Every finding on record at Eden Hospice at Portland, LLC

Based on documentation review and interview, it was determined the agency failed to meet the requirements established by the Division and the CMS Conditions of Participation for hospice programs in providing Medical social services in a manner that is consistent with accepted standards of practice. An agency employee who did not have the required qualifications of a Medical Social Service provider was permitted to provide services to patients in Oregon. --- Findings:Review of the document titled "Medical Social Services Policy, Effective 7/18/2022" revealed the statement "Medical social services are provided by qualified individuals in accordance with the state's Social Work Practice Act professional standards, the Eden Hospice job description and policies and procedure." The agency failed to provide documentation that qualified Employee #1 to practice Social Work in the State of Oregon.Review of the document titled "JOB DESCRIPTION Medical Social Worker (MSW)" and signed by Employee #1 on 04/19/2023, revealed a section titled, "PROFESSIONAL REQUIREMENTS, #7 Maintains regulatory requirements, including federal, state, local regulations, and accrediting organization standards." It also revealed a section titled "EDUCATION AND EXPERIENCE, #1 Has a Master of Social Work degree ... or, # 2 Has a baccalaureate degree in social work ... or, #3 Has a baccalaureate degree ... other field related to social work ..., #4 Current valid state clinical social worker license if required by state regulations." The agency failed to provide documentation of licensure from the Oregon State Board of Licensed Social Workers and evidence of completion of an education program that qualified Employee #1 to practice as a Medical Social Worker.Review of the document titled "ANNUAL EVALUATION MEDICAL SOCIAL WORKER (MSW), Date of Evaluation: 5/20/24," revealed the statement, "Maintains regulatory requirements, including federal, state, local regulations, and accrediting organization standards." Next to the statement is a column titled, "SCORING." Within this column and next to the statement is revealed a check mark next to "Met." Also, in this document under a section titled, "SUMMARY" it is revealed for goals and objectives for Employee #1 to "Continue to complete MSW degree." The agency failed to provide documentation of licensure from the Oregon State Board of Licensed Social Workers.Review of personnel records of Employee #1 with a hire date of 05/01/2023 lacked documentation of licensure from the Oregon State Board of Licensed Social Workers.During an interview with the Executive Director and the HR Manager on 07/10/2025 at 3:00 PM, the above findings were presented. The HR Manager acknowledged that employment records for Employee #1 did not contain licensure from the Oregon Board of Social Workers nor documentation of meeting the education requirements for a Social Worker. The Executive Director stated that recently a hospice agency, located in Washington State, was acquired by this hospice. The previous administration assumed that because this MSW had a Washington license and was over-seen by an LCSW that this was valid for the MSW to see Oregon clients. When the new administration preformed an audit of employee records after the acquisition, it was discovered Employee #1 did not meet qualifications to practice Social Work in Oregon. Employee #1 stopped providing services to Oregon patients on February 12, 2025.

Upon patient record review, 1 of 23 (Patient #8) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient #8: The Election Statement reads: "I choose below physician as my attending physician. If s/he declines or fails to respond to this request to follow my care onto hospice within two business days, I choose the Hospice Medical Providers to manage my medical care related to my terminal illness and related conditions." This Beneficiary chose their own attending physician from Kaiser (non-hospice physician). Agency did not have evidence of attempts to contact the attending physician of choice. Per Agency, they searched through emails and were unable to find.

Upon patient record review, 4 of 23 (Patients #1,2,5,6) 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 #1: During medication reconciliation on home visit, the hospice medication profile included Acetaminophen 325 mg 2 tabs and B-12 supplement. The patient had acetaminophen 500 mg tabs and acetaminophen 160mg/5mL solution on hand and B-Complex supplement (not B-12) on hand. Additionally, patient had Zinc Lozenges, Compound W cream and Lidocaine patch in home. These were not listed on hospice medication profile. Corrected on Site. Patient #2: During medication reconciliation on home visit, the patient had Eliquis 5mg BID, Levothyroxine 50 mcg daily and Mira-lax 17gm daily. These medications were not on the hospice medication profile. Corrected on Site. Patient #5: During medication reconciliation on home visit, the ALF had Diclofenac 1% cream and melatonin 5mg marked discontinued on their medication administration record. The hospice medication profile showed these meds as current. Corrected on Site. Patient #6: During medication reconciliation on home visit, the patient had Tylenol 500mg on hand. This medication was not on the hospice medication profile. Corrected on Site.

Upon patient record review, 4 of 23 (Patients #1,3,16,20) 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 #1: This patient was admitted on 3/25/25. The bereavement risk assessment was completed on 4/4/25 (>5days). Patient #3: This patient was admitted on 4/11/25. The bereavement risk assessment was completed on 5/6/25 (>5days). Patient #16: This patient was admitted on 1/24/25. The bereavement risk assessment was completed on 4/22/25 (>5days). Patient #20: This patient was admitted on 12/19/24. The bereavement risk assessment was completed on 12/26/24 (>5days).

Upon patient record review, 1 of 23 (Patient #8) did not have evidence that the hospice follows the individualized plan of care developed in in collaboration with the attending physician (if any), the patient or representative, and the primary caregiver in accordance with the patient's needs if any of them so desire. Patient #8: The Beneficiary chose their own attending physician from Kaiser (non-hospice physician). There was no evidence of collaboration of care with the attending physician in developing the POC.

Upon patient record review, 1 of 23 (Patient #1) did not have evidence the plan of care (POC) must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #1: During medication reconciliation on home visit, the hospice POC included Acetaminophen 325 mg 2 tabs and B-12 supplement. The patient had acetaminophen 500 mg tabs and acetaminophen 160mg/5mL solution on hand and B-Complex supplement (not B-12) on hand. Corrected on Site.

Upon patient record review, 4 of 23 (Patients #2,3,5,7) did not have evidence the plan of care (POC) must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient #2: This patient had a cane. This item was not included on the POC. Corrected on Site. Patient #3: This patient had a walker. This item was not included on the POC. Corrected on Site. Patient #5: This patient had an air mattress and wheel chair. These were not included on the POC. Corrected on Site. Patient #7: The record reflected that this patient had a cane. These were not included on the POC. Corrected on Site.

Upon patient record review, 1 of 23 (Patient #17) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care (POC). Patient #17: The POC indicated that the Hospice Nurse to provide wound care daily and PRN peri care to stage II cleanse with N/S, pat dry and cover. Instruct CG in wound care. The hospice nurse visit frequency is 2 x week. New order obtained. Corrected on Site.

Upon patient record review 3 of 23 (Patients #5, 11,12) 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 (POC) Patient #5: The aide care plan written instructions indicated the task of nail care every visit. The record indicated that this task was not performed on 5/7/25. Patient #11: The POC listed aide visit frequency of, 1wk2, 2wk12 (4/13/25). There have been no visits to current date by an aide. There is a coordination note by an aide on 5/7/25 that indicated missed visit note that read: "to stop visits for the time being." There is no evidence of an order by to stop aide services. Patient #12: The aide written instructions (4/1/25) indicated the tasks of turning, bed bath, dressing, skin care, shaving, nail care, change linens and empty trash every visit. The record indicated that these tasks were not performed and had no evidence the RN had been informed.

Upon patient client record review, 2 of 23 (Patients #2,15) did not have evidence that each patient record contains: • Signed election statement in accordance with 418.24 Patient #2: The Election Statement start of care (SOC) indicated 4/2/25. The agency electronic medical record (EMR) indicated SOC as 4/4/25. Corrected on Site Patient #15: Election Statement indicated 3/5/25. The agency EMR indicated SOC of 3/6/25.

Upon patient record review, 1 of 23 (Patient #20) did not have evidence that the discharge summary includes all required information as follows: • The patient's current plan of care

Upon patient record review, 4 of 10 (Patient #2,4,5,& 10) plan of care did not include the equipment's necessary for the palliation and management of the patient's terminal illness and related conditions; Patient #2 patient's quad cane was not included in the plan of care which was identified in the comprehensive nursing assessment performed on 5-20-2022 and was observed during HV. Patient #4 patient's grab bars,walker (wheeled & unwheeled),shower chair, overbed table were not included in the plan of care which was identified in the comprehensive nursing assessment performed on 2-18-2022. Patient #5 patient's wheelchair was not included in the plan of care which was identified in the comprehensive nursing assessment performed on 3-16-2022. Patient #10 patient's wheelchair, hospital bed, oxygen concentrator,walker, overbed table was not included in the plan of care which was identified in the comprehensive nursing assessment performed on 5-11-2022.

Upon patient record review, 4 of 4 applicable (Patient records #1,2,3,8) did not include specific instructions for the aide services there was no aide plan of care that indicated the specific tasks, hospice aide assignments, and duties including frequencies of the tasks. The aide tasks were being performed by the RN.

Upon patient client record review, 4 of 10 (Patient records #3,4,6 & 9) based upon review; Patient #3 the election statement did not include an evidence of the patient's signature or of designated individual as applicable. Patient #4 & 6 the election statement did not include an evidence of the patient's signature. Patient #9 the election statement did not include the effective date of the election statement.