Every finding on record at Divine Hospice LLC

Upon patient record review, 1 of 14 (Patient #4) 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 #4, No evidence of goals and interventions based on patients full code status. Care plan states will discuss patient code status without identifying patient is a full code.

Upon patient record review, 1 of 14 (Patient #3) 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 #3, The second certification period frequency for social worker was ordered as PRN. No evidence of scope and frequency.

Upon patient record review, 2 of 14 (Patient #7, 9) 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 #7, No evidence of goals and interventions identifying patient uses oxygen 3-7L/NC using 10 liter concentrator. Patient #9, No evidence of goals and interventions related to suprapubic catheter. Care plan identifies urinary incontinence.

Upon observation and home visits 1 of 3 (Patient #5), there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient #5, Per policy, the staff will have a clean and dirty area. Upon observation the RN used the clean blood pressure cuff and returned to clean area instead of a separated dirty area.

Upon patient record review, 1 of 14 (Patient #3) 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 #3, Aide care plan frequency for Aide was not updated from first certification of 1w1, 2w12, current frequency is 1w13.

Upon patient record review 6 of 14 (Patient #1,3,5,7,8,10) 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 #1, No evidence aide followed RN directed care plan. Aide visit 4/28/26, transfer to bed, documented as NO, not required Assist to toilet, documented as NO, not required, Shave, documented as NO, not required. Assist with feeding, documented NO, not required, visit completed 1130 to 1 pm. Patient #3, No evidence aide followed RN directed care plan. Aide visit 4/21/26, Shampoo, documented as NO, not required. Patient #5, No evidence aide followed RN directed care plan. Aide visit 4/6/26, assist with bedpan, documented as NO, not required. Aide visit 4/13/26, assist with feeding, documented as NO, not required. Visit time 145pm to 250pm. Aide visit 4/24/26, assist with bedpan, documented as NO, not required, Assist with feeding documented already completed, visit made 120pm to 250pm. Aide visit 5/4/26, Assist with feeding, documented as No, not required. Visit completed 839 to 10 am. Aide visit 5/6/26, Assist with bedpan documented as NO, not required. Assist with feeding, documented NO, already completed, visit time 310 to 425pm. Patient #7, No evidence aide followed RN directed care plan. Aide visit 5/11/26, assist with nail care, documented No, not required. Patient #8, No evidence aide followed RN directed care plan. Aide visit 5/9/26, assist with feeding documented NO, not required. Visit made 1022am to 1205pm.

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.

Upon personnel record review, 1 of 14 (Personnel #1) did not have evidence that the administrator is a hospice employee and possesses the education and experience required by the governing body. Personnel #1, Job description identified employee would have a bachelors degree, with an RN degree preferably included on job description. The Administrator does not have a degree.

Upon client record review, 2 of 14 (Patient #11,12) did not have evidence that the discharge summary includes all required information. Patient #11, 12, No evidence of discharge summary included treatments, symptoms and pain management.

Upon personnel record review, 1 of 14 (Personnel #14) did not have evidence that all Speech Therapy Services are provided by a qualified licensed Speech-Language Pathologist (SLP) or Audiologist in accordance with the state's Speech-Language Pathology Practice Act and the hospice's policies and procedures and/or job descriptions. Personnel #14, No evidence of HR file for speech pathologist

Upon personnel record review, 1 of 14 (Personnel #13) did not have evidence all Occupational Therapy Services are provided by a qualified licensed Occupational Therapist (OT) in accordance with the state's Occupational Therapy Practice Act and the hospice's policies and procedures and/or job descriptions. Personnel #13, No evidence of HR file for occupational therapist.

Upon personnel record review, 2 of 14 (Personnel #13, 14) 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 #13, 14, No evidence of HR file for the OT and ST.

Upon observation, there was no evidence the Emergency Plan communication plan must includes a primary and alternate means for communicating with hospice's employees and Federal, state, tribal, regional, and local emergency management agencies. The communication plan did not include a means for contacting the alternate administrator or current employees. No designated alternate office meeting location in the emergency preparedness plan. The agency did not have an updated communication plan at the time of survey.

Upon observation, there was no evidence the agency has conducted exercises to test the emergency plan every two years. There was no evidence of emergency preparedness training and testing program that is based on the emergency plan and the communication plan since 2020.

Upon patient record review 2 of 14 (Patient #10,#11) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient #10: The patient was admitted on 3/15/23. The psychosocial assessment was completed on 3/28/23. The spiritual care assessment was not attempted until 3/21/23. Patient #11: The patient was admitted on 10/31/22. The psychosocial assessment was completed on 11/6/22.

Upon patient record review, 3 of 14 (Patient #5,#6,#9) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #5: The record indicated the patient was on oxygen 2L/min NC. Oxygen was not included on the medication list. Patient #6: The record indicated an order for Polyethylene Glycol 17 grams every day. There was not evidence of directions or a diluent. Patient #9: The record indicated an order for Polyethylene Glycol 17 grams every day. There was not evidence of directions or a diluent.

Upon patient record review, 1 of 14 (Patient #5) 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 #5: The patient was admitted 3/22/22, the record did not contain evidence of an initial bereavement assessment.

Upon patient record review, 9 of 14 (Patient #1,#2,#4,#5,#8,#9,#10,#11,#12) 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 record indicated the patient requested assistance on advance directives and identifying a caregiver. There was no evidence of updated problem statements with goals, interventions and progress toward outcomes related to the psychosocial aspect of the patient. Patient #2: The record indicated the patient spiritual care services. There was no evidence of updated problem statements with goals, interventions and progress toward outcomes related to the spiritual aspect of the patient. Patient #4: The record indicated the patient spiritual care services. There was no evidence of updated problem statements with goals, interventions and progress toward outcomes related to the spiritual aspect of the patient. Patient #5: The nursing assessment dated 3/22/22 indicated that the patient was on Oxygen @ 2 liters nasal cannula. There is no evidence of statements with goals, interventions and progress toward outcomes on the plan of care related to oxygen safety. Patient #8: The visit frequency for the spiritual care provider was indicated at 1x/month. The patient was admitted on 3/21/23. There was no evidence of problem statements with goals, interventions and progress toward outcomes related to the spiritual aspect of the patient. Patient #9: The medical record nursing assessment dated 11/4/22 indicated that the patient complained of nausea and vomiting. There is no evidence of statements with goals, interventions and progress toward outcomes on the plan of care to address the concerns. The nursing assessment dated 5/11/23 indicated that the patient was started on Augmentin. There is no evidence of statements with goals, interventions and progress toward outcomes on the plan of care related to infection. Patient#10: The record indicated the patient spiritual care services. There was no evidence of updated problem statements with goals, interventions and progress toward outcomes related to the spiritual aspect of the patient Patient #11: The record indicated the patient spiritual care services. There was no evidence of updated problem statements with goals, interventions and progress toward outcomes related to the spiritual aspect of the patient Patient #12: The record indicated the patient spiritual care services. There was no evidence of updated problem statements with goals, interventions and progress toward outcomes related to the spiritual aspect of the patient.

Upon patient record review, 3 of 14 (Patient #4,#5,#6) 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 #4: The record indicated the patient had oxygen at 2L/min via nasal cannula. There was no evidence of an order for 02. Patient #5: The record indicated an order for Polyethylene Glycol 17 grams every day. There was not evidence of a diluent and the direction is unclear. Patient #6: The record indicated an order for Polyethylene Glycol 17 grams every day. There was not evidence of a diluent and the direction is unclear.

Upon patient record review, 2 of 14 (Patient #9,#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 #9: The record indicated the medical social worker visits were discontinued per CG on 12/1/22. The plan of care continues to reflect problem statements with goals, interventions and progress toward outcomes related to the psychosocial aspect of the patient. Patient #10: The record indicated the patient requested assistance on advance directives and identifying a caregiver. There was no evidence of updated problem statements with goals, interventions and progress toward outcomes related to the psychosocial aspect of the patient.

Upon client record review, 7 of 14 (Patient #1,#2,#4,#5,#10,#11,#12) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1,#2,#4,#5,#10,#11,#12: The record included an order for the SC visit frequency to be 1x/m. There are no visits documented in the record. There was no evidence of missed visit documentation.

Upon patient record review, 1 of 14 (Patient #14) did not have evidence the hospice offers bereavement counseling that includes: • Making bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. Bereavement counseling also extends to residents of a SNF/NF or ICF/IID when appropriate and identified in the bereavement plan of care • Ensuring that bereavement services reflect the needs of the bereaved • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery Patient 14 The medical record did not contain documentation the bereavement plan of care was followed, no evidence of sympathy card, 3 month and 6 month letters.

Upon patient record review, 1 of 14 (Patient #9) 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 #9: The patient record did not contain evidence of frequencies for the tasks to change linen and skin care on the aide care plan.

Upon patient record review 1 of 14 (Patient #9) 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 #9: The aide visits dated 4/24/23, 4/26/23, 5/1/23, 5/2/23, documented the task to shampoo hair was "not required this visit". The aide care plan instructed the hospice aide to shampoo hair every visit.

Upon personnel record review, 1 of 12 (Personnel #12) 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 #12: The personnel record did not contain evidence of an initial skills competency.

Condition of Participation: Medical Director.

Upon observation, there was no evidence the hospice designates a physician to serve as Medical Director which includes: • When the Medical Director is not available, a physician designated by the hospice assumes the same responsibilities and obligations as the Medical Director. At the time of survey there was no evidence the hospice designates a physician to assume responsibilities and obligations as Medical Director when the Medical Director is not available.

Upon patient client record review, 3 of 14 (Patient #1,#9,#10) 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. Signatures are legible, legal and include the proper designation of all credentials. Patient #1: Documentation on the plan of care dated 5/3/23 states "Ch did not see patient before IDG. Chaplin visits 1 x mo" conflicts with the physicians order dated 2/10/23 "no further visits required". The medical record did not contain orders for further visits and no further visits were made. Patient #9: Throughout the record documentation by the aide did not have the clinicians title and signature on the visit notes. Patient #10: Throughout the record documentation by the registered nurse dated 3/16/23- 5/9/23 did not have the clinicians title and signature on the visit notes.

Upon client record review, 1 of 14 (Patient #4) did not have evidence that the hospice plan of care reflects the participation of the hospice, the SNF/NF or ICF/IID and the patient/caregiver. Patient #4: The medical record did not contain evidence of a coordinated plan of care with the facility to include wound care.

Upon personnel record review, 1 of 12 (Personnel #12) did not have evidence of criminal background checks being obtained in accordance with state requirements. In the absence of state requirements, criminal background checks are obtained within three months of the date of employment for all states that the individual has lived or worked in the past 3 years. Personnel #12: The personnel record did not contain evidence of an obtained criminal background check within three months of employment.

Upon personnel record review, 2 of 12 (Personnel #7,#8) did not have evidence that all personnel have been fully vaccinated for COVID-19. Personnel #7, #8: The personnel record did not contain evidence the personnel were fully vaccinated for COVID-19 or had an approved exemption at the time of survey.