Every finding on record at Ensure Hospice Inc

Condition of Participation: Patient’s Rights. L500

Upon patient record review, 3 of 14 (Patient #7,9,10) 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 #7: Patient has admitting diagnosis of Alzheimer's disease. This patient signed all of her own consents. Patient #9: The comprehensive assessment states patient is alert and oriented to person only, and patient signed their own paperwork. Patient #10: The comprehensive assessment states patient is alert and oriented to person only, and patient signed their own paperwork.

Upon patient record review, 3 of 14 (Patient #7,9,10) 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 #7: Patient has admitting diagnosis of Alzheimer's disease. This patient signed all of her own consents. Patient #9: The comprehensive assessment states patient is alert and oriented to person only, and patient signed their own paperwork. Patient #10: The comprehensive assessment states patient is alert and oriented to person only, and patient signed their own paperwork.

Upon patient record review, 3 of 14 (Patient #7,9,10) 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 #7: Patient has admitting diagnosis of Alzheimer's disease. This patient signed all of her own consents. Patient #9: The comprehensive assessment states patient is alert and oriented to person only, and patient signed their own paperwork. Patient #10: The comprehensive assessment states patient is alert and oriented to person only, and patient signed their own paperwork.

Upon patient record review, 3 of 14 (Patient #7,9,10) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient #7: Patient has admitting diagnosis of Alzheimer's disease. This patient signed all of her own consents. Patient #9: The comprehensive assessment states patient is alert and oriented to person only, and patient signed their own paperwork. Patient #10: The comprehensive assessment states patient is alert and oriented to person only, and patient signed their own paperwork.

Upon patient record review, 3 of 14 (Patient #7,9,10) did not have evidence of the appropriate documentation for release of confidential information. Patient #7: Patient has admitting diagnosis of Alzheimer's disease. This patient signed all of her own consents. Patient #9: The comprehensive assessment states patient is alert and oriented to person only, and patient signed their own paperwork. Patient #10: The comprehensive assessment states patient is alert and oriented to person only, and patient signed their own paperwork.

Upon patient record review, 3 of 14 (Patient #7,9,10) did not have evidence that the patient received information about the services covered under the hospice benefit. Patient #7: Patient has admitting diagnosis of Alzheimer's disease. This patient signed all of her own consents. Patient #9: The comprehensive assessment states patient is alert and oriented to person only, and patient signed their own paperwork. Patient #10: The comprehensive assessment states patient is alert and oriented to person only, and patient signed their own paperwork.

Upon patient record review, 3 of 14 (Patient #7,9,10) 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 #7: Patient has admitting diagnosis of Alzheimer's disease. This patient signed all of her own consents. Patient #9: The comprehensive assessment states patient is alert and oriented to person only, and patient signed their own paperwork. Patient #10: The comprehensive assessment states patient is alert and oriented to person only, and patient signed their own paperwork.

Upon patient record review, 3 of 14 (Patient #2,5,9) did not have evidence 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: Oxygen was ordered and not on the medication list. Patient #5 and #9: Oxygen was on POC but not on medication list.

Upon patient record review, 3 of 14 (Patients #4,5,9) 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 #4,5,9: The record did not have evidence of an initial bereavement assessment.

Upon patient record review, 3 of 14 (Patients #2,3,10) 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 #2: The POC does not list Respiratory despite this being the patient's primary diagnosis Patient #3: In the initial POC, there is no problem listed for respiratory despite COPD being the primary diagnosis. Under the POC for Impaired mobility, interventions include teaching the family to reposition patient every 2 hours, despite this patient being ambulatory and up as tolerated. Under the POC for Skin breakdown, the interventions include teaching family to "change wet diapers" despite the fact that the patient is continent. Patient #10: On the patient's POC, it lists interventions under impaired mobility that include using side rails, trapeze and Hoyer, though patient does not have these in the home. In addition,The record had documentation in the RN comprehensive assessment under bereavement that there were concerns for disenfranchised grief, and a referral was to be made for early bereavement interventions per the Bereavement Counselor. The plan of care did not include interventions/goals to address this need.

Upon patient record review, 1 of 14 (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: Oxygen is ordered and is not present in POC.

Upon patient record review, 2 of 14 (Patients #3,10) 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 #3 and #10: Patient has been provided with a cane per the DME list, but it is not included in the POC.

Upon patient record review, 2 of 14 (Patients #6,7) 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 #6: The patient had documented IDG on 07/21/24 and then no further IDG was documented until 08/24/24 Patient #7: The record shows no IDG has been done since 03/06/24. This remains an active patient.

Upon patient record review, 1 of 14 (Patient #9) 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 #9: In the current hospice IDG POC, self care deficit lists interventions to provide certified home health aide. Patient is no longer receiving aide, since 05/2024.

Upon client record review, 1 of 14 (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: SC initial assessment on 05/04/24 was present but there was no content in the note, and it was not signed or dated. There was a SC visit completed on 07/31/24 that had no content in the note and was not signed and dated therefore, there was no evidence visit made and POC followed.

Upon patient record review 2 of 14 (Patient #2,10) 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. Patient #2: The comprehensive nursing assessment states that patient needs assist with personal care, however, aide services were not provided. Patient #10: The record had documentation in the RN comprehensive assessment under bereavement that there were concerns for disenfranchised grief, and a referral was to be made for early bereavement interventions per the Bereavement Counselor. This was not acknowledged by the Bereavement Counselor.

Upon patient record review 1 of 14 (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: The current hospice POC under self care deficit lists the intervention to provide certified home health aide. No aide has been provided.

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. There was no evidence the Board of Directors/governing body had oversight to ensure patients were capable of making informed decision when signing consents, Medical Director or designee was available for patients/agency needs, and that patients are provided with equipment/supplies needed.

Upon observation, there was no evidence the hospice designates a physician to serve as Medical Director which includes: • The Medical Director must be a doctor of medicine or osteopathy who is an employee or is under contract. • When the Medical Director is not available, a physician designated by the hospice assumes the same responsibilities and obligations as the Medical Director. During survey, the medical director was unavailable to speak with surveyors and there was not evidence that a physician designated by the hospice can assume the same responsibilities and obligations as alternate was on vacation and both were not able to speak with this surveyor or available for patient/agency needs.

Condition of Participation: Clinical Records.

Upon patient patient record review, 3 of 14 (Patient #7, 9, 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 #7: Patient has admitting diagnosis of Alzheimer's disease. This patient signed all of her own consents. Patient #9: The comprehensive assessment states patient is alert and oriented to person only, yet patient signed their own EOB. Patient #10: The comprehensive assessment states patient is alert and oriented to person only, yet patient signed their own EOB.

Upon patient client record review, 6 of 14 (Patients #3,5,6,7,8,9) 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 #3: IDG meting note on 06/12/24 does not contain all participant signature/dates to complete the note. Patient #5: The Initial nursing assessment questions whether "the patient has a prn opiate initiated or continued" and the nurse responded yes. There was no record of opiate medication being started or discontinued on medication list. RN visits on the following dates were not signed and dated: 05/24/24, 06/08/24, 06/22/24, 07/06/24, 07/20/24. Patient #6: There were RN assessment visits documented for 05/24/24, 06/08/24, 06/22/24, 07/06/24, and 07/20/24 though they were not authenticated with signature and date completed. Patient #7: The SC initial assessment was present but not signed or dated. The following IDG notes do not contain all signatures required to complete the note: 06/10/24, 08/07/24, 08/21/24, 09/04/24. Patient #8: The SC initial assessment was present but not signed or dated. On comprehensive nursing assessment, it is documented that the patient had a "prn and scheduled opiate initiated or continued". There is no record of any opiate medication being started or discontinued. IDG team notes from the following dates, do not contain all signature/date required to complete note: 04/03/24, 04/17/24, 05/01/24, 05/15/24, 05/29/24, 06/12/24, 06/26/24, 07/10/24, 07/24/24, 08/07/24, 08/21/24, 09/04/24. Patient #9: The nursing assessment states patient has "initiated or continued scheduled and PRN opiates". There is no record of any opiate medication being started or discontinued. Initial SC evaluation is not signed or dated. The Comprehensive nursing assessment from 03/02/24 is not signed or dated. The aide visit from 04/06/24 is not signed or dated. The SC has 2 visits that are labeled as telehealth, but the notes themselves are empty and they do not have a signature or date.

Upon patient record review, 2 of 14 (Patients #11,12) did not have evidence that the discharge summary includes all required information. Patient #11: Discharge summary is missing Plan of Care and latest physician orders. Patient #12: Discharge summary is missing Plan of Care and latest physician orders.

Upon patient record review, 3 of 14 (Patients #1,4,7) did not have evidence that medical supplies, appliances, durable medical equipment, drugs and biologicals related to the palliation and management of the terminal illness and related conditions used in the management of the patient's end of life care needs are provided based on a needs assessment and are included in the plan of care. Patient #1: RN comprehensive assessment identified need for hospital bed, which was not ordered Patient #4: RN comprehensive assessment identified the need for hospital bed, W/C, pressure relieving device, suction, oxygen and bedside commode. The only DME ordered was a cane. Patient #7: RN comprehensive assessment identified the need for hospital bed, W/C, pressure relieving device, suction, oxygen and bedside commode, shower bench, and toilet aides. These items were not ordered for patient.

Upon personnel record review, 1 of 11 (Personnel 7) did not have evidence that all Medical Social Services are provided by a qualified Medical Social Worker in accordance with the state's Social Work Practice Act, the hospice's policies and procedures and/or job descriptions. Personnel #7: Job position requirement is for minimum bachelor degree in psychology. She does not have formal education in social work. She has a masters degree in forensic psychology. However, the hospice has not arranged for her to be supervised by an MSW. The hospice must employ or contract with at least one MSW to serve as an active advisor, consulting on assessing the needs of patients and families, developing and updating the social work portion of the POC, and delivering care to patients and families.

Upon patient record review, 1 of 5 (Patient #1) 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 Medical record contained information that the patient required oxygen. Medication list did not include Oxygen.

Upon patient client record review, 5 of 5 (Patient #1, #2, #3, #4, and #5) did not have evidence that each patient record contains: • Signed election statement in accordance with 418.24 Patient #1, #2, #3, #4, #5: Did not have required elements for hospice elections beginning on or after October 1, 2020 the hospice must provide: • Information on individual cost-sharing for hospice services; • Notification of the individual's (or representative's) right to receive an election statement addendum if there are conditions, items, services, and drugs the hospice has determined to be unrelated to the individual's terminal illness and related conditions and would not be covered by the hospice; • Information on the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO), including the right to immediate advocacy and BFCC-QIO contact information.

Upon patient client record review, 2 of 5 (Patient #3, #5) 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 #3 The agency medication teaching sheets for responses to medications, symptom management, treatments, and services did not include the following meds: Caridopa/Levodopa, Olmesartan/Hydrochlotothiazide, Pravastatin and Sulindac. Patient #5 The agency medication teaching sheets for responses to medications, symptom management, treatments, and services did not include the following meds: Anoro Ellipta (inhaler), Meclizine and Voltaren Gel.