Every finding on record at Eldercare Healthcare Services LLC

Upon patient record review, 3 of 5 (Patient #1,2,3) 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 1: Assessed plan of care needs: wound/skin care, pain, confusion, falls. No evidence of plan of care with problems, goals, interventions: pain. Patient 2: Assessed plan of care needs: fall, respiratory, oxygen, wound care, pain. No evidence of plan of care with problems, goals, interventions: pain. Patient 3: Assessed plan of care needs: respiratory/dyspnea, oxygen, falls, edema, diabetes/kidney failure. No evidence of plan of care with problems, goals, interventions: respiratory/dyspnea, oxygen, falls, edema.

Upon patient record review, 3 of 5 (Patient #2,3,4) 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 2: There is no evidence of physician's orders for wound care in the medical record. Patient 3: Patient wears oxygen at 2 liters per minute via nasal cannula. There is no evidence that oxygen is included on the plan of care. Patient 4: Patient wears oxygen at 2 liters per minute via nasal cannula as needed. There is no evidence that oxygen is included on the plan of care.

Upon patient record review, 2 of 5 (Patient #1,3) 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 equipment and supply needs. Patient 1: Identified DME needs: airloss mattress, bedside table, walker, wheelchair. No evidence of DME included on plan of care: walker, wheelchair. Patient 3: Identified DME needs: oxygen concentrator, walker. There is no evidence of the DME included on the plan of care.

Upon patient record review, 1 of 5 (Patient #2) 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: There is no evidence that plan of care was updated to include problems, goals, interventions when patient developed wound.

Upon patient record review, 2 of 5 (Patient #2,3) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 2: Physician's nursing visit frequency order is twice weekly. There is no evidence of documented nursing visit made after 12/27/2024. Patient 3: Physician's nursing visit frequency order is weekly. There is no evidence of documented nursing visit made after 12/25/2024. The 12/25/2024 nursing visit has documentation in the visit indicating it is a telehealth visit. There is no evidence physician's orders for telehealth SN visits.

Upon patient record review, 1 of 5 (Patient #3) 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 3: Ordered task on aide care plan: change linen has frequency of weekly and PRN. No indication of when to perform PRN.

Upon patient record review 1 of 5 (Patient #3) 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 3: Physician's visit frequency order is weekly. There is no evidence of documented aide visits in the medical record.

Upon patient record review, 2 of 5 (Patient #1,4) 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 #1,4: Discharge summary not sent to the physician.

Upon patient record review, 2 of 5 (Patient #1,4) did not have evidence that the discharge summary includes all required information. Patient #1,4: The discharge summary was missing required components. • A summary of the patient's stay, including treatments, symptoms and pain management • The patient's current plan of care • The patient's latest physician orders • Any other documentation that will assist in post-discharge continuity of care or that is requested by the attending physician or receiving facility.

Upon client record review, 4 of 19 (Patient #1, 3, 9, 15) did not have evidence that the plan of care included IDG's documentation of the patient's or families level of understanding, involvement and agreement with the plan of care. Patient #1, 3, 9, 15 did not contain evidence of the patient/family involvement in the development of their plan of care.

Upon patient record review, 1 of 16 (Patient #10) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient #10: Hospice Election Statement space allocated for MD choice is left blank.

Upon patient record review, 4 of 16 (Patient #1, 3, 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 Patients# 1,3: There was no medication profile. Patient #1, 5: Oxygen in use by patient, but not listed on medication profile. Patient #9: During home visit at group home where patient resides, noted that comfort care medications (per RN) had been order and delivered, but were not listed on medication profile and no orders in EMR for: Morphine 5 mg q6 hrs. prn pain (25 ml dose of 20 mg/ml suspension); Haldol 0.5 ml q 6 hrs. as needed (2 mg/ml); Ativan 0.5 ml q6 hrs. prn of 2mg/ml; Zofran 4 mg q8 hrs. prn; Dulcolax 10 mg suppository prn constipation.

Upon patient record review, 3 of 16 (Patient #4, 9, 12) 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 #4, 9, 12 did not have evidence of a bereavement assessment.

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

Upon observation, there was no evidence the hospice has an interdisciplinary group (IDG) or groups composed of individuals who work together to meet the physical, medical, psychosocial, emotional, and spiritual needs of the hospice patients and families facing terminal illness and bereavement. Interdisciplinary group members must provide the care and services offered by the hospice, and the group, in its entirety, must supervise the care and services. Upon observation, although there is an interdisciplinary group of professionals, there is not evidence of the IDG members supervising the care and services of their patients as the plans of care are not updated for all patients following IDG meetings and patients 1,3,5, 9 did not have initial plan of care developed with all required elements and patient #15 not updated after November recertification.

Upon patient record review, 4 of 16 (Patient #1, 3, 9, 15) did not have evidence that each patient and family received education and training provided as appropriate to their responsibilities for the care and services identified in the plan of care. Patients 1, 3, 9, 15: There is no evidence the patient/family received education and training regarding their responsibilities for the care and services needed.

Upon patient record review, 4 of 16 (Patient #1, 2, 3, 15) 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 #1: Admitted 9/26/24 has no Plan of Care on file - including discipline frequencies, medications and does not include any problems, goals, interventions for patient admitted with COPD and documented shortness of breath.. Patient #2: Admitted 9/16/24 with colostomy and initial plan of care did not contain problems, interventions, and goals. Patient #3 Admitted 9/20/24 has incomplete Plan of Care. It does not include discipline frequencies or medications.-Initial Plan of Care includes problem for generalized pain. It does not include problems, goals, interventions including, but not limited to Foley catheter, safety, altered mental status, personal care needs. Patient #15: Admitted with COPD with documented SOB and O2 dependency. There are no related problems, goals, interventions documented.

Upon patient record review, 5 of 16 (Patient #1, 3, 6, 9, 15) 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. Patients #1,3,9 no evidence of an order for disciplines or frequency. Patient #6: Discipline frequency for SC and MSW is 5 prn. Patient #15 no evidence of orders for disciplines and frequencies for benefit period beginning 11/7/24.

Upon patient record review, 7 of 16 (Patient # 1, 3, 5, 8, 9, 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 #1, 9: There is no order for Oxygen although CTI states patient dependent on 5LPM. Patient #3: 9/16/24 order "Okay to put foley catheter and may flush with acetic acid 0.25% prn weekly". The order does not specify size and or indications/frequency indications for change. Patient #5: According to physician certification statement narrative, patient is on Oxygen 3LPM, however there is no physician order in EMR. Patient #8: 3/8/24 Plan of Care includes problems, goals, interventions for Foley Catheter, to include Foley catheter 3/8/24: indwelling foley catheter change per protocol. There is no evidence of protocol for exact orders. Plan of Care does not include wound treatment orders which is provided by outside wound care provider. There is also no order for Oxygen in use by patient. Patient #13: 8/29/24 physician order that simply says "wound care". Staff reports there should be an attached written order, but on site review by staff confirms no attachment. Patient #14: Has oxygen 5L continuous in use per CTI, however no physician order

Upon patient record review, 6 of 16 (Patient #1, 5, 8, 10, 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 equipment and supply needs. Patient #1: There is no Plan of Care, including but not limited to orders for Oxygen concentrator and supplies for Oxygen, Foley supplies or wound care supplies in use by patient Patient #5, 8: Plan of Care does not include Oxygen concentrator and supplies for Oxygen in use by patient. Patient #10 : Plan of Care does not include indwelling catheter supplies Patient #13: Plan of Care does not include wound care supplies. Patient #14: Patient requires oxygen 5L continuous per CTI, but DME oxygen on plan of care.

Upon client record review, 4 of 16 (Patient #1, 3, 9, 15) did not have evidence that the plan of care included IDG's documentation of the patient's or families level of understanding, involvement and agreement with the plan of care. Patients 1, 3, 9, 15: There was not evidence of the patient/families level of understanding, involvement, and agreement with the plan of care.

Upon client record review, 16 of 16 (Patient #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16) did not have evidence that the IDG in collaboration with the attending physician reviewed, revised and documents the individualized plan as frequently as the patient's condition requires but no less frequently then every 15 calendar days. Patient #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16: The agency records all IDG meetings and these occur every 15 calendar days and discussions along with attendance recorded in hard copy binder. The information is not used to update and revise the patient's plan of care in EMR.

Upon patient record review 5 of 16 (Patient #2, 3, 8, 10, 15) 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: 10/27/24 Patient started Bactrim DS 800-160 mg 1 tab twice daily for infection. There was no update to problems, goals, interventions. Patient #3, 8: Problems, Goals and Interventions not updated to reflect involvement of wound care provider. Patient #10: 16fr 10 cc Foley placed 10/12/24. No updated problems, goals, interventions Patient #15: Admitted 9/8/23. There is no updated Plan of Care on file for benefit period beginning 11/7/24.

Upon client record review, 9 of 16 (Patient #1, 2, 3, 4, 5, 7, 9, 10, 15) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1, 9: There are no discipline frequency orders for any disciplines, but multi-discipline visits were made. Patient #1 had RN visits weekly without an order. Patient #2: Admitted with colostomy, but no related orders for SN to perform colostomy care. Patient #3. There were no discipline frequency orders. However, RN and aide visits were provided. 9/18/24 SN visit noted initiated a TB test during the visit. There was no order for TB test. PRN visits 9/17/24 and 9/20/24 to change foley. No order documented for Foley changes these dates Patient #4: 9/20/24 POC orders: MSW 1/wk 13/wk, PRN 5. Patient was only seen 9/23/24 by MSW. SC 1/wk 13/wk, PRN5. SC visit declined via no response to calls. Orders not updated to reflect. RN's initial assessment documents hand wound (skin tear) with treatment to Cleanse with normal saline, pat dry with gauze then leave open to air. Perform treatment once daily and as needed for 2 weeks then re-evaluate. There is no order for wound treatment performed by nurse Sept 20, 21, 26, and 10/2/24. Patient #5: 9/18/24 POC: MSW 1/mo 5 prn and SC 1/mo and 5 prn. No evidence of Oct visits for MSW or SC. Patient #7: 10/3/24 POC order MSW and SC 1/mo 3 mo however, neither visited in Oct. Patient #9 had RN visits weekly and aide visits 4-5x/week without evidence of orders. Patient #10: SC and MSW 1/mo 2/mo. No evidence of visits provided in October. Also Foley placed by nurse 10/12/24 16 fr 10 cc balloon. No specific order to replace this date. Foley changed 10/30/24 with no evidence of physician order until 10/31/24. Patient #15: Admitted 9/8/23 in 3rd benefit period 9/8-11/6/23 and passed away 11/23/23, but there was no generated POC for 11/7/24 benefit period, including but not limited to no discipline frequency orders however, SN provided visits 11/16, 11/21, 11/22, 11/23/24.

Upon patient record review 4 of 16 (Patient #1, 3, 9, 15) did not have evidence that the IDG ensures that the care and services provided are based on all assessments of the patient and family needs. Patients 1, 3, 9, 15: There is not evidence the IDG ensures the care and services provided are based on all assessments of the patient and family needs.

Upon patient record review, 2 of 16 (Patient #3, 8) did not have evidence that the IDG shares information on a on-going basis with non-hospice healthcare providers furnishing services unrelated to the terminal illness and related conditions. Upon record review, there is not evidence that the hospice coordinates care with outside wound care provider.

Upon personnel record review, 1 of 13 (Personnel #7) did not have evidence that the hospice routinely provide substantially all core services directly by hospice personnel (The hospice issues a W-2 form for the employee). These services include: • Physician services (may contract for physician services) • Nursing • Medical social services • Counseling Personnel #7: MSW is a W9 contracted employee.

Upon patient record review, 1 of 16 (Patient #2), there was not evidence in the patient record that the hospice has offered and/or provided spiritual counseling in accordance with the patient/family's desires which include: •Providing an assessment of the patient's and family's spiritual needs (individual comprehensive assessments missing the spiritual assessment is cited under L524) •Providing spiritual counseling to meet these needs in accordance with the patient's and family's acceptance of this service and in a manner consistent with their beliefs and desires •Making all reasonable efforts to facilitate visits by local clergy, pastoral counselors, or other individuals who can support the patient's spiritual needs to the best of their ability •Advising the patient and family of this service Patient #2: SC contacted POA who refused SC services, so no SC provided. However, the patient signed her own consents and is documented as alert and oriented x4. There is no evidence the patient was contacted and/or consulted regarding offering of spiritual care services. SC documented that SC, vol and bereavement were declined by POA.

Condition of Participation: Hospice Aide and Homemaker Services. L607

Upon personnel record review, 1 of 13 (Personnel #6 ) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) ·Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff. ·Reading and recording temperature, pulse, and respiration ·Safe transfer techniques and ambulation. ·Normal range of motion and positioning ·Appropriate and safe techniques in personal hygiene and grooming that include-- ·(A) Bed bath ·(B) Sponge, tub, and shower bath ·(C) Shampoo, sink, tub, and bed ·(D) Nail and skin care ·(E) Oral hygiene ·(F) Toileting and elimination The other subject areas in this section may be evaluated through written examination, oral examination or after observation of a Hospice Aide with a patient. Personnel #6: All tasks are checked off, but competency checklist is incomplete in that Completion Date is left blank. Observed in home with patient yes or no is left blank. Hospice Aide Competent to provide care is left blank. (signed by both aide and nurse 9/12/24). Also aide was assigned task to empty colostomy bag for Patient #2, but no evidence of demonstrated competency of specific task in personnel file.

Upon patient record review, 6 of 16 (Patient #2, 3, 5, 6, 9, 10) 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 #2: Initial hospice aide frequency 3x/wk, but increased 10/18/24 to 5x/wk. Aide Care Plan not updated Patient #3: Patient has Foley catheter and it is not addressed in hospice aide care plan/assignment Patient #5: Hospice Aide Care Plan 9/18/24 has assigned tasks of partial bath/shower every visit, complete shower every visit, complete bed bath once a week. complete shampoo once /wk. It is beyond hospice aide scope to choose among the tasks and there is no cognitive statement of patient's ability to choose. Patient #6: Hospice Aide Care Plan 9/16/24 tasks frequency assigned as needed for shampoo, shave, make bed. Patient #9: Hospice aide initial frequency of 5x week on admission, but was decreased to 3x/wk on 10/18/24. Hospice Aide Care Plan was not updated to reflect updated frequency. Many tasks assigned as needed: shave, housekeeping, make bed, assist with ambulation, transfer, turn position, rom and change linen 1/wk and as needed. Patient #10: Foley placed 10/12/24, but Hospice Aide Care Plan was not updated to reflect change. 10/10/24 Order to increase hospice aide frequency to 5x/wk. Hospice Aide Care Plan frequency was not updated.

Upon patient record review 4 of 16 (Patient #2, 3, 5, 9) 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 #2: Missing multiple visits that were assigned according to frequency: Oct 11, 28, 29, 30, 31, Nov 1, 4, 5, 6, 7, 8, 10 11, 2024. Patient #3: Oct 6, 14, 15 no tasks marked as completed. Multiple missed visits: Oct 9 (called off), 10 (requested day off). Staff reports patient did not want replacement, however this is not documented. Patient #5: Hospice Aide Care Plan 9/18/24 has assigned tasks of partial bath/shower every visit, complete shower every visit, completed bed bath once a week. complete shampoo once /wk. Hospice Aide performed complete bed bath Sept 25 and 27. Patient #9: Missing multiple visits Oct 14, 15, 15, 17, 20, 21, 23, 25, Nov 3, 2024.

Condition of Participation: Organization and Administration of Services.

Upon observation, there was no evidence the hospice is directed by a Board of Directors/governing body which assumes full legal authority and responsibility for the operation of the hospice. Considering the widespread evidence of non-compliance in the clinical record such as updates to the plan of care, lack of signed orders, patient/family involvement along with use of contracted employee for core service (medical social services), there is not evidence that the governing body assumes responsibility for overall compliance and effective operations of agency.

Upon contract review, 1 of 5 (West Coast Wound and Skin Care comp) 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 Patient #3: Referred to wound care specialist with subsequent visits (including debridement). No contract in place with wound care provider for specialized wound care, including visit dates 10/16, 10/30/24. Considered related to primary dx of senile degeneration of brain, as there is no documentation to the contrary. Patient #8: Referred to wound care specialist with subsequent visits including 3/6, 3/13, 3/23/24 (including debridement). No contract in place with wound care provider for specialized wound care. Considered related to primary dx of Hypertensive Heart Disease, as there is no documentation to the contrary.

Condition of Participation: Clinical Records.

Upon patient client record review, 3 of 16 (Patient # 4, 7, 10) 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: Patient requested Non-covered Items, Services, Supplies. Medication sections of addendum are blank, however identified as not covered on medication profile include: Tamsulosin HCL, Silver Nitrate Ointment, Atorvastatin. Patient #7: Patient requested Non-covered Items, Services, Supplies. Addendum includes covered diagnosis of Parkinson's only. Identified as not covered on medication profile include: Amantadine, Hydralazine, Carbidopa-Levodopa. Patient #10: Hospice Election Statement space allocated for MD choice is left blank. Patient requested Non-covered Items, Services, Supplies. The form is blank.

Upon patient client record review, 3 of 16 (Patient #1, 3, 15) did not evidence that each patient record contains physician orders. Patient #1, 3: Does not include physician orders. Patient #15 has no orders for Recertification Benefit Period beginning 11/7/24

Upon patient client record review, 1 of 16 (Patient #6) 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 #6: RN 9/13/24 initial assessment is not signed/authenticated by RN. 9/29/24 visit to decrease hospice aide visits to 3x from 5 is signed by RN, but date received space for these orders is left blank.

Upon client record review, 1 of 16 (Patient #12) did not have evidence that the hospice forwarded a summary and a copy of the patient record, if requested, to a facility when transferring the patient to that facility. Patient #12: Transferred to "another hospice" 10/26/24. There is no evidence summary sent to receiving hospice.

Upon client record review, 2 of 16 (Patient #12, 13) 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 #12: Transferred to "another hospice" 10/26/24. There is no evidence discharge summary sent to attending. Patient #13: Patient discharged to hospital 9/4/24. There is no evidence discharge summary sent to attending.

Upon client record review, 2 of 16 (Patient #12, 13) did not have evidence that the discharge summary includes all required information. Patient #12: Transferred to "another hospice" 10/26/24. There is not evidence of a discharge summary with all required information. Patient #13: Patient discharged to hospital 9/4/24. There is not evidence of a discharge summary with all required information.

Upon patient record review, 14 of 16 (Patient #2, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16 ) did not have evidence that if a drug order is verbal or given via an electronic transmission, it is given to a Registered Nurse, Nurse Practitioner, pharmacist, physician or other licensed individuals as designated by state regulations. The person receiving the order records and signs it immediately and has the prescribing person sign it in accordance with state and federal regulations. Patients# 2, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13: There is no evidence that medication orders are signed by prescribing person. Patient #6: MD order for initial assessment visits dated 9/13/24 is not signed by clinician or physician. Not clear what clinician received order. 9/20/24 order to decrease SN to 1/week is not signed by clinician or physician.

Upon observation, there was no evidence the patient has the right to voice grievances/complaints regarding treatment or care that is (or fails to be) furnished and lack of respect of property by anyone who is furnishing care/service on behalf of the hospice. Patient #4: Per communication documentation dated 5/10/23, The patient's daughter texted that her father's pain medication was adjusted by the NP. The nurse made her aware that the agency was working on a delivery 'tonight.' The daughter mentioned her frustration of lacking communication but the nurse made her aware that they had been coordinating between the Medical Director and the NP. The nurse also mentioned that the NP was able to call in the medication himself to the pharmacy and it would be delivered that night. The patient transferred to another hospice agency on 5/12/23. There was not evidence of an grievance report.

Upon patient record review, 3 of 5 (Patient #1,#3,#4) did not have evidence the plan of care 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,#3: The patient declined visits by the spiritual care counselor. The visit frequency was then documented as 5 prn. Patient #4: The visit frequency for the social worker was 5 prn.

Upon client record review, 2 of 5 records (Patient #1,#3) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1: The visit frequency for the social worker was 1x/month and on 4/12/23, it was increased to 2x/month. There was not evidence of a visit by the social worker in April. Patient #3: The visit frequency for the social worker was 1x/month. There was not evidence of a visit by the social worker in March

Upon observation, there was no evidence the program shows measurable improvement in indicators related to improved palliative outcomes and hospice services.

Upon observation, there was no evidence QAPI activities focus on high risk ,high volume, or problem prone areas.

Upon observation, there was no evidence the number and scope of distinct QAPI projects conducted annually is based on the needs of the hospice's population and internal organizational needs and must reflect the scope, complexity, and past performance of the hospice's services and operations.

Upon observation, there was no evidence the hospice documents what QAPI projects are being conducted, the reasons for conducting these projects, and the measurable progress achieved on these projects.

Upon patient record review, 1 of 5 records (Patient #5) 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. • The bereavement assessment is updated at the time of death • 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 #5: There was not evidence that bereavement services were offered.

Upon contract review, 1 of 3 contracts (Robby Ann Quintos) did not have evidence of a contract to fulfill the role of alternate medical director. The contracts for the Medical Director and the Alternate Medical Director both indicated Medical Director.

Upon observation, there was no evidence the Emergency Preparedness plan: • Was based on and included a documented, facility-based and community-based risk assessment, an all-hazards approach • Includes strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care

Upon observation, there was no evidence that the Emergency Preparedness plan included a process for cooperation and collaboration with local, tribal, regional, state, and federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation.

Upon patient record review 2 of 6 (Patient #3, #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. Patient 3: SOC was 5/18/21 there was no evidence of a comprehensive assessment by the social worker within 5 days. There was no evidence the comprehensive assessment included a psychosocial or emotional component. Patient 5: SOC was 4/8/21 there was no evidence of a comprehensive assessment by the chaplain within 5 days. There was not evidence the comprehensive assessment included a spiritual care component.

Upon patient record review, 2 of 6 (Patients #2 and #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. Patient 2: The Initial Nursing Comprehensive Assessment identified the use of Oxygen. Oxygen was not listed on the Medication Profile. Patient 5: The Initial Nursing Comprehensive Assessment identified the use of Tylenol 500mg for pain and continuous use of Oxygen. Tylenol and oxygen were not listed on the Medication Profile.

Upon patient record review, 1 of 6 (Patient #5) did not have evidence in the patient record that the comprehensive assessment included a bereavement component which included 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. Patient 5: There was no evidence of an initial bereavement assessment on record.

Upon patient record review, 2 of 6 (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: Physician wound order dated 10/19/2021 did not include who was responsible for providing the wound care. Patient 2: Physician wound order dated 11/4/2021 did not include the location of the wound and who was responsible for providing the wound care.

Upon patient record review, 3 of 3 applicable (Patient #1, #2, #3) did not have evidence that the IDG in collaboration with the attending physician reviewed, revised and documents the individualized plan as frequently as the patient's condition requires but no less frequently then every 15 calendar days. Patient 1: There was no evidence of an update by the IDG to the plan of care until 09/22/2021 (Day 21). There was no documentation to indicate the Social Worker and the Chaplain attended and had involvement. The Hospice Physician had not been involved in any of the IDG meetings. Patient 2: There was no update by the IDG to the plan of care until 09/08/2021 (Day 16). There was no documentation to indicate the Chaplain attended and had involvement. On 09/22/2021, the IDG met, and there was no documentation to indicate the RN attended and had involvement. The IDG met on 10/6/2021, 10/20/2021 and 11/03/2021 with no documentation that the Chaplain attended and had involvement. The Hospice Physician had not been involved in any of the IDG meetings. Patient 3: On 09/08/2021, the IDG met, and there was no documentation to indicate the RN attended and had involvement. The IDG met on 10/6/2021, 10/20/2021 and 11/03/2021 with no documentation that the Chaplain attended and had involvement. The Hospice Physician had not been involved in any of the IDG meetings.

Upon patient record review, 1 of 6 (Patient #2) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #2: Chaplain services were ordered 1x week. There was no evidence of Chaplain visits the weeks of 8/29/2021, 9/5/2021, 9/19/2021, 9/26/2021, 10/12/2021 and 10/17/2021. On 11/5/2021, the RN removed the foley catheter. There was no evidence of a physician order to remove the catheter.

Upon observation, there was no evidence that the board of directors/governing body approved the frequency and detail of the data collection.

Upon patient record review, 2 of 2 applicable (Patients #4 and #5) did not have evidence that the hospice offered bereavement counseling that included: • 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. • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery Patient 4: The patient expired on 4/25/2021. There was no Bereavement Support offered until a phone call was made on 7/10/2021. There has been no additional Bereavement follow-up since that call. There was no Bereavement Plan of Care in the Clinical Record. Patient 5: The patient expired on 4/20/2021. On 4/26/2021, the Social Worker conducted a Bereavement phone call and documented ..."He agreed to periodic check ins, to see how he is doing". On 7/10/2021, the Chaplain attempted to call with no answer. There has been no additional Bereavement follow-up since the call on 4/26/2021. There was no Bereavement Plan of Care in the Clinical Record.

Upon patient record review 3 of 5 applicable (Patients #2, #4 and #5) did not have documented evidence that the hospice aide provided services that were ordered by the interdisciplinary group. Patient 2: The aide care plan included document last bowel movement every visit. This task was not documented on 8/24/2021, 8/27/2021 and 9/30/2021. Patient 4: There was documentation of an aide visit on 4/23/2021. There was no Physician order for Aide Services. Patient 5: The aide care plan included nail care on every visit. There was no nail care provided on 4/13/2021.

Upon patient record review, 6 of 6 (Patients #1, #2, #3, #4, #5) did not have evidence that the medical director or physician designee provided written certification that it is anticipated that the patient's life expectancy is 6 months or less if the illness runs its normal course. Patients 1, 2, 3, 4, 5, 6: The written certification was composed and signed only by the RN. There was no documentation to indicate the Physician was involved.

Upon patient record review, 6 of 6 (Patients #1, #2, #3, #4, #5, #6) the clinical record did not contain documentation that the Agency's policies for managing controlled drugs had been discussed.