Every finding on record at Dynasty Hospice Inc.

Upon patient record review 1 of 14 (Patient #5) did not have evidence that the hospice Registered Nurse must complete an initial assessment within 48 hours after the election of hospice care in accordance with §418.24 Patient #5: The Initial Nursing Comprehensive Assessment was not provided within 48 hours of signed Election of Benefit form that was dated 8/14/24 (not 8/23/24).

Upon patient record review 1 of 14 (Patient #5) 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 #5: The IDG Initial Comprehensive Assessment was not completed within 5 calendar days of signed Election of Benefit form that was dated 8/14/24 (not 8/23/24).

Upon patient record review, 7 of 14 (Patients #1,2,4,5,9,13,14) 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. Patients #1,2,9: The initial bereavement was completed. However, it was incomplete as there was no primary bereaved identified. Patients #4,13,14: The initial bereavement assessment was not completed within 5 days of SOC to date. Patient #5: The initial bereavement was completed on 8/24/24. Start of Care was 8/23/24. However, the EOB effective date indicates 8/14/24 (not 8/23/24).

Upon patient record review, 1 of 14 (Patient #3) 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#3: There is no evidence the plan of care reflected patient goals or interventions related to wound care needs. Current goals, included that the patient is "at risk for" pressure ulcer. This patient has Stage II wound on right lateral sacrococcyx and Stage 1 on right medial malleolus present.

Upon patient record review, 8 of 14 (Patients #1,3,4,5,6,7,8,9) 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 equipment and supply needs. Patient #1: This patient had a C-Pap machine, wheelchair and over the bed table. These were not included on the Plan of Care. Patient #3: The record reflected that patient had a nebulizer machine. This item was not included on the Plan of Care. Patient #4: The record reflected that this patient had a hospital bed, cane and walker. These were not included on the Plan of Care. Patient #5: The record reflected that this patient had a hospital bed, air mattress,walker, wheelchair and O2 concentrator. These were not included on the Plan of Care. Patient #6: The record reflected that patient needs a walker. There is no no record that this was provided. Patient #7: The record reflected that this patient had a hospital bed, wheelchair, bedside commode, suction machine. These were not included on the Plan of Care. Patient #8:The record reflected that patient has an egg crate and walker, These were not included on the Plan of Care. Patient #9: The record reflected that patient has a walker. This item was not included on the Plan of Care.

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: There were no indication of physician order for physical therapy (PT) visit provided on 9/12/24. Patient #5: There were no indication of physician orders for physical therapy (PT) visits provided on 9/16/24, 9/23/24, 9/30/24

Upon patient record review, 1 of 14 (Patient #3) did not have evidence that the IDG shares information on a on-going basis with non-hospice healthcare providers furnishing services unrelated to the terminal illness and related conditions. Patient#3: There is no evidence of coordination of care documented in IDG regarding care provided by Wound Pros.

Upon personnel record review, 1 of 12 (Personnel #8) 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-- ·(A) Bed bath ·(B) Sponge, tub, and shower bath ·(C) Shampoo, sink, tub, and bed ·(D) Nail and skin care ·(E) Oral hygiene ·(F) Toileting and elimination 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 #8: Did not have evidence that "Normal range of motion and positioning" was evaluated on competency skills checklist.

Upon personnel record review, 1 of 12 (Personnel #2 ) did not have evidence the alternate administrator's personnel record verifies that: • There is a signed job description for this role • The employee has been orientated to this role Personnel #2: This employee does not have a job description or orientation information to this role. Corrected on Site.

Upon contract review, 1 of 5 (Wound Pros contract) did not have evidence the agreement to furnish any services under arrangement included that the hospice must retain administrative and financial management, and oversight of staff and services for all arranged services, to ensure the provision of quality care. Arranged care/services are supported by written contract/agreement that requires all care/services are: • Authorized by the hospice • Furnished in a safe and effective manner by qualified personnel • Delivered in accordance with the patient's plan of care The agency did have a contract with Wound Pros that had been providing services to hospice patients. However, there was no reference to hospice having administrative and financial oversight. Additionally, there was no documentation in the medical record whether wounds were or were not related to patient hospice stay.

Upon personnel record review, 2 of 12 (Personnel #3,12) did not have evidence the hospice employees and contract employees have received orientation on the hospice philosophy. Personnel #3,12: These employees do not have evidence that Hospice Philosophy was received during orientation.

Upon personnel record review, 3 of 12 (Personnel #1,2,10) did not have evidence that the hospice employees have received orientation on their specific job requirements. Personnel #1: This employee does not have Administrator job description that was reviewed/signed at hire. Personnel #2: This employee does not have Alternate Administrator job description that was reviewed/signed at hire. Corrected on Site. Personnel #10: This employee does not have bereavement coordinator job description that was reviewed/signed at hire.

Upon personnel record review, 3 of 12 (Personnel #2, 10,12 ) 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 #2: The RN Competency Assessment was not countersigned by like discipline. Corrected on Site. Personnel #10: There is no Bereavement Counselor Competency Assessment in this employee file. Has Spiritual Counselor only. Personnel #12: There is no Volunteer Competency Assessment in this employee file.

Upon patient record review, 1 of 14 (Patient #5) 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 #5: The signed Election of Benefit form indicated 8/14/24 as the effective date. The patients start of care began on 8/23/24. The physician written/verbal certification was on 8/23/24.

Upon patient client record review, 4 of 14 (Patients #5,8,10,11) did not have evidence that each patient record contains: • Signed election statement in accordance with 418.24 Patient #5: The signed Election of Benefit form indicated 8/14/24 as the effective date. The patients start of care began on 8/23/24. Patients #8,10,11: BFCC-QIO contact info missing in space provided on the form

Upon client record review, 1 of 14 (Patient #11) did not have evidence that the discharge summary includes all required information. Patient #11: The patient's current plan of care was not included in discharge summary document(s).

Upon patient record review, 1 of 14 (Patient #6 ) did not have evidence in the patient record that the interdisciplinary group, as part of the review of the plan of care, determines the ability of the patient and/or family to safely self-administer drugs and biologicals to the patient in his or her home. If the patient and/or family are not capable of safely administering drugs and biologicals in the home, the hospice must address this issue in the patient's plan of care. Patient #6: The patient/caregiver ability to safely administered drugs and biologicals was not assessed by a member(s) of the interdisciplinary group.

Upon SNF/NF contract review, 1 of 4 (Country Villa contract) did not have evidence that it is the SNF/NF's responsibility to continue to furnish 24 hour room and board care, meeting the personal care and nursing needs at the same level of care that would have been provided by the family at the facility before hospice care was elected. This contract defined room and board only. There was no language indicating the care was 24 hours.

Upon SNF/NF contract review, 1 of 5 (Country Villa contract) did not have a provision stating that the hospice reports all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by anyone unrelated to the hospice to the SNF/NF administrator within 24 hours of the hospice becoming aware of the alleged violation. This contract did not have provision that any abuse, injuries or misappropriation of property would be reported to the SNF/NF Administrator within 24 hours of alleged violation.

Upon personnel record review, 1 of 12 (Personnel #9) 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 #9: This contracted employee did not have Criminal Background check in his personnel file.

Upon personnel record review, 3 of 12 (Personnel #7,8,11) 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 #7,11: These employees did not have Criminal Background check in their personnel files. Personnel #8: This employees did not have Criminal Background check in their personnel file. Report generated for the Aide on 12/18/24. Corrected on Site.

Observed in Record Review. In 5 of 5 patient records reviewed, it was noted that most patient goals in the plans of care were generic, and very few included specific, measurable, attainable, relevant, and/or timed outcomes. This was discussed with the Administrator/DPCS.

Observed in Record Review. For hospices that elect to use The Joint Commission deemed status option: The plan of care includes all services needed for the palliation and management of the terminal illness and related conditions, including the following: - Medications and treatment necessary to meet the patient’s needs. In the record of HV#2 the LVN wrote the following: “Instructed to take Nitroglycerin at the first sign of angina.” However, there was no order for Nitroglycerin. This was discussed with the Administrator/DPCS.

Observed in Record Review. In 5 of 5 patient records reviewed, the organization did not provide current subjective and objective medical findings to support terminal diagnoses. The surveyor found no objective data such as diagnostic findings, or a history and physical to support terminal diagnoses in the records of HV#1, HV#2, HV#3, RR#1 and RR#2. This was discussed with the Administrator/DPCS.

Observed in Patient Home. In 2 of 3 home visits conducted, the organization did not ensure that education and training to the patient included the following: - Procedures to follow if care, treatment, or services were disrupted by a natural disaster or emergency. While reviewing the patients' handbooks at HV#1 and HV#2 the surveyor found that there was no individualized emergency plan that identified specific needs such as use of oxygen or DME, mobility issues, etc. During review of the records there was no documentation of the patient and/or caregiver having been educated. This was discussed with the Administrator/DPCS.