Every finding on record at Empress Hospice Inc.

Upon observation, there was no evidence the Emergency Plan communication plan must includes a primary and alternate means for communicating with hospice's employees and Federal, state, tribal, regional, and local emergency management agencies. The agency had primary contact (telephone) only. During survey an alternate method (email) was added. Corrected on Site.

Upon patient record review, 1 of 14 (Patient #2) 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 #2: The medication reconciliation with hospice and board and care did not match. The medication Tussin was included on hospice medication profile and not at the Board and Care. Hospice obtained a discontinue order from the physician during survey. Corrected on site.

Upon patient record review, 1 of 14 (Patient #11) 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 #11: Initial Bereavement Risk Assessment was not completed from SOC to current survey date.

Upon patient record review, 3 of 14 (Patients #1,2,3) 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: This patient had a bedside table and wheel chair. These were not included on the Plan of Care. Corrected on Site. Patient #2: This patient had a rollator walker. This was not included on the Plan of Care. Corrected on Site. Patient #3: This patient had a hospital bed with rails and low air loss mattress. These were not included on the Plan of Care. Corrected on Site.

Upon client record review, 1 of 14 (Patient #9) 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 POC listed Volunteer visit frequency of, 2 X's per week (3/2/25). There were no visits provided by the Volunteer for two benefit weeks, they were: 3/2/25 to 3/8/25 and 3/9/25 to 3/15/25. Evidence of the first Volunteer visit was performed on 3/17/25.

Upon patient record review 5 of 14 (Patients #1,3,6,9,10) 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 Patient #1: The POC listed Aide visit frequency of, 2 X's per week (1/20/24). There were no visits provided by the Aide during first Benefit Week. Patient #3: The POC listed Aide visit frequency of, 2 X's per week (10/25/24). There were no visits provided by the Aide during first Benefit Week. Patient #6: The POC listed Aide visit frequency of, 2 X's per week (6/13/24). There was 1 visit provided by the Aide during first Benefit Week on 6/14/24. Patient #9: The POC listed Aide visit frequency of, 2 X's per week (2/20/25). There were no visits provided by the Aide during first Benefit Week. Patient #10: The POC listed Aide visit frequency of, 2 X's per week (1/24/25). There were no visits provided by the Aide during first Benefit Week.

Upon patient client record review, 14 of 14 (Patients #1,2,3,4,5,6,7,8,9,10,11,12,13,14) did not have evidence that each patient record contains: • Signed election statement in accordance with 418.24 Patients #1,2,3,4,5,6,7,8,9,10,11,12,14: Did not have SOC date filled in space provided on election statement in admission document. However, the NOE did have SOC date. Patients #1,2,3,4,5,6,7,8,9,10,11,12,13,14: Did not have BFCC-QIO contact information included on the form.

Upon client record review, 1 of 14 (Patient #11) did not have evidence that the discharge summary includes all required information. Patient #11: Did not include the following required items: • The patient's current plan of care • The patient's latest physician orders

Upon SNF/NF contract review, 1 of 5 (Canyon Oaks contract) did not have a provision stating that the hospice reports all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by anyone unrelated to the hospice to the SNF/NF administrator within 24 hours of the hospice becoming aware of the alleged violation. Agency obtained addendum on 4/10/25. Corrected on Site.

Upon client record review, 1 of 11 (Patient #1) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1: During the visit conducted on 2/3/2022, the Nurse conducted wound care. There was no Physician order for that care.