Every finding on record at Emunah Hospice LLC

Upon observation, there was no evidence the hospice complies with all applicable federal, state, and local emergency preparedness requirements by establishing and maintaining an emergency preparedness program that meets the requirements of 42 CFR 418.113. No evidence of Emergency Preparedness Program

Upon observation, there was no evidence the hospice has developed and maintained an emergency preparedness plan that must be reviewed, and updated at least every two years. No evidence of Emergency Preparedness Program

Upon observation, there was no evidence the Emergency Preparedness plan: • Is based on and includes a documented, facility-based and community-based risk assessment, utilizing 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 No evidence of Emergency Preparedness Program

Upon observation, there was no evidence the The Emergency Preparedness plan addresses patient population, including, but not limited to: • The type of services the hospice has • The ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans No evidence of Emergency Preparedness Program

Upon observation, there was no evidence the Emergency Preparedness plan includes 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. No evidence of Emergency Preparedness Program

Upon observation, there was no evidence the hospice develops and maintains an emergency preparedness communication plan that complies with federal, state, and local laws and must be reviewed and updated every two years. No evidence of Emergency Preparedness Program plan.

Upon observation, there was no evidence of emergency preparedness training and testing program that is based on the emergency plan, policies and procedures and the communication plan. No evidence of Emergency Preparedness Program

Upon personnel record review, 8 of 14 (Personnel #1,2,3,4,5,6,7,11) did not have evidence Emergency Preparedness training including: • Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles • Demonstrate staff knowledge of emergency procedures • Provide emergency preparedness training at least annually • Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others • Maintain documentation of all emergency preparedness training Personnel #1,2,3,4,5,6,7,11- No evidence of Emergency Preparedness Program training.

Upon observation, there was no evidence that the hospice that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The inpatient hospice must do the following: i. Participate in an annual full-scale exercise that is community-based; or A. When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or B. If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community-based or facility-based functional exercise following the onset of the emergency event. ii. Conduct an additional exercise that may include, but is not limited to the following: A. A second full-scale exercise that is community-based or facility-based functional exercise; or B. A mock disaster drill; or C. A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed.

Upon patient record review, 6 of 16 (Patient #1,3,4,5,8,9) 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 Medication profile errors as follows: Patient #1 4/28/25-Ketoconozole cream with no evidence of specific location to apply cream. COS Patient #3 5/20/25-Diclofenac cream and Lidocaine patch order with no evidence of where to apply cream. COS Patient #4 5/14/25 Tylenol and 2/2/24 Acetaminophen with no evidence of maximum allowable. COS Patient #5 5/28/25-Polyethylene Glycol have no evidence of instructions on how to mix powder for administration. COS Patient #8 2/3/25 Tylenol and Acetaminophen with no evidence of maximum allowable. 4/29/25-Polyethylene Glycol orders have no evidence of instructions on how to mix powder for administration. COS Patient #9 10/9/24 Tylenol with no evidence of maximum allowable. COS

Upon patient record review, 1 of 16 (Patient #5) did not have evidence in the patient record that the written plan of care is developed by the IDG, in consultation with the patient's attending physician, which specifies the services necessary to meet the patient and family-specific needs identified in the comprehensive assessment as it relates to the terminal illness and related conditions. Patient #5-No POC from SOC 5/7/25 and no evidence of collaboration with attending

Upon patient record review, 7 of 16 (Patient #3,5,6,7,8,9,12) 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 #3 No evidence of Safety Measures on plan of care. COS. Patient #5-No evidence of Initial Plan of Care Patient #6 No evidence of Bleeding precautions or Oxygen precautions on plan of care. COS Patient #7, 8, 9, 12 No evidence of Oxygen precautions on plan of care. COS

Upon patient record review, 6 of 16 (Patient #1,3,4,5,8,9) 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 4/28/25-Ketoconozole cream order with no evidence of specific location to apply cream on the plan of care. COS Patient #3 5/20/25-Diclofenac cream order and Lidocaine patch order with no evidence of where to apply cream on the plan of care. COS Patient #4 5/14/25 Tylenol orders and 2/2/24 Acetaminophen orders with no evidence of maximum allowable on the plan of care. COS Patient #5 5/28/25-Polyethylene Glycol orders have no evidence of instructions on how to mix powder for administration on the plan of care. COS Patient #8 2/3/25 Tylenol orders and Acetaminophen orders with no evidence of maximum allowable on the plan of care. 4/29/25-Polyethylene Glycol orders have no evidence of instructions on how to mix powder for administration on the plan of care. COS Patient #9 10/9/24 Tylenol orders with no evidence of maximum allowable on the plan of care. COS

Upon client record review, 1 of 16 (Patient #12) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #12 SC visit frequency is ordered 2x/month, a visit was made 5/12/25 and no evidence of a 2nd visit completed or attempted that month.

Condition of Participation: Infection Control.

Upon observation, there was no evidence the organization develops, implements, and maintains an effective, on-going, organization wide Quality Assessment and Performance Improvement (QAPI) program.

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

Upon observation, there was no evidence the hospice measures, analyzes, and tracks quality indicators, including adverse patient events and other aspects of performance that enable the hospice to assess processes of care, hospice services, and operations. No evidence of QAPI Program

Upon observation, there was no evidence the program must use quality indicator data, including patient care, and other relevant data, in the design of the program.

Upon observation, there was no evidence the QAPI program uses quality indicator data, including patient care and other relevant data in the design of its program. The hospice must use the data collected to: • Monitor the effectiveness and safety of services and quality of care • Identify opportunities and priorities for improvement No evidence of QAPI Program

Upon observation, there was no evidence the board of directors/governing body approves the frequency and detail of the data collection. No evidence of Governing Body

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

Upon observation, there was no evidence Quality Assessment and Performance Improvement activities focus on high risk, high volume or problem-prone areas by considering incidence, prevalence, and the severity of problems. No evidence of QAPI program

Upon observation, there was no evidence Quality Assessment and Performance Improvement activities focus on high risk, high volume or problem-prone areas by understanding how they affect palliative outcomes, patient safety and quality of care. No evidence of QAPI program

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 observation, there was no evidence of involvement of the governing body and organizational leaders in the Quality Assessment/Performance Improvement (QAPI) program.

Upon observation, there was no evidence the hospice's governing body is responsible for ensuring that the hospice-wide Quality Assessment and Performance Improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness. No evidence of QAPI Program, No evidence of Governing Body

Upon observation, there was no evidence the hospice ensures the implementation of a hospice wide Quality Assessment/Performance Improvement (QAPI) program by the designation of a person responsible for coordinating QAPI activities.

Upon observation, there was no evidence the hospice maintains and documents an effective infection control program that protects patients, families, visitors, and hospice personnel by preventing and controlling infections and communicable diseases. No evidence of Infection Control Program

Upon observation, there was no evidence in QAPI reports that the hospice maintains a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the hospice's Quality Assessment and Performance Improvement program. No evidence of QAPI program

Upon observation, there was no evidence in the QAPI reports that the hospice maintains a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases. No evidence of QAPI program, No evidence of Infection Control Program

Upon observation, there was no evidence the hospice provides infection control education regarding basic and high-risk infection control procedures as appropriate to the care/services provided that is consistent with OSHA and CDC recommendations. No evidence of Infection Control Program

Upon observation, there was no evidence licensed professionals participate in the hospice's QAPI program. No evidence of QAPI program

Upon observation, there was no evidence the hospice is in compliance with accepted professional standards and principles for all core services which includes nursing services, medical social services and counseling services. No evidence of counseling services for spiritual and bereavement services.

Upon observation, there was no evidence Spiritual counseling services must be available to the patient and family to assist in minimizing the stress and problems that arise from the terminal illness, related conditions and the dying process.

Upon personnel record review, 1 of 14 (Personnel #8) did not have evidence that all bereavement services are provided by a qualified counselor in accordance with applicable laws and regulations, professional practice standards, the hospice's policies and procedures and/or job descriptions which includes experience or education in grief or loss counseling. The agency does not have an individual to provide bereavement services.

Upon observation, there was no evidence the hospice is in compliance with accepted professional standards and principles for all non-core services which includes physical therapy, occupational therapy and speech-language pathology. No evidence of volunteers.

Upon patient record review 6 of 16 (Patient #5,7,8,9,10,12) 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 • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #5 5/22/25 Aide documented tasks for Ambulate patient, Trim/File Nails, Positioning and Dressing as "N/A", however the tasks are ordered to be completed at every visit. Patient #7 5/29/25,6/3/25,6/5/25,6/10/25 Aide documented tasks as "N/A" with no evidence of why the task was not completed. Aide narrative states "documentation completed in blue binder" with no evidence of documentation in patient record. Patient #8 5/29/25,6/3/25,6/5/25,6/10/25 Aide documented tasks as "N/A" with no evidence of why the task was not completed. Aide narrative states "documentation completed in blue binder" with no evidence of documentation in patient record. Patient #9 5/28/25, 6/3/25, 6/4/25, Aide documented skin care after shower completed, but noted task of shower and shampoo as "N/A". Linen task documented as "N/A", but the narrative states the linens were changed. Patient #10 5/21/25, 5/30/25, 6/6/25 Aide documented tasks as "N/A" with no evidence of why the task was not completed. Patient #12 4/22/25 no evidence of any documentation in aide visit. 5/29/25, 6/3/25, 6/5/25, 6/10/25 Aide documented tasks as "N/A" with no evidence of why the task was not completed. Aide narrative states "documentation completed in blue binder" with no evidence of documentation in patient record.

Upon patient record review 1 of 16 (Patient #11) 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 #11 5/30/25, 6/3/25 and 6/10/25 SN notes for aide supervisory visit state "Please refer to intervention documentation", no evidence of supervisory visits completed.

Upon personnel record review, 1 of 14 (Personnel #9) did not have evidence the individual who supervises volunteers is qualified by meeting the hospice's policies and procedures and/or job description criteria and is a designated hospice employee. The agency does not have a volunteer coordinator.

Upon observation, there was no evidence the hospice maintains, documents and provides volunteer orientation and training that is consistent with hospice industry standards.

Upon observation, there was no evidence volunteers are used in day to day administrative and/or direct patient care roles.

Upon observation, there was no evidence the hospice documents and demonstrates viable and ongoing efforts to recruit and retain volunteers.

Upon observation, there was no evidence the hospice documented the cost savings achieved through the use of volunteers. Documentation must include the following: • The identification of each position that is occupied by a volunteer • The work time spent by volunteers occupying those positions • Estimates of the dollar costs that the hospice would have incurred if paid employees occupied the positions identified in paragraph (d)(1) of CFR 418.78 for the amount of time specified in paragraph (d)(2) of CFR 418.78

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.

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. The agency did not have evidence of a governing body, ethics committee, QAPI or EPP program, volunteer, volunteer coordinator, counseling services-bereavement or spiritual care for patients. In addition, human resource management was not evidenced based on the lack of missing HR requirements.

Upon observation, there was no evidence the hospice is primarily engaged in providing the following care and services: • Nursing services • Medical social services • Physician services • Counseling services, including spiritual counseling, dietary counseling and bereavement counseling • Hospice aide, volunteer, homemaker services • Physical therapy, occupational therapy, speech-language pathology services • Short-term inpatient care • Medical supplies (including drugs and biologicals) and medical appliance No evidence of counseling services for spiritual and bereavement and no evidence of volunteer coordinator or volunteers.

Upon personnel record review, 2 of 14 (Personnel #2,3) did not have evidence that the hospice employees have received orientation on their specific job requirements.

Condition of Participation: Clinical Records.

Upon patient client record review, 3 of 16 (Patient #4,6,11) 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

Upon patient client record review, 1 of 16 (Patient #10) did not have evidence that each patient record contains Advance Directives.

Condition of Participation: Personnel Qualifications.

Upon personnel record review, 1 of 14 (Personnel #5) did not have evidence the hospice obtained a criminal background check on all contracted individuals who have direct patient care and access to patient records.

Upon personnel record review, 8 of 14 (Personnel #1,2,3,4,5,6,7,11) did not have evidence of criminal background checks being obtained in accordance with state requirements. In the absence of state requirements, criminal background checks are obtained within three months of the date of employment for all states that the individual has lived or worked in the past 3 years.

Upon observation, there was noo evidence the hospice has a safety management plan that addresses real or potential threats to the health and safety of the patients, others and property.

Upon observation, there was no evidence that the Hospice's inpatient facility maintains and documents an effective infection control program that protects patients, families, visitors, and hospice personnel by preventing and controlling infections and communicable diseases. No evidence of Infection Control Program

Upon observation, there was no evidence the hospice inpatient facility provides suitable linens for the care of the patient. Linens are provided in sufficient quantity for patient care and comfort. Linens are handled, stored, processed and transported in a manner that prevents the spread of infection. Shelf in Laundry room did not have a shelf liner on the bottom shelf to protect the linens. COS

Upon patient record review, 1 of 5 (Patient #2) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient which included all problems identified in the initial/comprehensive assessments. Patient #2: Patient admitted 5/17/22 S/P hospitalization for sepsis and antibiotic therapy. 5/18/22 RN note reports of frequent loose stools. RN consulted NP who ordered hold Augmentin and obtain stool culture. 5/21/22 stool culture results positive for C-Diff. Flagyl regimen initiated. Symptoms resolved with completion of Flagyl but recurrence of symptoms noted on 6/7/22 with orders obtained. The plan of care does not include problem/goals related to the C-diff infection.

Upon patient record review, 9 of 13 (Patient #1, #3, #4, #5, #7, #9, #10, #11, #13) 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 #1, #3, #4, #5, #9- The medication profile listed Miralax 17 gm powder PRN for constipation. A diluent is not listed for the reconstitution for the powder. Patient #7 - The medication profile includes Nitroglycerin Sublingual 400mcg PRN every 5 minutes for chest pain. The maximum number of dosing was not included. Patient #10 - The medication profile includes Haldol 0.5 mg oral every 6 hours as needed for nausea and vomiting. The profile also contains an order for Haldol 1 mg oral every 6 hours as needed for nausea and vomiting. There is no differentiation for the dosing. Patient #11, #13- The medication profile contains Biscodyl suppository 10 mg PRN. Indications for PRN dosing is not included.

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

Upon patient record review, 4 of 13 (Patient #2, #3, #4, #8) 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. Patient #2 - The patient was admitted on 1/25/22 with a diagnosis of Cardiovascular Disease, Atrial Fibrillation and Bronchiectasis. Patient was also admitted on Oxygen. The plan of care did not include interventions or goals for altered respiratory status, altered cardiac status or oxygen management. On 1/25/22 the nurse documented the patient had recent unobserved falls. The plan of care does not include interventions and goals for fall precautions. Patient #3 - The patient was admitted on 6/16/21 with diagnosis of malignant neoplasm of right lung. There are no goals or interventions on the plan of care related to altered respiratory status. Patient #4 - The patient was admitted on 2/23/22 with diagnosis of Diastolic Heart Failure and is on Oxygen. The plan of care does not include goals and interventions for altered cardiac status and Oxygen management. Patient #8 - The patient was admitted on 1/8/20 with a primary diagnosis of Combined Diastolic/Systolic CHF. The plan of care does not include cardiac goals or interventions.

Upon patient record review, 1 of 13 (Patient #2) 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 #2- Plan of care 1/25/22 includes a nursing frequency of 3-4 x month and 12 PRNs. The frequency is unclear of when the actual nursing visits would occur. 12 prn visits does not demonstrate a proactive approach in developing the plan of care.

Upon patient record review, 9 of 13 (Patient #1, #,3, #4, #5, #7, #9,#10, #11, #13) 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 specific and/or accurate orders for medications and treatments. Patient #1, #3, #4, #5, #9 - The plan of care listed Miralax 17 gm. powder PRN for constipation. A diluent is not listed for the reconstitution for the powder. Patient #7 - The 4/4/22 plan of care includes Nitroglycerin Sublingual 400mcg PRN every 5 minutes for chest pain. The maximum number of dosing was not included. Patient #10 - The 3/24/22 plan of care includes Haldol 0.5 mg oral every 6 hours as needed for nausea and vomiting. The profile also contains an order for Haldol 1 mg oral every 6 hours as needed for nausea and vomiting. There is no differentiation for the dosing. The plan of care order includes urinary catheter has been placed. The order is an error as the patient does not have a urinary catheter. Patient #11- The 2/24/22 plan of care contains Bisacodyl suppository 10 mg PRN. Indications for PRN dosing is not included. On 4/18/22 an interim order was written to update the plan of care to document the size, color and location of the decubiti every week. Specific management and location of wound is not included in the order. Patient #13- The 3/30/22 plan of care contains Bisacodyl suppository 10 mg PRN. Indications for PRN dosing is not included.

Upon patient record review, 2 of 13 (Patient #2, #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 equipment and supply needs. Patient #2 - The patient was admitted 1/25/22 with Oxygen and the nurse documented on admission that patient had a wheelchair. On 2/10/22 the nurse documented the patient has a walker. The plan of care does not include Oxygen, wheel chair or walker. Patient #4 - The patient was admitted 2/23/22 on Oxygen and the plan of care does not include Oxygen under the equipment section.

Upon patient record review, 1 of 13 (Patient #10) 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 #10 - The IDG dated 2/23, 3/2, 3/17, 3/24 and 3/31/22 only documented the patient's age and diagnosis. The IDG/Plan of care update does not document progress towards goals.

Upon patient record review, 1 of 1 applicable (Patient #3) 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 bereavement plan of care developed 6/18/21 only includes bereavement goals. The plan of care does not include the kind of bereavement services to be offered and the frequency of service delivery.

Upon patient record review, 1 of 10 applicable (Patient #2) did not have evidence in the patient record that hospice aide assignments and duties are: • Complete written patient care instructions for a hospice aide prepared by a Registered Nurse who is responsible for the supervision of a hospice aide. Patient #2- The patient was admitted on Oxygen and was at risk for falls. The aide plan of care des not include fall precautions or Oxygen precautions.

Upon patient record review, 3 of 10 applicable (Patient #2, #4, #5) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group and included in the plan of care Patient #2- The aide was assigned to perform a bed bath every visit and to report last bowel movement every visit. The aide documented on 2/1/22, 2/17/22, and 2/22/22 that a bed bath was not performed. The aide did not document the last bowel movement on 2/17/22, 2/22/22, 3/2/22, and 3/10/22. Patient #4 - The aide was assigned to perform a shower, oral care, hair care, nail and skin care every visit. Each of the tasks were documented not performed on 2/24/22, 2/25/22 and 3/3/22. Patient #5 - The aide is ordered to visit the patient 2 x week. The week of 4/10/22 - 4/16/22, one aide visit was performed on 4/15/22. There is no documentation regarding a missed visit.

Upon patient record review, 13 of 13 (Patient #1, #2, #3, #4, #5, # 6, #7, #8, #9, #10, #11, #12, #13, did not have evidence that all entries are clear, complete and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Patient #1, #2, #3, #4, #5, # 6, #7, #8, #9, #10, #11, #12, #13 - Each of the records contained visit notes that do not include the employee's credentials in the electronic signature. Patient #2 - The spiritual counselor documented on 2/22/22 that the patient was "seeking spiritual cnxn in a church setting". Cnxn is unclear and is not an approved abbreviation. Patient #7, #9, #10, #11- Each patient had paper visit notes for music therapy which were unsigned. Patient #7 - On 4/4/22 the nurse documents the patient has a progressive stage III-IV sacral wound. The chart does not contain measurements or a complete description of the wound, the form is incomplete.

Upon client record review, 1 of 1 applicable (Patient #2) 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 #2 - The patient transferred to another hospice on 3/14/22 and a transfer summary is not in the record.

Upon client record review, 2 of 2 applicable (Patient #1, #4) did not have evidence that the discharge summary includes all required information Patient #1 - The patient discharged on 2/2/22 due to being no longer appropriate for hospice. A discharge summary is not on record. Patient #4- The patient revoked the election on 3/4/22. There is no discharge summary on the record.

Upon observation, there was no evidence the building service equipment of a facility is provided consistent with the 2012 editions of the LSC of the National Fire Protection Association and NFPA 99. The electrical room in the Hospice Home had an electrical panel with a large ladder blocking it. (Corrected on site). Upon observation, there was no evidence all sprinkler system components of a facility are consistent with the 2012 editions of the LSC of the National Fire Protection Association and NFPA 99. It was observed the hospice inpatient unit had a loosely hanging escutcheon plate around the sprinkler head in the conference room.

Upon patient record review, 1 of 4 applicable (Patient #7) did not have evidence that the hospice plan of care identifies the care and services that are needed and specifically identify which provider (nursing facility or hospice) is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care. Patient #7 - The patient resides in a skilled nursing facility. The 4/4/22 plan of care includes wound orders to a right heel 3 x week and daily wound care orders to the bilateral lower extremities. The orders do not specify whether the hospice nurse and/or the facility nurse is responsible for the wound care.