Every finding on record at Ease of Mind Hospice Care Inc.

Upon patient record review, 1 of 14 (Patient #4) did not have evidence that the hospice informed and provided written information to the patient concerning its policies on advance directives, including a description of applicable state law. Patient #4: Admission Consent and Hospice Election Statement and POLST are signed by patient with admitting diagnosis is Alzheimer's Disease Unspecified G30.9 therefore, unable to determine is patient was able to fully comprehend the information provided. RN 6/25 initial assessment: Patient shows minimal orientation to person situation and place. 6/29 MSW initial assessment Patient is not aware of medical condition, oriented x 2 person and place. MD CTI admitting benefit period said FAST IV and for the following benefit period, he documented 7C.

Upon patient record review, 1 of 14 (Patient #4) did not have evidence that the hospice obtained the patient's or representative's signature confirming that they received a copy of the Patient's Rights and Responsibilities. Patient #4: Admission Consent and Hospice Election Statement and POLST are signed by patient with admitting diagnosis is Alzheimer's Disease Unspecified G30.9 therefore, unable to determine is patient was able to fully comprehend the information provided. RN 6/25 initial assessment: Patient shows minimal orientation to person situation and place. 6/29 MSW initial assessment Patient is not aware of medical condition, oriented x 2 person and place. MD CTI admitting benefit period said FAST IV and for the following benefit period, he documented 7C.

Upon patient record review, 1 of 14 (Patient #4) did not have evidence that if a state court has not adjudged a patient incompetent, any legal representative designated by the patient in accordance with state law may exercise the patient's rights to the extent allowed by state law. Patient #4: Admission Consent and Hospice Election Statement and POLST are signed by patient with admitting diagnosis is Alzheimer's Disease Unspecified G30.9 therefore, unable to determine is patient was able to fully comprehend the information provided. RN 6/25 initial assessment: Patient shows minimal orientation to person situation and place. 6/29 MSW initial assessment Patient is not aware of medical condition, oriented x 2 person and place. MD CTI admitting benefit period said FAST IV and for the following benefit period, he documented 7C.

Upon patient record review, 1 of 14 (Patient #4) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient #4: Admission Consent and Hospice Election Statement and POLST are signed by patient with admitting diagnosis is Alzheimer's Disease Unspecified G30.9 therefore, unable to determine is patient was able to fully comprehend the information provided. RN 6/25 initial assessment: Patient shows minimal orientation to person situation and place. 6/29 MSW initial assessment Patient is not aware of medical condition, oriented x 2 person and place. MD CTI admitting benefit period said FAST IV and for the following benefit period, he documented 7C.

Upon patient record review, 1 of 14 (Patient #4) did not have evidence of the appropriate documentation for release of confidential information. Patient #4: Admission Consent and Hospice Election Statement and POLST are signed by patient with admitting diagnosis is Alzheimer's Disease Unspecified G30.9 therefore, unable to determine is patient was able to fully comprehend the information provided. RN 6/25 initial assessment: Patient shows minimal orientation to person situation and place. 6/29 MSW initial assessment Patient is not aware of medical condition, oriented x 2 person and place. MD CTI admitting benefit period said FAST IV and for the following benefit period, he documented 7C.

Upon patient record review, 1 of 14 (Patient #4) did not have evidence that the patient received information about the services covered under the hospice benefit. Patient #4: Admission Consent and Hospice Election Statement and POLST are signed by patient with admitting diagnosis is Alzheimer's Disease Unspecified G30.9 therefore, unable to determine is patient was able to fully comprehend the information provided. RN 6/25 initial assessment: Patient shows minimal orientation to person situation and place. 6/29 MSW initial assessment Patient is not aware of medical condition, oriented x 2 person and place. MD CTI admitting benefit period said FAST IV and for the following benefit period, he documented 7C.

Upon patient record review, 1 of 14 (Patient #4) 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. Patient #4: Admission Consent and Hospice Election Statement and POLST are signed by patient with admitting diagnosis is Alzheimer's Disease Unspecified G30.9 therefore, unable to determine is patient was able to fully comprehend the information provided. RN 6/25 initial assessment: Patient shows minimal orientation to person situation and place. 6/29 MSW initial assessment Patient is not aware of medical condition, oriented x 2 person and place. MD CTI admitting benefit period said FAST IV and for the following benefit period, he documented 7C.

Upon patient record review, 2 of 14 (Patient #5,9) 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: During home visit, noted discrepancies with medication profile vs. medications taken by patient. During patient interview, caregiver/daughter reported that she administers 20 units Lantus insulin (100units/ml) every HS. However, medication profile listed medication dose as 12 units qhs. When reviewed pen/box, the prescription on box dated 9/25/24 says 40 units qhs. Atorvastatin Calcium bottle in home says 20 mg tab at bedtime, with prescription date of 2/16/24. Medication Profile has 40 mg dose HS. The patient caregiver admittedly pours new meds in old bottles. Unable to verify dosage in current bottle. LVN will follow up. Medication profile includes Januvia 100 mg once/day, but patient caregiver/daughter states that MD stopped few months ago. Med profile includes Colace 100 mg twice a day, but she states takes prn only. Also has Senokot 1 tab twice a day as needed on medication profile, which was not available for review. Patient #9: Tramadol HCL 50 mg every 8 hrs as needed for severe pain. The medication is not available in the home. LVN and patient not aware of any use or availability of medication. Patient reports Tylenol and local cream/gel effective. Medication Profile includes Flexeril 10 mg at bedtime. Patient had in home but states does not take any more.

Upon patient record review, 1 of 14 (Patient #12) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient #12: 11/29/24 Communication note: RN reported stage 2 sacro coccyx ulcer. Reported MD notified ordered cleanse with wound cleanser, pat dry, apply Medi-honey, and cover with foam dressing. PCG to do treatment during non SN visit. 11/29/24 (same date) SN note states integumentary assessment as wounds none, Ulcer/bed sores none, and no mention of wound or wound care in visit narrative. No evidence wound was assessed.

Upon patient record review, 1 of 14 (Patient #8) 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 #8: Admitted with abdominal incision and staples with no reference in Plan of Care of related problems, goals, interventions.

Upon patient record review, 3 of 14 (Patient #2,3,4) 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 #2: 3/15/24 MSW frequency every recert period and as needed...PRN was not quantified. Patient #3: 5/11/24 Chaplain monthly and as needed and 5/11/24 MSW every recert period and as needed. PRN was not quantified. Patient #4: 6/29/24 order MSW every recert and as needed. 6/26/24 order Chaplain visits every recert and as needed. PRN was not quantified.

Upon patient record review, 2 of 14 (Patient #1,2) 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 #1: IDG Plan of Care includes orders to cleanse wound with prescribed wound cleanser as ordered. Pat dry and cover with Kerlix. Does not specify wound care frequency. Patient #2: 11/29/24 order Sacro coccyx unstageable pressure ulcer: cleanse with wound cleanser and pat dry, apply Medi-honey and cover with foam dressing. PCG to do treatment during non-SN visit. The prescribed frequency of wound care is not specified.

Upon patient record review, 1 of 14 (Patient #13) 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 #13: 9/13 and 9/19/24 orders for medication to treat UTI. There was no update to the problems, goals and interventions.

Upon client record review, 4 of 14 (Patient #3,8,12,13) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #3: 5/11/24 MSW every recert period and as needed. MSW visits were made 5/11, 5/22, 8/5, 9/12, 9/21, 10/4, 10/31/24. Patient #8: Admitted 10/17/24. Order present for MSW to perform initial visit within 5 days however, MSW initial assessment not until 11/2/24 with no documented explanation for delay beyond 5 days. Patient #12: Dates of service 9/30-10/8/24. 10/8/24 communication note patient was discharged before SC/BC did initial assessment, however patient was on service beyond 5 days and there is an order for SC to perform initial visit within 5 days and there is no documented reason for delay, including no refusal of visit. Patient #13: MD Order 8/30/24 PT evaluate 9/9/24. No documented evidence it was provided and/or declined.

Upon contract review, 1 of 6 (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 was unable to provide evidence of a contract between hospice agency and Wound Pros. The agency presented to surveyor a one page account set up for the Wound Pro online portal. Surveyor offered opportunity to provide any additional information that might be available from the portal, but no additional information was provided.

Upon patient client record review, 1 of 14 (Patient #4) 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 #4: Admission Consent and Hospice Election Statement and POLST are signed by patient with admitting diagnosis is Alzheimer's Disease Unspecified G30.9 therefore, unable to determine is patient was able to fully comprehend the information provided. RN 6/25 initial assessment: Patient shows minimal orientation to person situation and place. 6/29 MSW initial assessment Patient is not aware of medical condition, oriented x 2 person and place. MD CTI admitting benefit period said FAST IV and for the following benefit period, he documented 7C.

Upon patient client record review, 5 of 14 (Patient #2,4,5,12,14) 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. Patient #2: Hospice Aide Assignment entered by one employee and assigned to another employee (RN). The document is not authenticated with RN signature. Patient #4: RN Assessment Narrative of CTI Benefit Period identified as Benefit #2 throughout medical record, begins with Patient is an age 81 ....admission with Ease of Mind Hospice Care terminal hospice diagnosis of Alzheimer's disease unspecified for hospice period 9, 6/25-9/22/24. Patient #5: Visit notes documented as MSW Initial Assessment 7/5/24 and MSW Initial Assessment 9/26/24 and also note for Recert assessment 9/26/24. Patient #12: Communication note 10/9/24 received report from nurse that a patient is flying to El Salvador tonight will be gone for 2 weeks. PCG requested to revoke hospice services. Revocation says reason moved out of area. (DC summary says patient revoked to seek aggressive treatment.) Patient #14: Communication note 8/24/24 says Patient passed away before MSW, Chaplain and Bereavement Coordinator did initial assessment. However, visits are documented for all assessments: in person MSW and by phone for SC/BC, within 5 day window for comprehensive.

Upon client record review, 1 of 14 (Patient #12) did not have evidence that the discharge summary includes all required information. Patient #12 DC summary says patient revoked to seek aggressive treatment. Revocation statement says reason is moved out of area.

Upon observation, there was no evidence a copy is provided of the hospice written policies and procedures on the management and disposal of controlled drugs to the patient or patient representative and family. Patient #4: Admission Consent and Hospice Election Statement and POLST are signed by patient with admitting diagnosis is Alzheimer's Disease Unspecified G30.9 therefore, unable to determine is patient was able to fully comprehend the information provided. RN 6/25 initial assessment: Patient shows minimal orientation to person situation and place. 6/29 MSW initial assessment Patient is not aware of medical condition, oriented x 2 person and place. MD CTI admitting benefit period said FAST IV and for the following benefit period, he documented 7C.

Upon observation, there was no evidence the hospice discussed the policies and procedures for managing the safe use and disposal of controlled drugs with the patient or representative and the family in a language and manner that they understand to ensure that these parties are educated regarding the safe use and disposal of controlled drugs. Patient #4: Admission Consent and Hospice Election Statement and POLST are signed by patient with admitting diagnosis is Alzheimer's Disease Unspecified G30.9 therefore, unable to determine is patient was able to fully comprehend the information provided. RN 6/25 initial assessment: Patient shows minimal orientation to person situation and place. 6/29 MSW initial assessment Patient is not aware of medical condition, oriented x 2 person and place. MD CTI admitting benefit period said FAST IV and for the following benefit period, he documented 7C.

Upon client record review, 1 of 14 (Patient #4) did not have evidence that the written policies and procedures for managing controlled drugs was provided and discussed. Patient #4: Admission Consent and Hospice Election Statement and POLST are signed by patient with admitting diagnosis is Alzheimer's Disease Unspecified G30.9 therefore, unable to determine is patient was able to fully comprehend the information provided. RN 6/25 initial assessment: Patient shows minimal orientation to person situation and place. 6/29 MSW initial assessment Patient is not aware of medical condition, oriented x 2 person and place. MD CTI admitting benefit period said FAST IV and for the following benefit period, he documented 7C.

Upon personnel record review, 1 of 12 (Personnel #10) 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 #10: There is no Criminal Background Check for Physical Therapist