Every finding on record at E2 Hospice, Inc.

Upon patient record review 5 of 5 (Patient #1,2,3,4,5) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Surveyor unable to abate due to there have been no new admissions since plan of correction compliance date.

Upon patient record review, 1 of 5 records reviewed (Patient #3) 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 #3: The medication administration records indicated ASA 81mg (1mg dosage)po one tab daily-prophylactics, the 1mg dosage is an entry error. COS. Also Atorvastatin Calcium 20mg (20 dosage) one tab po daily for HTN was indicated, (20 dosage) was an entry error. COS. In addition, Clonazepam 0.5mg (dosage tab mg) take one Q6hours prn anxiety, (dosage tab mg) was an entry error. COS

Upon patient record review, 1 of 5 records reviewed (Patient #3) 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 #3: The MD order indicated ASA 81mg (1mg dosage)po one tab daily-prophylactics, the 1mg dosage is an entry error. COS. Also Atorvastatin Calcium 20mg (20 dosage) one tab po daily for HTN was indicated, (20 dosage) was an entry error. COS. In addition, Clonazepam 0.5mg (dosage tab mg) take one Q6hours prn anxiety, (dosage tab mg) was an entry error. COS

Upon client record review, 1 of 5 records reviewed (Patient #5) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #5: The record indicated frequency orders effective on 7/3/24 RN 1 X W and SN 1 X W. There was no evidence of an RN visit until 7/12/24, 9 days after the order.

Upon patient record review, 3 of 14 (Patient #5,13,14) did not have evidence that the patient received information about the scope of services that the hospice will provide and specific limitations on those services. Patients 5,13,14: The consents provided do not contain evidence the patient was made aware of the services the hospice will provide and specific limitations on those services. There is a section to include all disciplines and the anticipated visit schedules. This section was left blank.

Condition of Participation: Initial and Comprehensive Assessment of the Patient.

Upon patient record review 2 of 14 (Patient #8,13) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient 8: The POC ordered MSW once per month. There is no evidence the MSW has made any visits to the patient. There is no evidence the RN completed the psychosocial assessment on the comprehensive assessment. Patient 13: The POC contains orders for MSW once per month. There is not evidence the MSW made any visits to the pt and no evidence the RN completed the psychosocial assessment on the comprehensive assessment.

Upon patient record review, 14 of 14 (Patient #1,2,3,4,5,6,7,8,9,10,11,12,13,14) did not have evidence in the patient record that the comprehensive assessment takes into consideration the imminence of death. Patients 1,2,3,4,5,6,7,8,9,10,11,12,13,14: The medical record did not have evidence in the patient record that the comprehensive assessment takes into consideration the imminence of death.

Upon patient record review, 10 of 14 (Patient #3,4,5,6,7,8,10,11,12,14) 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: Patient 3: The medication profile contains an order for Acetaminophen 500mg with a dose of 1mg oral every 6 hours prn pain. Corrected on site. Patient 4: The medication profile contains Potassium 20mg with dose of 20 daily, Pyridium 100mg with dose of 1mg daily,Famotidine 20mg dose of 1mg daily, Oxycodone 30mg dose 30tab Q6 hours prn. Corrected on site. Patient 5: The medication profile contains orders for Atorvastatin 80mg 1mg daily, Plavix 75mg 75 daily. Corrected on site. Patient 6: The medication profile contains orders for Colace 100mg 100 daily, Famotidine 20mg 20 daily,Losartan 50mg 50 daily. Corrected on site. Patient 7: The medication profile contains orders for Oxycodone 20mg 1mg q6 hours prn, Clonidine 0.1mg 0.1 daily, Propranolol 10mg 10 daily. Corrected on site. Patient 8: medication profile orders Clonidine 0.1mg 0.1 tab daily, Soma 350mg 350 tab daily. Corrected on site. Patient 10: The medication profile contains an order "Oxygen 2 L via NC for SOB and increase to 3 L for oxygen stat >91%" Patient 11: Medication profile contains Ambien 10mg 10tabs daily, Brilinta60mg 60 daily, gabapentin 400mg 800 daily. Patient 12: Medication profile orders Atorvastatin 10mg 10tabs daily, Percocet 10/325 10 tabs q6 hours prn. Patient 14: medication profile orders Doxycycline 100mg 100cap daily.

Upon patient record review, 1 of 14 (Patient #13) 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 13: The medical record contains a Comprehensive Bereavement Assessment note by the chaplain/bereavement coordinator on 8/11/23. The pt was not admitted until 8/15/23.

Condition of Participation: Interdisciplinary Group, Care Planning, and Coordination of Services. L536

Upon patient record review, 10 of 14 (Patient #1,2,4,7,8,9,10,11,12,13) 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 1: The POC 3/30/24 contains an order for MSW and SC 1 as needed-every month and PRN with no frequency. Patient 2: The POC 5/23/24 contains an order for MSW and SC 1-monthly and PRN with no frequency. Patient 4: The SC is ordered 1 every month and prn with no frequency. Patient 7: POC contains an order "SN to once weekly and as needed thereafter ongoing comprehensive assessment". At the bottom of the POC it is documented LVN 1 per week with 1 prn, RN every 2 weeks for updates. Corrected on site Patient 8: POC contains orders for MSW and SC for once monthly and prn with no frequency. Patient 9: POC orders for MSW & SC once monthly and prn with no frequency. Corrected on site. Patient 10: POC contains orders for MSW and SC monthly and prn with no frequency. Patient 11: MSW and SC once monthly and prn with no frequency. Patient 12: MSW and SC once monthly and PRN with no frequency. Patient 13: MSW and SC monthly and prn with no frequency.

Upon patient record review, 11 of 14 (Patient #3,4,5,6,7,8,10,11,12,13,14) 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 3: The POC 5/23/24 contains an order for Acetaminophen 500mg with a dose of 1mg oral every 6 hours prn pain. Patient 4: The recent POC contains Potassium 20mg with dose of 20 daily, Pyridium 100mg with dose of 1mg daily,Famotidine 20mg dose of 1mg daily, Oxycodone 30mg dose 30tab Q6 hours prn. Patient 5: The POC contains orders for Atorvastatin 80mg 1mg daily, Plavix 75mg 75 daily. Corrected on site. There are no diet orders or admitting orders on the POC. Corrected on site. SN on 2/9/24 in comprehensive assessment documented "received order to cleanse wound with wound wash, pat dry, apply triple atb ointment and cover with non stick pad". There was no order written on the POC for the non stick pad. Patient 6: The POC contains orders for Colace 100mg 100 daily, Famotidine 20mg 20 daily,Losartan 50mg 50 daily. The POC contains orders for "RN:___per week+3 prn-every 2 weeks for updates" and "SC:1 per week+3prn-eval and then monthly". Corrected on site Patient 7: The POC contains orders for Oxycodone 20mg 1mg q6 hours prn, Clonidine 0.1mg 0.1 daily, Propranolol 10mg 10 daily. Corrected on site There are no diet orders or admitting orders on the POC. Corrected on site. Patient 8: POC orders Clonidine 0.1mg 0.1 tab daily, Soma 350mg 350 tab daily. There are no diet orders or admitting orders on the POC. Patient 10: The POC contains an order "Oxygen 2 L via NC for SOB and increase to 3 L for oxygen stat >91%". There are no diet orders or admitting orders on the POC. Patient 11: POC does not contain diet order. Ambien 10mg 10tabs daily, Brilinta60mg 60 daily, gabapentin 400mg 800 daily. Patient 12: POC orders Atorvastatin 10mg 10tabs daily, Percocet 10/325 10 tabs q6 hours prn. Patient 13: POC orders Fluconazole 200mg 200tabs daily, Lasix 20mg 20 tabs daily. There are no diet orders on the POC. Admit order does not have a level of care. Patient 14: POC orders Doxycycline 100mg 100cap daily. POC 5/16/23 contains "Foley catheterization kit 18FR" no further insertion, frequency or flush orders. "Fancy silicone form 7x7 wound dressing to be applied to sacral wound" and "Medvance tom silicone bordered silver adhesive 7x4 form dressing to be applied to sacral wound" no further directives or frequencies. Pt has biliary drain with no orders for site care, dressing or draining. The nurse mentions "there is a dressing over the biliary drain on 5/22/23. Patient 14: The nurse documented on 5/12/24 "Has foley inserted 16 fr last changed 5/12/24". There is no order for a 16 fr foley.

Upon client record review, 10 of 14 (Patient #4,5,6,7,8,9,10,11,12,14) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 4: The MSW performed visits 12/8/23 and 12/23/23 with no evidence of an order for visits.SC ordered to visit once a month did not make visits in February or April. Patient 5: The POC has SC orders for every 2 weeks. The SC made visits 11/6/23,12/3/23,2/1/24,5/1/24. The MSW has orders for every 2 weeks visits and has seen the pt 1 time for comprehensive assessment. SN made "routine home visit" on 4/16 and 4/19/24 with visit orders being once per week. There is no evidence the extra visit was ordered or was PRN. Patient 6: The SC has orders to see the pt once a week though saw pt 1 time for eval only on 3/24/24. The MSW was ordered to see pt monthly saw 3/26/24 only. All corrected on site. Patient 7: The SC was ordered monthly and there is not evidence the SC saw the pt in April 2024. No evidence of a refused visit. MSW ordered monthly and MSW saw pt one time on 3/3/24 with no evidence of refusals. Patient 8: The SC is ordered 1x per month SC saw pt on 1/31/24 and 4/20/24, no evidence of any other visits made or visit refusals. The MSW is ordered monthly and the MSW has not made any visits to the patient. There is no discontinue orders or evidence of refusals. The SN documented on 5/15/24 and 5/23/24 teaching and reinforcing "Usage of ice packs and warm compresses to alleviate mild to moderate pain". There are no orders for heat or ice on the POC. Patient 9: The SC is ordered monthly and has seen pt 1/12/24 and 4/8/24. There is no documentation of refusals for visits in Feb, Mar,May. The MSW has orders for monthly visits and saw pt 1 time for comprehensive assessment 1/13/24 and there is no evidence of any other visits or refusals. Patient 10: The SC is ordered 1x per month and saw 10/29/23 with no evidence of any further visits made or refusals. The MSW is ordered 1x per month and made visit 10/28/23 with no evidence of any further visits make or refusals. Patient 11: SC ordered once monthly and saw pt 2/18/24 with no evidence of any further visits made or refusals. Patient 12: The MSW is ordered 1x per month. There is no evidence the MSW made visits in April 2023, June 2023, Nov 2023, December 2023 or January 2024.There is no evidence of refusals or discontinue orders. Patient 14: The SN documented 6/12/24 "new foley catheter inserted and balloon inflated with 10ml NSS". There is no evidence of an order to insert a foley or discontinue a foley. The nurse documented on 5/14/23 "applied barrier cream" there is no order for barrier cream. The nurse documented 5/25/23 "foley catheter in place drainage bag with red urine, intervention done, balloon checked, contained 6cc causing placement to loosen. Additional 4cc added to inflate balloon for adequate pressure. There are not orders for this foley care. On 5/25/23 the SN documented "Another comfort measure done was to pad somehow the top dressing of the drainage located at the right upper abdomen". There is no evidence of an order for a dressing on the right upper abdomen. On 5/26/23 the SN documented "Gallbladder drain appears to be clogged. SN observed a mucous plug that traveled down the line in to the bag and clogged the drain. Troubleshooting we were able to break up the clots and get it to come out of the drain." There are no orders to manipulate this drain. On 5/29/23 the SN documented "completed gallbladder line care" there are not orders. On 5/29/23 the SN documented completed wound care and that PU appears to not be getting worse". There are no orders for wound care. On 6/1/24 the SN documented "completed wound care applied heart bandage". There are no orders for this wound care. 6/12/23 The SN documented "O2 at 2 Liters NC was able to reapply the oxygen as appears pt was able to fall asleep". There are no orders for oxygen on the POC.

Upon patient record review, 2 of 14 (Patient #4,5) did not have evidence in the patient record that hospice aide assignments and duties are: Patient 4: The aide plan of care contains orders to turn and reposition and to change linens with no frequency. Patient 5: The aide POC contains orders to change linens with no frequency. Corrected on site.

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: Patient 4: The POC has orders for aides 2 times per week. The aide has been seeing the pt 3 times per week every week since 5/6/24 with no evidence of an order to increase visits. Corrected on site.

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. The hospice documented a cost savings of 4.75% in 2023 documented from July 2023-December 2023.

Upon patient client record review, 9 of 14 (Patient #1,3,5,9,10,11,12,13,14) 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. Patients 1,3,5,10,12,13,14: The Hospice consents have a list of the core services available to the patient with bullet points next to them. The SN placed checks next to the boxes for Routine care and Continuous care indicating those are the only services being provided. These bullet points are not meant to be marked they are just indicating all levels of services provided. Patient 9: The SN documented on 4/30/24 and 5/21/24 "INH" This is not an approved abbreviation. Patient 10: The SN documented on 1/3/24 and 1/10/24 "INH" This is not an approved abbreviation. Patient 11: POC contains "Admit to Elka Hospice".

Upon client record review, 3 of 14 (Patient #10,11,12) did not have evidence that the discharge summary includes all required information. Patients 10, 11,12: The discharge summaries did not include the pain management, current plan of care, latest physician orders or any other documentation that will assist in post-discharge continuity of care or that is requested by the attending physician or receiving facility.

Upon SNF/NF contract review, 1 of 3 (contract St Vincent Healthcare) 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.