Every finding on record at Elevate Hospice LLC

Upon patient record review, 1 of 5 (Patient #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 2: The patient had Miralax 17gm powder present on the medication list once daily as needed. There was no documented evidence of instructions to add a diluent for mixing medication.

Upon client record review, 1 of 5 (Patient #4) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 4: The RN conducted a PRN visit on 8/15/25. There was no documented evidence of PRN order frequency found on the plan of care or of a new supplemental order for a PRN visit.

Upon patient record review, 2 of 14 (Patient #3,12) 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 #3, Patient has dementia, RN initial assessment documents patient is oriented x1. Patient signed her own consents. Patient is unable to understand hospice benefit. Patient has POA with no evidence of POA signing consent forms. Patient #12, Patient signed her own consent with terminal diagnosis of Alzheimer Disease. Patient is unable to understand hospice benefit.

Upon patient record review, 2 of 14 (Patient #3,12) 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 #3, Patient has dementia, RN initial assessment documents patient is oriented x1. Patient signed her own consents. Patient is unable to understand hospice benefit. Patient has POA with no evidence of POA signing consent forms. Patient #12, Patient signed her own consent with terminal diagnosis of Alzheimer Disease. Patient is unable to understand hospice benefit.

Upon patient record review, 2 of 14 (Patient #3,12) 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 #3, Patient has dementia, RN initial assessment documents patient is oriented x1. Patient signed her own consents. Patient is unable to understand hospice benefit. Patient has POA with no evidence of POA signing consent forms. Patient #12, Patient signed her own consent with terminal diagnosis of Alzheimer Disease. Patient is unable to understand hospice benefit.

Upon patient record review, 4 of 14 (Patient #3,11,12,14) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient #3, Patient has dementia, RN initial assessment documents patient is oriented x1. Patient signed her own consents. Patient is unable to understand hospice benefit. Patient has POA with no evidence of POA signing consent forms. Patient #12, Patient signed her own consent with terminal diagnosis of Alzheimer Disease. Patient is unable to understand hospice benefit. Patient #11,14, No evidence patient made a choice to pick their health care provider. This area on the consent form was left empty.

Upon patient record review, 2 of 14 (Patient #3,12) did not have evidence that the patient received information about the services covered under the hospice benefit. Patient #3, Patient has dementia, RN initial assessment documents patient is oriented x1. Patient signed her own consents. Patient is unable to understand hospice benefit. Patient has a POA with no evidence of POA signing consent forms. Patient #12, Patient signed her own consent with terminal diagnosis of Alzheimer Disease. Patient is unable to understand hospice benefit.

Upon patient record review, 2 of 14 (Patient #3,12) 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 #3, Patient has dementia, RN initial assessment documents patient is oriented x1. Patient signed her own consents. Patient is unable to understand hospice benefit. Patient has POA with no evidence of POA signing consent forms. Patient #12, Patient signed her own consent with terminal diagnosis of Alzheimer Disease. Patient is unable to understand hospice benefit.

Upon patient record review 2 of 14 (Patient #8,10) 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 #8, SC assessment completed on 11/14/24, patient was admitted on 11/8/24. Patient #10, SC assessment completed on 11/14/24 and SW assessment completed 11/22/24. Patient was admitted on 11/8/24.

Upon patient record review 1 of 14 (Patient #9) 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 #9, There is no evidence of a spiritual assessment or psychosocial assessment. SC and MSW services were declined. RN did not complete spiritual or psychosocial 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. Patient #9, Upon patient record review there was no evidence of a signature for MSW on IDG meeting note dated 6/12/25 or SC on IDG meeting note dated 6/18/25. No evidence the IDG was composed of all disciplines to meet the physical, medical, psychosocial, emotional, and spiritual needs of the patient

Upon patient record review, 10 of 14 (Patient #1,2,3,4,5,6,7,8,9,10) 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 #1-10, No evidence of initial MSW assessment documentation of funeral home and plans for funeral home arrangements noted in plan of care.

Upon patient record review, 3 of 14 (Patient #2,7,8) 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, Order reads oxygen gas/cannula 1-5 lpm. No evidence of frequency noted. Patient #7, Order reads Symbicort inhalation aerosol once daily oral. No evidence of correct direction of inhale. Oxygen was ordered 1 liter/NC, order was missing frequency. Patient #8, Order reads SN to change Foley catheter 14F, 10cc monthly and prn, may flush or irrigate prn for clogging or other problems. No evidence of flushing solution or amount to flush.

Upon patient record review, 2 of 14 (Patient #1,2) 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, Patient was admitted on 10/8/24. No evidence of IDG meeting documented until 10/31/24 which is greater than 15 days. In addition, there was no evidence of a signature for MSW or SC on IDG meeting note dated 10/31/24. The disciplines were actively involved with the patient therefore there was no evidence of collaboration since there was no signature to validate participation. Patient #2, Upon patient record review there was no evidence of a signature for MSW or SC on IDG meeting note dated 5/16/25 and 6/12/25. No evidence of MSW signature on IDG meeting note dated 5/1/25 and 5/30/25. The disciplines were actively involved with the patient therefore there was no evidence of collaboration since there was no signature to validate participation.

Upon patient record review, 7 of 14 (Patient #1,2,4,5,7,8,10) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1, SC frequency ordered 1-2x/month effective 4/1/25, patient seen every week for the month of June. No orders for SC prior to 4/1/25 with patient seen 2x/month in December, January, February, with patient seen 3x/month for March. No orders for MSW prior to 4/1/25 with patient seen 2x in October, 1x in December, February and March. Patient #2, MSW frequency order 1x/month. No evidence of MSW visit completed for the month of July 2024. SC frequency ordered 1x/month. No evidence of any visits completed as there was no documentation. Patient #4, MSW frequency 1x/month. No evidence of MSW visit completed for the month of December 2024. SC frequency 1x/month. SC completed weekly visits for the months of May and June 2025. Patient #5, SC frequency 1x/month. SC completed weekly visit month of May and twice the month of April. Patient #7, SC frequency 1x/week. No evidence of SC visit week of 6/8/25. Patient #8, MSW frequency 1x/month. No evidence of MSW visit completed in January and February. SC frequency 1x/month. Patient seen 2x/month for March and April, 3x/month for May and 4x/month for June. Patient #10, MSW frequency 1x/month. No evidence of MSW visit completed in January and February. SC frequency1x/month. Patient seen 2x/month for April and May. 4x/month for June.

Upon patient record review, 2 of 14 (Patient #1,2) did not have evidence that the IDG documents the sharing of information between all disciplines providing care and services in all settings, whether the care and services are provided directly or under arrangement. Patient #1,2, No evidence of sharing of information between all disciplines providing care and services. OT services were provided to patients without information shared at IDG meeting.

Upon observation, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient #3, Hospice aide did not place barrier between bag and counter. No evidence the aide cleaned equipment prior to placing back into work bag.

Upon patient record review, 2 of 14 (Patient #1,7) 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 #1,7, Aide care plan directs vital signs every visit. There was no evidence of parameters to report to RN.

Upon patient record review 4 of 14 (Patient #1,2,4,7) 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, Upon chart review, aide note dated 6/30/25 documents care plan direction of make bed as NA. Patient #2, Upon chart review, aide frequency 2x/week. Patient was seen 3x/week for the week of 6/10/24, 6/17/24, 6/24/24, 7/1/24. Patient #4, Upon chart review, aide frequency 1x/week, no evidence of a visit the week of 10/13/24. Patient #7, Upon chart review, aide care plan directions for vitals every visit. On 6/30/25 vitals marked NA.

Upon patient record review 2 of 14 (Patient #2,5) 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 #2, Supervisory visits completed 2/24/25 then 3/11/25. No evidence supervisory visit was completed every 14 days. Patient #5, Supervisory visits completed 5/25/25 then 6/10/25. No evidence supervisory visit was completed every 14 days.

Upon observation, there was no evidence the annual report documents the use of volunteers providing day to day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract personnel. No evidence of volunteer hours documented for 2024.

Upon patient record review, 2 of 14 (Patient #2,10) did not have evidence that before the recertification period for each patient, the medical director or physician designee must review the patient's clinical information and provide written documentation that it is anticipated that the patient's life expectancy is 6 months or less. Patient #2, No evidence of clinical information documented under physician narrative note for certification periods five and six. Patient #10, No evidence of clinical information documented under physician narrative note for second certification period.

Upon patient record review, 5 of 14 (Patient #1,3,11,12,14) 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 #1, No evidence of effective date of the election was documented on the election of benefit form. Patient #3, Patient has dementia, RN initial assessment documents patient is oriented x1. Patient signed her own consents. Patient is unable to understand hospice benefit. Patient has POA with no evidence of POA signing consent forms. Patient #11,14, No evidence patient made a choice to pick their health care provider. This area on the EOB form was left empty. Patient #12, Patient signed her own consent with terminal diagnosis of Alzheimer Disease. Patient is unable to understand hospice benefit.

Upon patient record review, 3 of 14 (Patient #1,3,7) did not have evidence that each patient record contains Advance Directives. Patient #1,3,7, RN assessment documents patient has Advanced Directive. No evidence of a copy of Advanced Directive obtained.

Upon patient record review, 1 of 14 (Patient #7) 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 #7, Upon patient record review, patient was admitted for general progressive decline. CTI states terminal diagnosis is ASHD.

Upon client record review, 1 of 14 (Patient #12) did not have evidence that the discharge summary includes all required information. Patient #12, Upon chart review. No evidence of discharged note completed.

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 #3, Patient has dementia, RN initial assessment documents patient is oriented x1. Patient signed her own consents. Patient is unable to understand hospice benefit. Patient has POA with no evidence of POA signing consent forms. Patient #12, Patient signed her own consent with terminal diagnosis of Alzheimer Disease. Patient is unable to understand hospice benefit.

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 #3, Patient has dementia, RN initial assessment documents patient is oriented x1. Patient signed her own consents. Patient is unable to understand hospice benefit. Patient has POA with no evidence of POA signing consent forms. Patient #12, Patient signed her own consent with terminal diagnosis of Alzheimer Disease. Patient is unable to understand hospice benefit.

Upon patient record review, 2 of 14 (Patient #3,12) did not have evidence that the written policies and procedures for managing controlled drugs was provided and discussed. Patient #3, Patient has dementia, RN initial assessment documents patient is oriented x1. Patient signed her own consents. Patient is unable to understand hospice benefit. Patient has POA with no evidence of POA signing consent forms. Patient #12, Patient signed her own consent with terminal diagnosis of Alzheimer Disease. Patient is unable to understand hospice benefit.

Upon patient record review, 1 of 6 (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: Patient #5. The medication profile contains Miralax 17 gm powder by mouth daily. A diluent was not listed on the medication profile.

Upon patient record review, 1 of 6 (Patient #1) 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: The patient was admitted to the hospice on 3/31/22. Review of clinical record did not have evidence of the patient's Advance Directives. The RN indicates the patient refused to discuss Advance Directives during the admission process. The clinical record lacks evidence that patient is a Full Code.

Upon patient record review, 1 of 6 (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 medications and treatments. Patient #5. The plan of care contains Miralax 17 gm powder by mouth daily. A diluent was not included.

Upon patient record review, 1 of 6 (Patient #1) did not have evidence the plan of care included all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient #1. The patient was admitted to the hospice on 3/31/22 utilizing a hospital bed, the hospital bed is not included in the plan of care.

Upon patient record review, 3 of 3 applicable (Patient #3,#4,#5) did not have evidence the hospice offers bereavement counseling that includes: • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery. Patient #3 - The patient was admitted to the hospice on 1/21/22 and died on 1/28/22. Review of clinical record did not have evidence that a bereavement plan of care was developed following the death of the patient. The record lacked evidence that indicates the frequency letters would be mailed, frequency of phone calls and/or visits, and information regarding a memorial for the deceased. The bereavement coordinator provided evidence of a sample of the sympathy card that was mailed to the bereaved. Patient #4 - The patient was admitted to the hospice on 3/30/22 and died on 4/3/22. Review of clinical record did not have evidence that a bereavement plan of care was developed following the death of the patient. The record lacked evidence that indicates the frequency letters would be mailed, frequency of phone calls and/or visits, and information regarding a memorial for the deceased. The bereavement coordinator provided evidence of a sample of the sympathy card that was mailed to the bereaved. Patient #5 - The patient was admitted to the hospice on 8/5/21 and died on 10/22/21. Review of clinical record did not have evidence that a bereavement plan of care was developed following the death of the patient. The record lacked evidence that indicates the frequency letters would be mailed, frequency of phone calls and/or visits, and information regarding a memorial for the deceased. The bereavement coordinator provided evidence of a sample of the sympathy card that was mailed to the bereaved.

Upon patient record review, 1 of 5 applicable (Patient #1) did not have evidence in the patient record that hospice aide assignments and duties are: • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the aide. Patient # 1: The patient was admitted to the hospice on 3/29/22, and is at high risk for falls, no evidence of fall risk on aide care plan. Aide plan of care indicates bathing, and does not specify the type of bathing shower, a sponge bath or a bed bath.