Every finding on record at Evergreen Home Care & Hospice Inc

Upon client record review, 1 of 1 (Patient #1) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1 LVN frequency was ordered as 2 x week and 3prn visits at SOC; No LVN visits noted on the weeks of 8/6, 8/13, 8/20, 8/27, 9/3, and 9/10. RN frequency ordered as once every 14 days but record reflects that RN visit were done on 8/3 and 8/4 with no mention of PRN visits. MSW ordered for one time evaluation. No evidence of visit made by MSW. The agency was working to enter a visit for 9/1/23 for the MSW during the survey however it was not completed.

Upon patient record review, 3 of 14 (Patient #1, 5, 6) 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 #1 signed by agency employee (LVN). The agency employee is in fact the caregiver, but is not a relative and there is not legal representative documentation. There is a letter from the nephew (next of kin) that identifies caregiver as caregiver. Patient #5, 6, agency MSW is caregiver and signed consents/admission documentation, but there is no documentation identifying her as legal representative.

Upon patient record review, 3 of 14 (Patient #1, 5, 6) 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 #1 admission forms signed by agency employee (LVN). The agency employee is in fact the caregiver, but is not a relative and there is not legal representative documentation. There is a letter from the nephew (next of kin) that identifies caregiver as caregiver. Patient #5, 6, agency MSW is caregiver and signed consents/admission documentation, but there is no documentation identifying her as legal representative.

Upon patient record review, 4 of 14 (Patient #1, 5, 6, 9) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient #1 signed by agency employee (LVN). The agency employee is in fact the caregiver, but is not a relative and there is not legal representative documentation. There is a letter from the nephew (next of kin) that identifies caregiver as caregiver. Additionally, the section allocated for MD choice is blank. Patient #5, 6, agency MSW is caregiver and signed consents/admission documentation, but there is no documentation identifying her as legal representative. Patient #9: The section allocated for physician choice is blank.

Upon patient record review, 3 of 14 (Patient #1, 5, 6) did not have evidence of the appropriate documentation for release of confidential information. Patient #1 signed by agency employee (LVN). The agency employee is in fact the caregiver, but is not a relative and there is not legal representative documentation. There is a letter from the nephew (next of kin) that identifies caregiver as caregiver. Patient #5, 6, agency MSW is caregiver and signed consents/admission documentation, but there is no documentation identifying her as legal representative.

Upon patient record review, 3 of 14 (Patient #1, 5, 6) did not have evidence that the patient received information about the services covered under the hospice benefit. Patient #1 signed by agency employee (LVN). The agency employee is in fact the caregiver, but is not a relative and there is not legal representative documentation. There is a letter from the nephew (next of kin) that identifies LVN as caregiver. Patient #5, 6, agency MSW is caregiver and signed consents/admission documentation, but there is no documentation identifying her as legal representative.

Upon patient record review, 3 of 14 (Patient #1, 5, 6) 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 #1 signed by agency employee (LVN). The agency employee is in fact the caregiver, but is not a relative and there is not legal representative documentation. There is a letter from the nephew (next of kin) that identifies caregiver as caregiver. Patient #5, 6, agency MSW is caregiver and signed consents/admission documentation, but there is no documentation identifying her as legal representative.

Upon patient record review, 1 of 14 (Patient #7) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual's attending physician, if any) • Changes that have taken place since the initial assessment • Information on the patient's progress toward desired outcomes • Reassessment of the patient's response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days Patient #7: IDG POC for RN q2wk and 1 prn every 14 days. There are no RN visits except benefit period assessments. There was no evidence of an RN visit other than 1 per 90 day benefit period, then 1 q 60 days with every benefit period with updated comprehensive assessments. No evidence of a comprehensive assessment update no less than every 15 days.

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

Upon patient record review, 1 of 14 (Patient #8) did not have evidence that the plan of care includes all services necessary for the palliation and management of the terminal illness and related conditions which including interventions to manage pain and symptoms. Patient #8: 01/15/21 SC visit note. SC documents that patient is alert but however she is stressed out and depressed. She says she is out of medication. I informed her that I would call the office to let them know of her situation." Documentation is not clear if in fact SC did make call. No follow up RN documentation or communication with patient. No documented communication or visit until 1/29/21 SN visit note. This SN note is incomplete and is not signed or dated. LVN. 2/2/21 visit note by RN included "... patient complain of not getting all of her pain medications. RN checked the way patient is taking the medications. Patient is eating a full meal, drinking water, patient is able to verbalize her needs to the staff." The note is not clear if RN found compliance or non-compliance and what related observations were made.

Upon patient record review, 1 of 14 (Patient #3) 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: 12/22/20 SN communication note refers to bariatric bed and gel mattress needed and delivered for patient. There is no order in the record although nurse verified delivery. The order was not included in record.

Upon client record review, 2 of 14 (Patient #4, 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. Upon client record review, there is no evidence that IDG reviewed plan at least every 15 calendar days. Patient #4: 5/3/21, 5/31/23 IDG meeting note has no signatures of any disciplines to validate participation in review, no updates. There was no hard copy of attendance as back up. Patient #7: Admitted 9/23/20. The last documented IDG meeting review is 5/21/21 (which is actually blank). Patient was discharged 8/12/21.

Upon client record review, 1 of 14 (Patient #7) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #7: IDG POC for RN q2wk and 1 prn every 14 days. There are no RN visits except benefit period assessments. There was no evidence of an RN visit other than 1 per 90 day benefit period with updated comprehensive assessments, then q 60 days with each benefit period.

Upon patient record review 1 of 14 (Patient #6) 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 #6: 3/26/22 Communication note by MSW. Documents that when she called, "Patient declined to speak (by phone) due to shortness of breath. CG was very polite. CG states patient has been doing okay. He refuses to talk about illness and gets frustrated when she mentions plans. CG recommended we cancel SW until patient feels better. Case Manager has been notified." There was no documented follow up until 3/27/22 visit note by RN. It was documented that "patient appears tired - admits lack of sleep due to fear. ... hospice SW counseling visits to assess patient needs and to provide support. Reviewed coping skills discussed to help cope with grieving process." There was no documented follow up communication between the two disciplines. There were no additional visits by MSW.

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/Administrator which assumes full legal authority and responsibility for the operation of the hospice as evidence by: staff signing consents for patients that are not related to or have proper authority to sign consents, no evidence of a contract for GIP/Respite level of care, and lack of certification of terminal illness narratives.

Upon observation, there was no evidence the hospice is primarily engaged in providing the following care and services: • Short-term inpatient care Upon observation, the agency does not present evidence of an arrangement to provide short-term inpatient care. There is a contract in place, but it is not specific to the provision of general inpatient/respite, but rather hospice services at a routine level of care for the SNF resident.

Upon patient record review, 2 of 14 (Patient #3, 9) 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, 9: Upon record review, there is no physician narrative as part of the CTI for the initial benefit period.

Upon patient record review, 1 of 14 (Patient #3) 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 #3 admitted 10/8/20 in 8th benefit period. There is no evidence of physician narrative as part of or addendum to CTI for subsequent benefit periods (9th, 10th, 11th, 12th.).

Upon patient client record review, 4 of 14 (Patient #1, 5, 6, 9) 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 #1 signed by agency employee (LVN). The agency employee is in fact the caregiver, but is not a relative and there is not legal representative documentation. There is a letter from the nephew (next of kin) that identifies caregiver as caregiver. Patient #5, 6, agency MSW is caregiver and signed consents/admission documentation, but there is no documentation identifying her as legal representative. Patient #9: Section of consent/election addressing Election/choice of physician is left blank.

Upon patient client record review, 10 of 14 (Patient #1, 2, 3, 4, 5, 6, 7, 8, 9, 10) 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 #1,2, 5, 8, 10, Patient Service Agreement Page 9, #5: Effective Date says "This notice is effective at incorporation date, 12-01-2005. If you have any questions regarding this notice, please contact our privacy office at AC Hospice Inc at 424-634-7630." Upon interview, AC Hospice is another agency with common ownership. (The form refers to Evergreen Hospice in other places). Patient #3, 4, 6, 7, 9, Patient Service Agreement Page 9, #5: Effective Date says "This notice is effective at incorporation date, 12-01-2005. If you have any questions regarding this notice, please contact our privacy office at Evergreen Hospice at 323-293-7072) Agency contact information was revised, but the incorporation date is confirmed to be AC Hospice and info is not applicable to this patient agreement form. Patient # 2: 7/20/23 Initial Comprehensive Assessment visit assigned to RN. The note was not signed by the visiting nurse. Note was signed by a different RN 7/26/23, “to close note on behalf of staff assigned.” SC assessment visit 7/21/23 signed by RN to close note on behalf of staff assigned. Date 7/25/23. Patient #5: MSW assessment created by one clinician and Staff Assigned is MSW. No signature by visiting clinician. Note says electronically submitted for review 1/19/22 @ 1538 by Admin. Patient #6: SN 3/13/22 Comprehensive assessment visit note. EMR created by and Staff assigned are 2 different clinicians. Signed by admin, to close note on behalf of staff assigned, 4/3/23. MSW 3/14/22 assessment. Created by one clinician and another clinician assigned LCSW. No signature, but says electronically review approved. No date. Patient #8: 1/29/21 SN visit note is incomplete and is not signed or dated by assigned LVN. Patient #9: MSW Assessment 8/19/23 assigned to one clinician, entered by different clinician and signed by RN to close note on behalf of staff assigned. Patient #10. 10/14 death visit assigned to LVN was signed by RN to close note on behalf of staff assigned and dated 10/14/22.

Upon client record review, 3 of 14 (Patient #1, 5, 6) did not have evidence that the written policies and procedures for managing controlled drugs was provided and discussed. Patient #1 signed by agency employee (LVN). The agency employee is in fact the caregiver, but is not a relative and there is not legal representative documentation. There is a letter from the nephew (next of kin) that identifies caregiver as caregiver. Patient #5, 6, agency MSW is caregiver, but there is no documentation identifying her as legal representative.

Upon observation, there was no evidence of a contract for short term inpatient care for pain control and symptom management with a Medicare certified hospice, if applicable.