Every finding on record at Faith and Family Hospice, Inc

Upon patient record review 1 of 19 (Patient #10) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process: Patient # 10: Review of initial RN assessment revealed that a comprehensive patient pain assessment was not included.

Upon patient record review, 1 of 19 (Patient's # 3) did not have evidence the plan of care must included all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs: Patient # 3: During surveyor attended home visit on 02/18/2025 the patient was noted to have the following DME: Broda Wheelchair and Hoyer Lift. These items where not on the POC.

Upon patient record review, 3 of 19 (Patients # 17, 18, 19) did not have evidence the hospice offers bereavement counseling that includes: • Ensuring that bereavement services reflect the needs of the bereaved • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery: Patient # 17: No evidence of a written Bereavement POC. However, there was documented evidence in the record of the provision of multiple planned bereavement activities. Patient # 18: No evidence of a written Bereavement POC. However, there was documented evidence in the record of the provision of multiple planned bereavement activities. Patient # 19: No evidence of a written Bereavement POC. However, there was documented evidence in the record of the provision of multiple planned bereavement activities.

Upon personnel record review, 1 of 12 (Personnel # 8) did not have evidence of an aide skills competency assessment having been performed by the aide with a patient at the time of hire, which included all CMS required skills: Personnel # 8: DOH 11/14/2023. An aide skills competency was conducted by an RN on 11/28/23. However, the following skills were not assessed: •Communications 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 •Recognizing emergencies and knowledge of emergency procedures and their application •The physical, emotional, and developmental needs of and ways to work with the populations served by the hospice, including the need for respect for the patient, his or her privacy and his or her property •Bed bath •Sponge, tub, and shower bath •Shampoo, sink, tub, and bed •Nail and skin care •Oral hygiene •Toileting and elimination •Safe transfer techniques •Normal range of motion •Adequate nutrition and fluid intake

Upon patient record review 2 of 19 (Patients # 2, 6) did not have documented evidence that a hospice aide provided 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: Aide visits were made on January 31, and February 3, 5, 7, 10, 11, 12, 14, 17, and 18. No physician orders on the POC for the aide visits. Patient # 6: Aide visits were made on December 6, 13, 17, 19, 20, 23, 31, January 3, 6, 10, 13, 17, 21, 24, 27 and 31, February 3, 4, 7, 10, and 14. No physician orders on the POC for the aide visits.

Upon personnel record review, 1 of 12 (Personnel #8) did not have evidence that a registered nurse made an annual on-site visit to the location where a patient is receiving care in order to observe and assess each aide while he or she is performing care. The supervising nurse must assess an aide's ability to demonstrate initial and continued satisfactory performance in meeting outcome criteria that include all required content: Patient # 8: Hospice aide annual on-site visit observation and assessment did not include; complying with infection control policies and procedures.

Upon observation, there was not evidence that the Hospice's Annual Report documented 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 Hospice's 2024 calendar year results were 1.1%

Upon patient record review, 1 of 19 (Patient # 15) 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 the following to the patient's attending physician: • A copy of the hospice discharge summary • The patient's clinical record, if requested Patient # 15: Revoked 08/02/2024. Clinical Manager confirmed there was no evidence a discharge summary was sent to the attending physician.

Upon inpatient contract review, 1 of 4 (Countryside) did not contain verbiage 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.

Upon inpatient contract review, 1 of 4 (Countryside) did not contain verbiage that a copy of the Discharge Summary shall be provided to the Hospice at the time of inpatient discharge.

Upon patient record review 3 of 11 (Patient #4, 5, 9) 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 # 4 - Admitted to services 4/7/22. Chaplain assessment was completed 4/13/22. Patient # 5 - Admitted to services 4/7/22. Chaplain assessment was completed 4/14/22. Patient # 9- Admitted to services 10/14/21. Chaplain assessment was completed 10/20/21.

Upon patient record review 1 of 11 (Patient #9) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Pt # 9 - No evidence of a SW assessment completion.

Upon patient record review, 1 of 11 (Patient #6) 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. Pt #6 - pt was admitted to services 3/22/22. The bereavement risk assessment was completed 4/11/22.

Upon patient record review, 1 of 11 (Patient #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 #9 - Pt admitted 10/14/21. There was no evidence of any problem statements with goals, interventions and progress toward outcomes, except social isolation. Pt had wound care needs, was actively dying, etc with no care plans to address any pt goals and interventions.

Upon client record review, 1 of 11 (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 - MD order for Chaplain services 1 X week starting 3/11/21. Chaplain wrote notes on patient 4/27 and 4/29 for visits. No prn noted on visit note.

Upon patient record review, 1 of 6 applicable (Patient # 11) 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 #11- POC order 2/10/22 states Aide 1-2 x week. MD order of 2/28/22 state to increase hospice aide services to 5-10 times/week for ADL's, companionship, and environmental needs. Aide Care Plan reflects the aide instructions to 1-2 times week. No evidence of parameters or guidance on range.

Upon personnel record review, 1 of 1applicable (Personnel #2) did not have evidence the alternate administrator's personnel record verifies that: • The employee has appropriate education and experience requirements • There is a signed job description for this role • The employee has been orientated to this role Personnel #2 - no evidence of signed job description for DOCS to include Alt Administrator (corrected on site)

Upon patient client record review, 1 of 11 (Patient #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 #9 - No evidence of staff designation for chaplain communication note of 1/30/21 or on note 1/29/22 by the on call RN. Note states digitally signed by CM. (Corrected on site)

Upon client record review, 2 of 2 applicable (Patient #6, 10) did not have evidence that the hospice forwarded a summary and a copy of the patient record, if requested, to a facility when transferring the patient to that facility. Patient #6 - admitted to hospital 5/4/22. No evidence of a transfer summary in record. Patient #10 - pt transferred 4/30/22 to a non contracted facility following a fall. No evidence of a transfer summary in pt record.

Upon client record review, 2 of 2 applicable (Patient #10, 11) 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 10, 11 - No evidence that a discharge summary was sent to the attending following their revocation.