Every finding on record at Eden Hospice at Carson City, LLC

Upon patient record review 1 of 19 (Patient # 11) 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 11: The patient was admitted on 5/1/23, the caregiver declined spiritual care, there is no evidence in the record that a spiritual care assessment was completed by an RN or SW.

Upon patient record review, 4 of 19 (Patient #1, 2, 4, 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: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient 01: The medication profile includes Latanoprost 0.005% eyes drops, 1 drop daily, it does not include which eye/eyes to instill the drops. The profile includes Calazime paste apply thin layer to affected area, it does not include an application site. The profile includes Lidocaine plus 4%, apply to wound bed and surrounding area, it does not include the site of the wound. (Corrected on site.) Patient 02: The medication profile includes Calazime 0.44%-20.6% topical paste, apply small amount the affected area, this does not indicate an application site. (Corrected on site.) Patient 04: The medication profile includes Cephalexin 500mg 1 pill 3 times daily for 11 days, this medication was started on 5/3/23 and remains on the medication profile. The medication profile includes Doxycycline 100mg take 1 pill twice daily for 5 days, this medication was started on 5/3/23 and remains on the medication profile. (Corrected on site.) Patient 14: The medication profile includes Miralax 17gram powder, take 2 capfuls by mouth daily, this does not include instructions for mixing with a diluent. (Corrected on site.)

Upon patient record review, 7 of 19 (Patient #3, 4, 5, 6, 15, 16, 19) 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 03: The patient was admitted on 5/5/23, the initial bereavement assessment was completed on 5/18/23. Patient 04: The patient was admitted on 5/2/23, there is no initial bereavement assessment completed to date. Patient 05: The patient was admitted on 12/6/22, the initial bereavement assessment was completed on 12/16/22. Patient 06: The patient was admitted on 2/17/23, the initial bereavement assessment was completed on 5/18/23. Patient 15: The patient was admitted on 11/10/22, the initial bereavement assessment was completed on 12/7/22. Patient 16: The patient was admitted on 10/27/21, the initial bereavement assessment was completed on 12/02/21. Patient 19: The patient was admitted on 12/8/22, the initial bereavement assessment was completed on 1/26/23.

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

Upon patient record review, 8 of 19 (Patient #1, 2, 4, 6, 7, 8, 9, 11) 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 01: Upon admit on 11/7/22 it is identified that the patient has atrial fib and is on Eliquis 5mg po BID, the plan of care does not include interventions/goals for the management of bleeding risks related to the anti-coagulant. Patient 02: Upon admit on 6/22/23 it was identified that the patient has had significant weight loss from 154 to 132lbs in less than 30 days, the plan of care does not include a problem statement with interventions and goals for nutrition. The record shows evidence that the patient was receiving wound care to bilateral heels upon admit, and the plan of care does not include a problem statement with interventions and goals for wound care. Patient 04: Upon admit on 5/2/23, it is identified that the patient has diabetes mellitus type II and is on insulin injections. The plan of care does not include a problems statement with interventions and goals for the nutritional needs of the patient. The plan of care does not include interventions or goals for monitoring/educating the patient and caregiver for diabetic changes. Patient 06: The patient was admitted to hospice services on 2/17/23 with a primary diagnosis of Parkinson's Disease and is taking medications related to Parkinson's management, the plan of care does not include a problem statement with interventions and goals for the neurological disease process. Patient 07: The patient is admitted for Huntington's disease, the plan of care does not include a problem statement with interventions and goals for the management of the neurological disease. The patient has dysphagia and malnutrition and requires a feeding tube, the plan of care does not identify the problem or provide interventions and goals for the management of the altered nutrition. Patient 08: The patient is admitted for cerebral atherosclerosis with co-morbidities of protein calorie malnutrition and Parkinson's disease. The plan of care does not include a problem statement with goals and interventions for neurological conditions or nutrition. Patient 09: The patient is admitted for esophageal cancer and has complaints of pain, dysphagia and malnutrition. The plan of care does not include a problem statement with interventions or goals for pain management, nutrition, or aspiration precautions. Patient 11: The patient was admitted on 5/1/23 with a primary diagnosis of COPD and documentation in the nursing assessment of nocturnal hypoxia, asthma and O2 sats of 79% with O2, the plan of care does not include a problem statement with interventions and goals for the respiratory management.

Upon patient record review, 4 of 19 (Patient #1, 2, 4, 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. Paitent 01: The order on 11/8/22 for Latanoprost 0.005% 1 drop daily, does not indicate which eye/eyes to instill the drops into. The medication order on 11/8/22 for Calazime paste apply thin layer to affected area, does not include an application site. The order on 2/28/23 for Lidocaine plus 4%, apply to wound bed and surrounding area, does not include the site of the wound. (Corrected on site.) Patient 02: The medication order on 6/27/23 for Calazime 0.44%-20.6% topical paste, apply small amount the affected area, does not indicate an application site. (Corrected on site.) The record shows evidence that the patient was receiving wound care to bilateral heels upon admit, there are no orders for wound care. Patient 04: The medication orders on 5/3/23 for Cephalexin for 11 days have not been discontinued. The medication order on 5/3/23 for doxycycline for 5 days have not been discontinued. (Corrected on site.) Patient 14: The medication order on 10/26/22 for Miralax 17gram poweder, take 2 capfuls by mouth daily, does not include instructions for mixing with a diluent. (Corrected on site.)

Upon patient record review, 4 of 19 (Patient #1, 4, 7, 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 equipment and supply needs. Patient 01: The patient was provided with an oxygen concentrator at the time of admit on 11/7/22, the medication profile includes orders for the use of PRN oxygen, this is not included in the DME/supply list. The patient started receiving wound care to her left breast on 2/7/23, the wound care supplies are not listed in the plan of care. (Corrected on site.) Patient 04: The patient requires the use of a walker/rollator for ambulation, this is not included in the plan of care. The patient is incontinent and uses briefs, underpads, wipes and gloves as noted and provided at the time of admit, these are not included in the plan of care. An electric hospital bed was requested on 6/15/23, this is not included in the plan of care. (Corrected on site.) Patient 07: The patient record reflects that the patient requires suction, over the bed table, and a bedside commode, these are not included in the plan of care. (Corrected on site.) Patient 14: The patient utilizes a bed, over the bed table, and oxygen, these items are not included in the plan of care. (Corrected on site.)

Upon patient record review, 4 of 19 (Patient #1, 3, 8, 11) 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 01: There is evidence in the patient record of orders for wound care to left breast starting on 2/7/23 and ongoing, with changes and additional orders throughout the continuum of care, the plan of care does not include a problem statement with interventions and goals for the wound care management. (Corrected on site.) Patient 03: The patient record indicates that the patient has a history of falls and required an after hours PRN visit on 5/7/23 due to a fall. The plan of care does not include a problem statement with interventions or goals for safety. (Corrected on site.) Patient 08: The patient has wounds requiring wound care orders initiated on 3/1/23 and updated wound care orders on 7/12/23. The plan of care does not include a problem statement with interventions and goals for the management of wounds/skin integrity. (Corrected on site.) Patient 11: The patient is admitted with a diagnosis of malignant neoplasm of the frontal lobe of the brain, she is prescribed Keppra on 3/28/23 and dexamethasone on 6/8/23. The plan of care does not include a problem statement with interventions and goals for the neurological conditions. (Corrected on site.)

Upon patient record review, 3 of 19 (Patient #17, 18, 19) 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 17, 18, 19: There is no evidence in the patient record that a sympathy card was sent, there is no evidence in the patient record that letters are sent according to the bereavement plan of care.

Upon patient client record review, 3 of 19 (Patient #6, 8, 16) did not have evidence that each patient record contains Advance Directives. Patient 6: During the MSW assessment and visit on 3/15/23 it was identified that the patient has an Advanced Directive with assignment of POA, this is not included in the patient record. Patient 8: The Election of Hospice Benefit is signed by the patient niece who is identified as the POA for the patient. The POA is not included in the patients record. Patient 16: The patient record does not include documentation regarding the patient's code status or presence/absence of advanced directives.

Upon client record review, 1 of 19 (Patient #2) did not have evidence that a written hospice plan of care is established and maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided is in accordance with this hospice plan of care. Patient 02: The patient medication record of the nursing facility does not correlate with the hospice plan of care. According to the medication record at the nursing facility, the patient receives Seroquel 50 mg 2 pills PO twice daily, Ondansetron 8mg every 8 hours by mouth as needed for nausea, Sennosides 8.6mg 1 tab by mouth daily, Hyoscyamine 0.125mg every 6 hrs as needed for increased secretions, Lorazepam 0.5mg every 4 hours as needed for anxiety, these are not included in the hospice plan of care. The patient receives Haloperidol 0.5mg by mouth once daily, the hospice plan of care indicates this medication is Haloperidol 2mg/ml give 1ml three times daily. (Corrected on site.)

Upon patient record review, 1 of 19 (Patient #2) did not have evidence that the hospice provided the following information: • Hospice election form and any Advance Directives specific to each patient • Physician certification and recertification of the terminal illness specific to each patient Patient 02: During the home visit at the SNF, it was identified that the agency has not provided the Hospice Election form or the certificate of terminal illness to the facility. (Corrected on site.)