Every finding on record at Divine Compassion LLC

Upon client record review, 2 of 8 (Patient #1, 2) 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. Record #1, 2: No documented evidence of POC Review/IDG Meeting between 2/16 and 3/16/22.

Upon client record review, 1 of 8 (Patient #2) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Record #2: Initial IDG/POC Order for SN 1xwk. There was no frequency change order. No SN visit documented 3/13-3/19/22.

Upon personnel record review, 1 of 1 applicable (Personnel #4) 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.) ·Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff. ·Reading and recording temperature, pulse, and respiration ·Safe transfer techniques and ambulation. ·Normal range of motion and positioning ·Appropriate and safe techniques in personal hygiene and grooming that include-- ·(C) Shampoo, sink, tub, and bed ·The other subject areas in this section may be evaluated through written examination, oral examination or after observation of a Hospice Aide with a patient. Personnel Record #4: The HA Competency checklist currently utilized by the agency does not differentiate types of shampoo to include sink, tub and bed, but "shampoo" only.

Upon patient record review 1 of 6 applicable (Patient #6) 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. Record #6 Initial IDG/POC Ordered HA Visits 2x/wk. No HA Visits documented week of Oct 23-29th, 2021.

Upon patient client record review, 5 of 8 (Patient #1, 2, 3, 7, 8) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 Patient Records 1, 2, 3, 7, 8: There is not a signed copy of The Patient Rights, and no evidence of acknowledgement form that staff discussed and received a copy.

Upon patient client record review, 1 of 8 (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. Record #4: RN Recert Visit (10/16/21) Summary for 10/22/21 Benefit Period reads like admission summary. "Hospice goals were discussed including all legal documents thoroughly to the pt/cg responsibilities and they agreed to hospice services and all legal documents were signed respectively including consent to admit to Shining Light Hospice." Electronically signed and dated 1/23/22. RN Recert Visit (1/17/22) Summary for 1/20/22 Benefit Period includes the same documentation above. There are additional details specific to patient condition. This entry is also electronically signed and dated 1/23/22

Upon client record review, 5 of 5 applicable records (Patient #4, 5, 6, 7, 8) 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 Records 4, 5, 6, 7, 8: There was no evidence that the hospice forwarded a copy of the hospice discharge summary to the patient's attending physician.

Upon personnel record review, 3 of 4 applicable records (Personnel # 10, 11, 12) 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 Records #10, 11, 12: Contracted therapy provider had not provided copies of criminal background checks by end of survey. No patient care had been provided thus far.

Upon policy review, there was no available policy related to COVID Vaccination process. The agency had provided education and expectation for staff vaccination. Leadership (owner, administrator, DPCS) was aware of exemption requirement, but there was no actual policy to present to surveyor. The agency had tracking log as evidence of 100% vaccination of staff. Before end of Survey Day 1, the agency purchased ACHC policy for COVID-19 Vaccinations. They reviewed/approved and implemented the policy effective immediately.