Every finding on record at Encore Hospice LLC

Upon patient record review, 1 of 14 (Patient #8) 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. The SOC was 5/10/23. The Bereavement assessment was completed late on 7/10/23.

Upon patient record review, 5 of 14 (Patients #1, 2, 3, 4 and 6) 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 walker and shower chair. These were not included on the Plan of Care. Patient #2, 3, 4 and 6: The record reflected that this patient had oxygen order. The oxygen concentrator was not included on the plan of care.

Upon client record review, 1 of 14 (Patient #1) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. The POC listed MSW visit frequency of 1 X per month (4/27/23/23). For the month of June there were no visits made by MSW.

Upon patient record review 4 of 14 (Patients #1, 4, 7 and 8) 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 (4/27/23). For Benefit Week 5/1/23 there was only 1 visit on 5/5/23. For Benefit weeks 5/15/23 and 7/10/23 the Aide visited 3xs on 5/15, 5/18, 5/21, 7/10, 7/13 and 7/16. Patient #4: The POC listed Aide visit frequency of 2 X's per week (6/19/23). For Benefit Week 6/19/23 there was only 1 visit on 6/22/23. Patient #7: The POC listed Aide visit frequency of 3 X's per week (6/5/23). For Benefit Week 6/5/23 there was only 2 visits on 6/8 and 6/11. Patient #8: The POC listed Aide visit frequency of 2 X's per week (5/10/23). For first Benefit Week there were no visits made.

Upon observation, there was no evidence the hospice is primarily engaged in providing the following care and services: - speech-language pathology services During survey fully executed contract obtained to include this service. No patient need or orders for this service to date. Corrected on site.

Upon contract review, 1 of 4 (Alternate Medical Director) did not have evidence within the contract to fulfill the role of medical director when the medical director is unavailable. Addendum to include the above was obtained during survey (Corrected on Site).

Upon inpatient contract review, 1 of 4 (Center for Arrowhead GIP/Respite contract) did not have evidence that the hospice supplies the inpatient provider with a copy of the patient's plan of care and specifies the inpatient services to be furnished. Addendum to include the above was obtained during survey and fully executed (Corrected on Site).

Upon inpatient contract review, 1 of 4 (Center for Arrowhead GIP/Respite contract) did not have evidence that the inpatient provider has established patient care policies consistent with those of the hospice and agrees to abide by the palliative care protocols and plan of care established by the hospice for its patients. Addendum to include the above was obtained during survey (Corrected on Site).

Upon inpatient contract review, 1 of 4 (Center for Arrowhead GIP/Respite contract) did not have evidence that the hospice patient's inpatient clinical record includes a record of all inpatient services furnished and events regarding care that occurred at the facility; that a copy of the discharge summary be provided to the hospice at the time of discharge; and that a copy of the inpatient clinical record is available to the hospice at the time of discharge. Addendum to include the above was obtained during survey (Corrected on Site).

Upon inpatient contract review, 1 of 4 (Center for Arrowhead GIP/Respite contract) did not have evidence that the inpatient facility has identified an individual within the facility who is responsible for the implementation of the provisions of the agreement. Addendum to include the above was obtained during survey (Corrected on Site).

Upon inpatient contract review, 1 of 4 (Center for Arrowhead GIP/Respite contract) did not have evidence that the hospice retains responsibility for ensuring that the training of personnel who will be providing the patient's care in the inpatient facility has been provided and that a description of the training and the names of those giving the training are documented. Addendum to include the above was obtained during survey (Corrected on Site).

Upon inpatient contract review, 1 of 4 (Center for Arrowhead GIP/Respite contract) did not have evidence of a method for verifying that the requirements for ACHC standard HSP1-8B and CFR 418.108c (1)-418.108c(5)are met. Addendum to include the above was obtained during survey (Corrected on Site).

Upon SNF/NF contract review, 1 of 4 (Center for Arrowhead Routine contract) did not have evidence of the manner in which the SNF/NF and the hospice are to communicate with each other and how each will document such communications to ensure that the needs of patients are addressed and met 24 hours a day (Corrected on Site).

Upon SNF/NF contract review, 1 of 4 (Center for Arrowhead Routine contract) did not have evidence that specifies the provision of hospice services in the facility, including: A provision that the SNF/NF or ICF/IID immediately notifies the hospice if: • A significant change in a patient's physical, mental, social or emotional status occurs • Clinical complications appear that suggest a need to alter the plan of care • When a need to transfer a patient from the SNF/NF or ICF/MR arises, and the hospice makes arrangements for, and remains responsible for, any necessary continuous care or inpatient care necessary related to the terminal illness and related conditions • A patient dies (Corrected on Site)

Upon SNF/NF contract review, 1 of 4 (Center for Arrowhead Routine contract) did not have evidence of a provision stating that the hospice assumes responsibility for determining the appropriate course of hospice care, including the determination to change the level of services provided (Corrected on Site).

Upon SNF/NF contract review, 1 of 1 (Center for Arrowhead Routine contract) did not have evidence that it is the SNF/NF's responsibility to continue to furnish 24 hour room and board care, meeting the personal care and nursing needs at the same level of care that would have been provided by the family at the facility before hospice care was elected (Corrected on Site).

Upon SNF/NF contract review, 1 of 4 (Center for Arrowhead Routine contract) did not have evidence that it is the hospice's responsibility to provide services at the same level and to the same extent as those services would be provided if the SNF/NF resident were in his or her own home. Addendum to include the above was obtained during survey (Corrected on Site).

Upon SNF/NF contract review, 1 of 4 (Center for Arrowhead Routine contract) did not have a delineation of the hospice's responsibilities, which include, but are not limited to the following: providing medical direction and management of the patient; nursing; counseling (including spiritual, dietary and bereavement); social work; provision of medical supplies, durable medical equipment and drugs necessary for the palliation of pain and symptoms associated with the terminal illness and related conditions; and all other hospice services that are necessary for the care of the resident's terminal illness and related conditions (Corrected on Site).

Upon SNF/NF contract review, 1 of 4 (Center for Arrowhead Routine contract) did not have a provision that the hospice may use the SNF/NF nursing personnel where permitted by state law and as specified by the SNF/NF to assist in the administration of prescribed therapies included in the plan of care only to the extent that the hospice would routinely use the services of a hospice patient's family in implementing the plan of care. Addendum to include the above was obtained during survey (Corrected on Site).

Upon SNF/NF contract review, 1 of 4 (Center for Arrowhead Routine 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. Addendum to include the above was obtained during survey (Corrected on Site).

Upon SNF/NF contract review, 1 of 4 (Center for Arrowhead Routine contract) did not have a delineation of the responsibilities of the hospice and the SNF/NF to provide bereavement services to SNF/NF personnel (Corrected on Site).

Upon personnel record review, 1 of 11 (Personnel #5) did not have evidence that all Speech Therapy Services are provided by a qualified licensed Speech-Language Pathologist (SLP) or Audiologist in accordance with the state's Speech-Language Pathology Practice Act and the hospice's policies and procedures and/or job descriptions. Currently there is a contract in place. There is no personnel file for this individual to date.

Upon personnel record review, 1of 11 (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. Currently there is a contract in place. There is no personnel file for this individual to date.