Every finding on record at Eternity Care Services Inc

Upon patient record review, 1 of 11 (Patient #11) 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 #11: There was evidence in the medical record the patient had a POLST indicating DNR. The physician wrote an order "full code". This was corrected on site with a physician order for DNR.

Condition of Participation: Patient’s Rights. L500

Upon patient record review, 7 of 7 (Patient #1, 2, 6, 7) 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. Patients #1, 2, 6, 7: Admission Consents not available to surveyor upon start of survey.

Upon patient record review, 4 of 7 (Patient #1, 2, 6, 7) 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. Patients #1, 2, 6, 7: Admission consent forms were not available in EMR and/or hard copy upon start of survey.

Upon patient record review, 4 of 7 (Patient #1, 2, 6, 7) 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. Patients #1, 2, 6, 7: Admission consent forms were not available in EMR and/or hard copy upon start of survey.

Upon patient record review, 6 of 7 (Patient #1, 2, 3, 4, 5, 6, 7) did not have evidence that the patient chooses a health care provider, including an attending physician. Patients #1, 2, 6, 7: Admission consent forms were not available in EMR and/or hard copy by midday Day 1 of survey. Patient #4: Election statement options (My choice of attending physician is and I do not wish to choose) are both left blank. Patient #5: No election statement included in documents provided (with patients choice to choose or not choose physician).

Upon patient record review, 4 of 7 (Patient #1, 2, 6, 7) did not have evidence of the appropriate documentation for release of confidential information. Patients #1, 2, 6, 7: Admission consent forms were not available in EMR and/or hard copy upon start of survey.

Upon patient record review, 4 of 7 (Patient #1, 2, 6, 7) did not have evidence that the patient received information about the services covered under the hospice benefit. Patients #1, 2, 6, 7: Admission consent forms were not available in EMR and/or hard copy upon start of survey.

Upon patient record review, 4 of 7 (Patient #1, 2, 6, 7) 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. Patients #1, 2, 6, 7: Admission consent forms were not available in EMR and/or hard copy upon start of survey.

Upon patient record review 1 of 7 (Patient #4) did not have evidence that the hospice Registered Nurse must complete an initial assessment within 48 hours after the election of hospice care in accordance with §418.24 Patient #4: There is no election statement to clearly determine date of election. The assessment is consistent with signature dates.

Upon patient record review 1 of 7 (Patient #6) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient #6: Psychosocial assessment not completed within 5 days by MSW and not completed by RN.

Upon patient record review, 2 of 7 (Patient #3, 4) 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 #3: Bereavement assessment by SC is incomplete with comment that patient has no family. However, there are numerous comments in EMR documenting that the patient signed consents with family around him. Patient #4: No documented initial bereavement assessment.

Upon observation, there was no evidence the hospice has an interdisciplinary group (IDG) or groups composed of individuals who work together to meet the physical, medical, psychosocial, emotional, and spiritual needs of the hospice patients and families facing terminal illness and bereavement. Interdisciplinary group members must provide the care and services offered by the hospice, and the group, in its entirety, must supervise the care and services. Patient #3: Three IDG meetings (1/24, 2/7, 2/21/25) with no evidence of MSW signature to verify participation.

Upon patient record review, 1 of 7 (Patient #2) 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: There are problems for weakness and musculoskeletal, but personal care needs are not addressed in interventions and no reference to assistance needed and to be provided by the time service initiated and aide services were being provided.

Upon client record review, 3 of 7 (Patient #5,6,7) 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 #5: 11/29/24 IDG has no RN note or signature and 12/13/24 no evidence of SC signature to verify participation or revised and updated individualized POC. Patient #6: Adm 12/13-12/20. 12/27/24 IDG Meeting (only IDG) narrative entries for RN, MSW, SC imply all disciplines made visits. There are no signatures for any disciplines for this IDG meeting. There are no notes in EMR for MSW, SC to support that service was provided as noted in IDG. (The only visit note in record is 12/19 for RN) Patient #7: Adm 11/26-12/20/24. 11/29/24 IDG: meeting narrative entries for RN, MSW, SC imply all disciplines made visits. There are no signatures for any disciplines for 11/29/24 IDG. There are no notes to support that MSW and SC services were actually provided. Meeting dates 12/7 and 12/14/24 had no signatures for any disciplines.

Upon client record review, 4 of 7 (Patient #3, 4, 5, 6) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #3: SN ordered frequency is documented as 1 every recert and 2 prn. RN visits made 1/24/25, 31, 2/6, 13, 20, 27 (weekly). Patient #4: SN order for 1/wk and 3 prn is only documented discipline order. No orders for MSW. However, MSW made visit 11/9/24 documented as routine monthly visit, when it was her first visit to assess new admission, 12/12/24 MSW note incomplete. Patient #5: MSW frequency 1/week and 1 prn throughout admission. SW visits only made monthly (11/9 was initial assessment documented in assessment). 12/12/24, 1/9/25. SC saw patient 2/3/25, but visit frequency was "SC 0 patient declined" throughout admission. Patient #6: POC had no visit frequencies. RN assessed patient 12/13 and revisit 12/19/24 with no order for the latter. 12/19/24 note with time 415-515 is incomplete and not signed by clinician.

Condition of Participation: Hospice Aide and Homemaker Services. L607

Upon patient record review, 1 of 7 (Patient #2) 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: Patient home visit with Hospice Aide initiated for surveyor observation. During interview, Hospice Aide reported that she had no care plan, as "Hospice MD is not ready yet." Inquired how aide knows what tasks to perform and she went on to list tasks. Asked how often she sees the patient and she said 2x/week Monday and Friday and she had seen patient before. Upon return to office, there was Hospice Aide assignment sheet in the EMR dated 3/1/25, but the aide apparently did not have access at the time of visit. There is no order for the Hospice Aide Visit at the time care was initiated and/or after visit completed.

Upon patient record review 1 of 7 (Patient #2) 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 #2: Patient home visit with Hospice Aide initiated for surveyor observation. During interview, Hospice Aide reported that she had no care plan, as "Hospice MD is not ready yet." Inquired how aide knows what tasks to perform and she went on to list tasks, with no reference to RN guidance. Asked how often she sees the patient and she said 2x/week Monday and Friday and she had seen patient before.

Upon patient record review, 5 of 7 (Patient #3, 4, 5, 6, 7) 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 #3: Physician narrative "Patient is AXOX3 able to make needs known. She signed her own consents with her family around. Patient has fair appetite." Patient #4: Initial CTI narrative only includes diagnoses and codes Patient #5, 6, 7 : Initial CTI includes patient age, dx only.

Condition of Participation: Clinical Records.

Upon patient client record review, 6 of 7 (Patient #1, 2, 4, 5, 6, 7) 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 Patients #1, 2, 6, 7: Admission consent forms were not available in EMR and/or hard copy by midday Day 1 of survey. Patient #4: There is no election statement to include choice of physician and also no effective date of election Patient #5: The election statement section for choice of MD is left blank for I do not wish and my choice of attending physician is blank. The choice of receiving or not receiving addendum section is blank. The addendum form is blank other than signature.

Upon patient client record review, 6 of 7 (Patient #1, 2, 3, 4, 5, 6) did not have evidence that each patient record contains Advance Directives. Patients #1, 2, 3, 4, 5, 6: Identified as DNR, but no supportive documentation available in EMR.

Upon patient client record review, 7 of 7 (Patient #1, 2, 3, 4, 5, 6, 7) 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. Patients #1, 2, 3: The Patient Concern / Grievance Process phone tree in the patient admission booklets in homes for Patient Visit 2 and 3 (Patients 1 and 3) had Eternity contact information in the heading, however a different hospice name and number was listed at the top of the phone tree. (The admission packet in the office is accurate). Patients #3, 4, 5: Admission Consent including Advanced Directives section has questions with yes or no answer and questions are unanswered. Patient #3: Patient admitted 1/17/25. IDT 1/24/25 IDG Meeting SC documented a visit, however, there is no documentation in the EMR regarding an assessment or a visit note by the SC and there is no physician order for SC services. SN Visit note narratives are duplicated 1/24, 1/31, 2/6. 2/13, 2/20, 2/27/25, to include "Patient signed her own consents with her family around". Patient #4: MSW made visits 11/9/24 documented as "routine monthly visit," when it was her first visit to assess new admission Patient #5: DC summary not signed. Patient #6: Admitted 12/13/24-12/20/24. 12/27/24 (only IDG) meeting says all disciplines made visits, but no notes to support visits made by MSW, SC. Patient #7: Adm 11/26-12/20/24. 11/29/24 IDG: meeting narrative entries for RN, MSW, SC imply all disciplines made visits, but no notes to support visits made by MSW, SC.

Upon client record review, 4 of 7 (Patient #4, 5, 6, 7) did not have evidence that if a patient revokes the election of hospice care or is discharged from hospice in accordance with §418.26, the hospice must forward to the patient's attending physician: • A copy of the hospice discharge summary • The patient's clinical record, if requested Patient #4, 5: DC Summary says DNR and/or Advance Directives sent, but there are no copies in record and/or available to surveyor that might have been available to send. Patient #6, 7: No documentation to verify any document(s) sent.

Upon client record review, 4 of 7 (Patient #4, 5, 6, 7) did not have evidence that the discharge summary includes all required information. Patient #4, 5, 6, 7: Live discharge records do not include discharge summary that includes comprehensive summary of patient's stay.

Upon observation, there was no evidence the patient record, whether hard copy or in electronic form, is made readily available on request by an appropriate authority. Patients #1, 2, 6, 7: Admission Consents not available to surveyor upon start of survey.