Every finding on record at Envision Hospice of Washington LLC

Condition of Participation: Emergency Preparedness

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. Emergency Plan only included a CMS template but unable to determine date of completion and a review that had been completed or any updates.

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

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.

Upon observation, there was no evidence of contracts/agreements with other facilities/agencies/hospices to receive patients in the event the hospice cannot provide care to their patients during an emergency.

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.

Upon observation, there was no evidence the Emergency Plan communication plan includes contact information for Federal, state, tribal, regional, or local emergency preparedness staff. Agency only had evidence of personnel listing that did not include tribal, regional, state, and federal emergency preparedness officials.

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.

Upon observation, there was no evidence the agency has conducted exercises to test the emergency plan every two years.

Upon patient record review, 2 of 19 (Patient #2,3) 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: On the home visit the caregiver stated the patient is using a medicated shampoo, ketoconazole 2% ordered on 10/15/25. This medication is not on the hospice medication profile. Corrected on site. Patient 3: There is an order for acetaminophen 325mg 2 tabs three times per day; give with tramadol, acetaminophen 325mg 2 tabs every 4 hours as needed, acetaminophen 650mg rectal suppository every 4 hours as needed. A daily limit for acetaminophen is not included in the order. In addition, on the home visit the SNF states the patient does not have Sertaline 25mg tablet daily on their medication list, this is listed on the hospice medication profile, the SNF has fleet enema prn and MiraLAX 17g as needed ordered and is not on the hospice medication profile. ALL corrected on site.

Upon patient record review, 3 of 19 (Patient #3,4,14) 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/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: In the patient record there is an order for Aspirin 81mg daily. There is not a risk for bleeding on the plan of care with goals and interventions. Corrected on site. Patient 4: On 12/29/25 there is evidence of a photo of right knee wound. There is not goals and interventions for the wound care. Corrected on site. Patient 14: In the patient record there is an order for Eliquis 5mg daily. There is not a risk for bleeding on the plan of care with goals and interventions. Corrected on site.

Upon patient record review, 7 of 19 (Patient #2,3,5,7,8,9,11) 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: There is evidence in the patient record that the patient has a foley catheter. There are no orders for the foley catheter or orders to care for the foley catheter on the plan of care. Corrected on site. Patient 3: There is an order for acetaminophen 325mg 2 tabs three times per day; give with tramadol, acetaminophen 325mg 2 tabs every 4 hours as needed, acetaminophen 650mg rectal suppository every 4 hours as needed. A daily limit on acetaminophen is not included in this order. In the patient record there is evidence that the patient as a wound for assessment and skin around it, there are no wound care orders on the plan of care. Corrected on site. Patient 5: On the recent plan of care there is MiraLAX 17g daily as needed, there is not a diluent included with this order. Corrected on site. Patient 7: On the plan of care there is an order for acetaminophen 500mg 2 tabs BID and Acetaminophen 650mg one suppository every 4-6 hours as needed. A daily limit on acetaminophen is not included in this order. Corrected on site. Patient 8: On the recent plan of care there is MiraLAX 17g daily as needed, there is not a diluent included with this order. Corrected on site. Patient 9: On the plan of care there is an order for acetaminophen 500mg 2 tabs 3 times daily and acetaminophen 650mg suppository every 4-6 hours as needed. A daily limit on acetaminophen is not included in this order. Corrected on site. Patient 11: In the patient record there is documentation " patient does not swallow any solids" and documentation of a PEG tube placed. On the plan of care the route for mediations is oral. Ensure is ordered four times daily route is oral and does not have a rate for the PEG tube, the route should be PEG tube. In addition, there are not orders to care for the PEG tube, including orders for wound care on the plan of care. Corrected on site.

Upon patient record review, 2 of 19 (Patient #4,6) 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 4: Upon a home visit the patient had a Hoyer lift, shower chair, bedside commode, hospital bed, elevated toilet seat, over the bed table in her room. These DME/supplies are not listed on the plan of care. Corrected on site. Patient 6: On 8/25/25 during a SN visit the nurse ordered a walker from DME. There is not a walker listed on the current plan of care. Corrected on site.

Upon client record review, 1 of 19 (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: On 12/29/25 the skilled nurse documented "dime sized r knee red, scrape noticed, washed with wound care spray and covered with bordered dressing". There are no orders for wound care on the plan of care. Corrected on site.

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. The total amount of volunteers providing day to day administrative and or direct patient care services equals 2.3%.

Upon patient client record review, 2 of 19 (Patient #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 8: On the SN assessment 12/30/25 there is documentation, "BT active x4" BT is not an approved abbreviation. Corrected on site. Patient 9: On the SN assessment 12/23/25 there is documentation, "No acute concerns at EOV". EOV is not an approved abbreviation. Corrected on site.

Upon patient record review, 7 of 13 (Patients #2,#4,#6,#7,#9,#11,#12) 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 2: The medication profile contained citracel oral powder with no instructions for a diluent. Corrected on site. Patient 4: The medication profile contained oxygen listed as a gastrointestinal agent/laxative, and polyethylene glycol oral powder with no instructions for a diluent. Corrected on site. Patient 6: The medication profile contained topical meds including CBD oil, Dragon salve, Dragon roll on, and methyl sallicylate with no defined areas for administration. Corrected on site. Patient 7: The medication profile contained nystatin topical powder with no defined area for administration. Corrected on site. Patient 9: The medication profile contained miralax oral powder with no instructions for a diluent. Corrected on site. Patient 11: The medication profile contained oxygen with no defined delivery method. Patient 12: The medication profile contained oxygen with no defined delivery method.

Upon patient record review, 4 of 13 (Patients #1,#4,#6,#12) 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 1: There was no evidence of an initial bereavement assessment completed taking into consideration social, spiritual, and cultural factors that may impact family ability to cope with the patient's death. Patient 4: There was no evidence of an initial bereavement assessment completed taking into consideration social, spiritual, and cultural factors that may impact family ability to cope with the patient's death. Patient 6: There was no evidence of an initial bereavement assessment completed taking into consideration social, spiritual, and cultural factors that may impact family ability to cope with the patient's death. Patient 12: There was no evidence of an initial bereavement assessment completed taking into consideration social, spiritual, and cultural factors that may impact family ability to cope with the patient's death.

Upon patient record review, 4 of 13 (Patients #3,#7,#8,#9) 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: The medical record identified patient hospice diagnosis of lung cancer. There was no evidence of problems, goals, and interventions related to respiratory dysfunction included on the plan of care. Patient 7: Upon observation during home visit, the patient had a skin lesion on scalp requiring wound care. There was no evidence of problems, goals, and interventions related to skin impairment included on the plan of care. Corrected on site. Patient 8: The plan of care contained current problems, goals, and interventions related to spiritual care with no receipt of spiritual services. Corrected on site. Patient 9: The medical record identified patient hospice diagnosis of Alzheimer's disease. There was no evidence of problems, goals, and interventions related to neurological dysfunction.

Upon patient record review, 8 of 13 (Patients #2,#4,#6,#7,#8,#9,#11,#12) 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 medical record contained an order for citracel oral powder with no instructions for a diluent. Corrected on site. Patient 4: The medical record contained an order for oxygen listed as gastrointestinal agent/laxative, and an order for polyethylene glycol oral powder with no instructions for a diluent. Corrected on site. Patient 6: The medical record contained orders for topical meds including CBD oil, Dragon salve, Dragon roll on, and methyl sallicylate with no defined areas for administration. The record also contained nursing documentation identifying patient use of a suprapubic catheter. There was no evidence of an order for catheter size, change frequency and maintenance. Corrected on site. Patient 7: The medical record contained an order for nystatin topical powder with no defined area for administration. Upon observation during home visit, the patient was seen with bandage on scalp identifying need for wound care. There was no evidence of an order for wound care. Corrected on site. Patient 8: The medical record contained nursing documentation 10/18/22 identifying patient wound care to coccyx. There was no evidence of a wound care order. Corrected on site. Patient 9: The medical record contained an order for miralax oral powder with no instructions for a diluent. Corrected on site. Patient 11: The medical record contained an order for oxygen with no defined delivery method. Patient 12: The medical record contained an order for oxygen with no defined delivery method.

Upon patient record review, 5 of 13 (Patients #2,#3,#4,#8,#12) 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 medical record contains nursing documentation 11/8/22 identifying patient use of a walker. There was no evidence of the walker included as DME on the plan of care. Patient 3: The medical record contains nursing documentation upon recertification 10/31/22 identifying patient use of a cane or walker. There was no evidence of the cane or walker included as DME on the plan of care. Patient 4: The medical record contains nursing documentation upon admission identifying patient use of nebulizer, oxygen concentrator, and wheelchair. There was no evidence of the nebulizer, oxygen, and wheelchair included as DME on the plan of care. Patient 8: The medical record contains an order for oxygen as needed. There was no evidence of an oxygen concentrator included as DME on the plan of care. Corrected on site. Patient 12: The medical record contains nursing documentation upon admission identifying use of a wheelchair and catheter supplies. There was no evidence of the wheelchair included as DME and the catheter supplies included on the plan of care.

Condition of Participation: Hospice Aide and Homemaker Services. L607

Upon personnel record review, 1 of 1 applicable (Personnel #5) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) ·Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff. ·Reading and recording temperature, pulse, and respiration ·Safe transfer techniques and ambulation. ·Normal range of motion and positioning ·Appropriate and safe techniques in personal hygiene and grooming that include-- ·(A) Bed bath ·(B) Sponge, tub, and shower bath ·(C) Shampoo, sink, tub, and bed ·(D) Nail and skin care ·(E) Oral hygiene ·(F) Toileting and elimination The other subject areas in this section may be evaluated through written examination, oral examination or after observation of a Hospice Aide with a patient. Personnel 5: There was no evidence of a competency assessment with a patient or pseudo patient.

Upon patient record review, 6 of 9 applicable (Patients #2,#5,#7,#9,#10,#12) 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 2: The aide care plan contained a task for skin care as needed. Patient 5: The aide care plan contained tasks for hair cut PRN and nail care as patient allows. Patient 7: The aide care plan contained a task to shave per patient request. Corrected on site. Patient 9: The aide care plan contained tasks for both bed bath every visit and shower if caregiver requests, nail care as needed, change linen when requested and assist dressing per caregiver request. Corrected on site. Patient 10: The aide care plan contained tasks for nail care and shaving as needed. Patient 12: The aide care plan contained all tasks stating follow primary caregiver preferences.

Upon patient record review 3 of 9 applicable (Patients #1,#5,#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 Patient 1: The medical record contained an order for aide visits once weekly. There was no evidence of a visit completed the week of 10/30/22. Patient 5: The medical record contained an order for aide visits once weekly. There was no evidence of a visit completed the week of 10/16/22. Patient 7: The medical record contained an order for aide visits once weekly. There was evidence of two visits completed the weeks of 10/9/22 and 10/16/22.

Upon personnel record review, 1 of 11 (Personnel #11) did not have evidence that the hospice employees have received orientation on their specific job requirements. Personnel 11: There was no evidence the medical director received orientation.

Upon personnel record review, 1 of 14 (Personnel #6) did not have evidence that a skills competency assessment, specific to each discipline had been conducted for all personnel including volunteers initially during orientation. Personnel 6: There was no evidence of an initial competency assessment during orientation for the social worker.

Upon patient record review, 1 of 13 (Patient #13) did not have evidence that the medical director or physician designee provides written certification that it is anticipated that the patient's life expectancy is 6 months or less if the illness runs its normal course. The physician must consider the following when making this determination: • The primary terminal condition • Related diagnosis • Current subjective and objective medical findings • Current medication and treatment orders • Information about the medical management of any of the patient's conditions unrelated to the terminal illness Patient 13: There was no evidence of a verbal certification order for the initial CTI in the medical record. Nursing documentation upon admission assessment states verbal certification was received but it is not in the medical record as an order with acknowledgement by the medical director. The written CTI was signed 7/26/22 with admission date of 6/23/22.

Upon patient record review, 1 of 13 (Patient #9) 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 9: There was no evidence of a verbal certification received for the benefit period starting 11/2/22. The written CTI was signed 11/8/22, outside timeframe allowed.

Upon patient client record review, 1 of 13 (Patient #6) 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 6: The medical record contained evidence that the election form addendum for patient notification of non-covered items was requested upon admission 9/21/22. The patient received the requested form 9/30/22, outside the allotted 5 day timeframe.

Upon patient client record review, 1 of 13 (Patient #12) did not evidence that each patient record contains physician orders. Patient 12: There was no evidence of a discharge order for patient who moved out of area and admitted to hospital with no hospice contract or agreement.