Every finding on record at Eden Hospice at Idaho Falls, LLC

Upon patient record review 1 of 14 (Patient #14) 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 #14, No evidence of SC visit completed within 5 days. Visit completed on 11/2/23 however, patient admitted 10/14/22.

Upon patient record review, 1 of 14 (Patient #5) 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, Documentation patient is using oxygen. No evidence of oxygen listed on medication list.

Upon patient record review, 2 of 14 (Patient #5,7) 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 #5, On 3/13/24 order for prazosin 1 mg tablet, take 2 before bed and reassess effectiveness in a few days and report to MD. Next SN visit on 3/18/24, No evidence of update to MD. Patient #7, Aide documented patient struggling to have BM, documented nurse notified. SN visit on 3/27/24, no evidence of documentation of last BM or evidence of addressing bowels. Patient medication list shows hydrocodone 5mg acetaminophen 325mg every 4 hours. No evidence of any bowel medication on med sheet.

Upon patient record review, 3 of 14 (Patient #8,11,12) did not have evidence that the plan of care includes all services necessary for the palliation and management of the terminal illness and related conditions which including interventions to manage pain and symptoms. Patient #8,11,12 No evidence of pain care plan.

Upon patient record review, 1 of 14 (Patient #5) 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 #5, No evidence of oxygen concentrator listed on DME.

Upon patient record review, 3 of 14 (Patient #2,10,14) 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 #2, No evidence of care plan updated with problems/goals/interventions for wound care. Patient #10, No evidence of care plan updated with problems/goals/interventions respiratory infection and new medication. Patient #14, No evidence of care plan updated with problems/goals/interventions. Care plan states chaplain to evaluate patient/family/caregiver. Plan of care to continue. Goals state chaplain POC will be established. MSW goal states POC will be established.

Upon client record review, 5 of 14 (Patient #4,5,6,7,8) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #4, No evidence of SC frequency orders, patient seen by SC on 2/7/24, 3/9/24, 3/14/24. Patient #5, SC frequency orders on 2/25/24, 1w8, no evidence of weekly visits. SC visit on 3/9/24 only. MSW documented missed visit 3/29/24 for MSW on vacation and there was no evidence of patient refusal/declination or alternative date offered. Patient #6, SN frequency 1w8, No evidence of SN visit week of 1/28/24. SC frequency 1w1, 1q2w8, No evidence of any visits being completed. Patient #7, SN frequency 4w1,1w11, no evidence of patient was seen 4x the first week, only 1 visit on 3/1/3/24. MSW frequency 4w1,1q3w3, No evidence patient was seen 4x the first week, patient seen on 3/13/24. Patient #8, SC frequency 1w13, no evidence of weekly visits completed. Initial visit completed 2/9/24, visit scheduled on 3/29/24 was not completed or documented as missed visit.

Condition of Participation: Hospice Aide and Homemaker Services. L607

Upon patient record review, 3 of 14 (Patient #5,6,9) 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 #5, Aide care plan states patient is cognitively and physically able to choose between shower or bed bath. Patient admitting diagnosis is Alzheimer. Patient #6, Aide care plan states patient is cognitively and physically able to choose between shower or bed bath. Documentation on 3/14/24 by MSW states patient has significant memory loss and requires 24 hour care. Aide care plan was not updated. Patient #9, Patient uses continuous oxygen 1-3 lpm via nasal cannula, no evidence oxygen precautions on aide care plan.

Upon patient record review 12 of 14 (Patient #1,2,3,4,5,6,8,9,11,12,13,14) 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 completed shower per Aide care plan. Aide visit note on 3/29/24 documents; shower, not required. Patient #2, No evidence aide completed turn and reposition every visit per Aide care plan. Aide visit note on 2/27/24 documents not required. Patient #3, No evidence aide completed transfer from bed to chair every visit. Aide visit note on 2/1/24 documents not required. Aide frequency 2w9. No evidence of 2nd visit week of 1/30/24, 2/5/24. Patient #4, No evidence aide completed transfer from bed to chair, change linens. Aide visit note on 1/29/24 documents not required. No evidence aide completed nail care and linen change. On 3/11/24 Aide documents nail care; not required, linen change; not required. Patient #5, No evidence aide completed turn and reposition. Aide visit not on 3/29/24 documents not required this visit. Aide frequency 3w8, No evidence patient was seen the 3rd visit for weeks of 2/4/24, 2/11/24, 2/18/24, 3/3/24, 3/17/24. Patient #6, Aide frequency on 1/28/24, 4w1,5w7,3w1, No evidence of visits followed the frequency. Week of 3/3/24 and 3/10/24, patient seen 4x. No evidence aide completed change linens every visit as directed on care plan. Aide visit note on 1/30/24, change linens document as not required this visit. No orders for aide on new certification date of 3/28/24, Aide made visit on 4/1/24. Patient #8, Aide frequency 2/11/24, 1w1,2w11, no evidence of patient seen 2x/week, patient seen on 2/16/24, 2/22/24, 2/26/24, 3/4/24. Patient #9, Aide care plan states to assist to bedside commode every visit. Aide documented on aide note 3/6/24, not required this visit. Patient #11, Aide care plan states nail care every visit. No evidence nail care was completed on 4/6/23 and 4/17/23. Aide documented no required this visit. Patient #12, Aide care plan states bath every visit. No evidence bath was completed on 10/17/23, documented as not required. Patient #13, Aide frequency 1x/week, No evidence of any visits completed. Patient #14, Aide care plan state shaving every visit, nail care every visit. Aide visit on 12/8/23, documentation states not required this visit.

Upon patient record review 1 of 14 (Patient #6) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs. Patient #6, No evidence of supervisory visit after 3/22/24 to present.

Upon contract review, 1 of 4 (Dr. Joseph Nelson, Medical Director) did not have evidence of a contract to fulfill the role of medical director or alternate medical director, if applicable. Contract #1, Medical Director's contract had his LLC company listed without Medical Director name on the contract. Corrected on site

Upon client record review, 1 of 14 (Patient #11) did not have evidence that if a patient revokes the election of hospice care or is discharged from hospice in accordance with §418.26, the hospice must forward to the patient's attending physician: • A copy of the hospice discharge summary • The patient's clinical record, if requested Patient #11, No evidence of discharge summary sent to patient attending.

Upon client record review, 1 of 14 (Patient #11) did not have evidence that the discharge summary includes all required information. Patient #11, No evidence of discharge summary completed.