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 1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17: No evidence of effective date or start of care date listed on election statements.

Upon observation, there was no evidence that when the hospice provides durable medical equipment under contract, then the DMEPOS provider is accredited by a CMS approved accreditation organization. Upon observation, no evidence provided to show that contracted DME agency is accredited by a CMS approved accrediting organization.