Every finding on record at Fellowship Hospice Services, Inc

Upon patient record review, 6 of 14 (Patient #2,5,6,7,11,12) 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. 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 orders written on 8/23/24 for A&D Ointment and Calmoseptine do not indicate place of application on medication profile. Patient #5 orders written on 10/14/24 for A&D Ointment and Calmoseptine do not indicate place of application on medication profile. Patient #6 Oxygen was noted by SN on 1/8/24, however no evidence of oxygen on medication profile. Patient #7 orders written on 2/26/24 for Hydrocortisone cream do not indicate place of application and orders written on 5/28/24 for Levaquin for 7 days does not indicate a stop date on medication profile. Patient #11 orders written on 9/14/24 for A&D Ointment does not indicate place of application on medication profile. Patient #12 orders written on 9/15/24 for Voltaren Gel does not indicate place of application on medication profile.

Upon patient record review, 1 of 14 (Patient #3) 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 #3 Comprehensive assessment not updated every 15 days as it was completed on 4/16/24 and was not updated on 4/30/24

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

Upon patient record review, 6 of 14 (Patient #2,5,6,7,11,12) 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 plan of care orders written on 8/23/24 for A&D Ointment and Calmoseptine do not indicate place of application. Patient #5 plan of care orders written on 10/14/24 for A&D Ointment and Calmoseptine do not indicate place of application. Patient #6 oxygen was noted by SN on 1/8/24, however no evidence of oxygen on the plan of care. Patient #7 plan of care orders written on 2/26/24 for Hydrocortisone cream do not indicate place of application. Patient #11 plan of care orders written on 9/14/24 for A&D Ointment does not indicate place of application. Patient #12 plan of care orders written on 9/15/24 for Voltaren Gel does not indicate place of application.

Upon patient record review, 8 of 14 (Patient #1,2,5,6,7,9,12,14) 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 #1, Walker ordered on admit, but no orders on the plan of care Patient #2 Oxygen, wheelchair and hospital bed ordered on admit, no orders on the plan of care Patient #5 Shower chair, walker and wheelchair ordered on admit, no orders on the plan of care Patient #6 Oxygen, walker and wheelchair ordered on admission , no orders on the plan of care Patient #7 Walker and wheelchair ordered on admit, no orders on the plan of care Patient #9 Walker and wheelchair ordered on admit, no orders on the plan of care Patient #12 Walker and wheelchair ordered on admit, no orders on the plan of care Patient #14 Oxygen, hospital bed ordered on admit, no orders on the plan of care

Upon patient record review, 6 of 14 (Patient #2,5,6,7,10,14) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #2 Upon review orders written 8/23/24 for LVN frequency are 2x/week, no visits made the week of 8/23/24 and only 1 visit made the week of 8/25/24. Orders written on 8/23/24 for RN visit frequency are 2x/month and the only visit made that month was on 8/23/24. Orders written on 8/23/24 for Chaplain visit frequency is for 1x eval, no evidence of visit completed. Patient #5 Orders written on 10/14/24 for MSW eval, no evidence of visit completed. In addition, PT visits were completed on 10/18/24, 10/23/24 and 10/29/24 however no orders in place for PT. Patient #6 Orders written on 1/23/24 for LVN visit frequency for 2x/week, however only 1 LVN visit per week completed. Patient #7 Orders written 9/30/23 for MSW eval to be completed, no evidence of visit completed. Patient #10 SN documents foley catheter in place during SN visits on 10/14/24, 10/21/24 and 10/28/24 however there are no orders for foley catheter. Patient #14 SN note on 7/16/24 and 7/23 state patient with wound to coccyx and "Wound care completed as ordered", however no wound care order present.

Upon personnel record review, 1 of 11 (Personnel #11) did not have evidence that the hospice routinely provide substantially all core services directly by hospice personnel (The hospice issues a W-2 form for the employee). These services include: • Physician services (may contract for physician services) • Nursing • Medical social services • Counseling Personnel #11 MSW services are provided via contract and no evidence of a W-2 issued to MSW.

Upon observation, there was no evidence the hospice provides medical social services as a core service.

Upon patient record review 8 of 14 (Patient #2,5,6,7,9,10,11,14) 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 Orders dated 8/23/24 for aide visits 3x/week, visits made 2x/week on 8/26/24 and 8/28/24 that do not meet visit frequency. Patient #5 Orders dated 10/14/24 for aide visits 1 every 2 weeks. Visits made on 10/16/24 and 10/23/24 that do not meet visit frequency. Patient #6 Orders written on 1/8/24 for Aide visit frequency is 3x/week, no evidence of Aide visits completed. Patient #7 Orders dated 9/30/23 for aide visits 3x/week. Visits made 10/28/24, 10/30/24, 11/3/24 and 11/5/24 that do not meet visit frequency. Patient #9 Orders written on 10/4/24 for Aide visit frequency of 1x/week, no evidence of Aide visits completed. Patient #10 Orders written on 9/18/24 for Aide visit frequency of 3x/week, no evidence of Aide visits completed. Patient #11 Orders dated 9/14/24 for aide visits 2x/week. No visits made week of 9/15/24, visit made 9/27/24 and no visits made week of 11/1/24. Patient #14 Orders dated 7/20/24 for aide visits 3x/week, visits made only 2x/week for benefit periods 1 and 2 that do not meet visit frequency.

Upon patient record review 2 of 14 (Patient #11,14) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs. Patient #11 Aide supervisory visits last completed on 9/30/24 by RN due 10/14/24 and 10/28/24 were not completed. Patient #14 Aide supervisory visits last completed on 09/20/24 by RN due 10/6/24 and 10/20/24 were not completed.

Upon observation, there was no evidence the hospice documented the cost savings achieved through the use of volunteers. Documentation must include the following: • The identification of each position that is occupied by a volunteer • The work time spent by volunteers occupying those positions • Estimates of the dollar costs that the hospice would have incurred if paid employees occupied the positions identified in paragraph (d)(1) of CFR 418.78 for the amount of time specified in paragraph (d)(2) of CFR 418.78 There was no cost savings report for the agency.

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 agency total percentage was 0% for 2023.

Upon patient record review, 1 of 14 (Patient #4) 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 #4 Patient transferred to a different hospice agency on 3/18/24, no evidence of a transfer summary sent to the receiving hospice agency.

Upon patient record review, 1 of 14 (Patient #3) 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 #3 Patient was a live discharge on 5/2/24, no evidence of discharge summary sent to physician.

Upon patient record review, 1 of 14 (Patient #3) did not have evidence that the discharge summary includes all required information. Patient #3 Patient was a live discharge on 5/2/24, no evidence of a discharge summary completed.

Observed in Record Review. In 1 of 11 patient records reviewed, the organization had not indicated the information on patient's progress toward desired outcomes as well as a response to care. For example, during the review of record for HV 1, the Surveyor identified the organization had not ensured the goals on the patient's plan of care were reviewed in a timely manner. This was evidenced with goal review that was 11 days past the planed date of review. This was confirmed by the Director of Patient Care Services.

Observed in Record Review. In 1 of 11 patient records reviewed, the organization had not provided measurable outcomes anticipated from implementing and coordinating the plan of care. For example, during RR7 the initial assessment had indicated an elevated fall risk, however, the plan of care failed to identify this risk or assign measurable, patient specific interventions or timed goals to address this safety risk. This was confirmed by the Director of Patient Care Services.

Observed in Record Review. In 4 of 11 patient records reviewed, the organization had not ensured the plan of care and services were provided in accordance with the plan of care. For example, in RR2 review of record the order for Triple antibiotic ointment three times a day did not indicate a specific use for the medication or duration of therapy. In example two, during record review of RR4 the organization had not indicated the liter flow on the medication list nor had the Hospice aide plan of care indicated instructions regarding oxygen use. Also in RR5 review of record the liter flow and method I.e. nasal canula vs mask were omitted from the initial certification period's medication list. This was also confirmed by the Director of Patient Care services. IN RR6 the Physical Therapist had provided care to the patient without an addition to the plan of care supporting this modality.

Observed in Tracer Activities. In 2 of 2 tracers conducted, the organization had not provided an organized program for the provision of bereavement services.. For example in review of the bereavement program and ongoing follow up the organization had not documented attempts to engage with bereavement support over the 13 month span as outlined by their bereavement plan. This was confirmed by the Administrator and the Administrator Designee.

Observed in Individual Tracer. In 1 of 3 tracers conducted, the organization had not maintained a clinical record that was readily available on request by an appropriate authority. For example, during HV 1 the Assisted Living's home record did not include a copy of the identified advanced directive. The Do Not Resuscitate form was only available in the office of the Administrator of building not in the patient's chart in the medication room or floor cart. This would not be available during off working hours if needed. This was confirmed with the Director of Clinical Services (DPCS) and a new copy was requested by the DPCS during the visit to complete the chart. Additionally the facility record also only reflected the vital signs from week five of care forward not the first four weeks of care. This too was confirmed by the DPCS.

Observed in Individual Tracer. In 1 of 3 home visits conducted, the organization had not ensured the Licensed Vocational Nurse (LVN) had provided a sanitary environment by following current standards of practice , including nationally recognized infection control precautions and avoided sources and transmission of infections and communicable diseases. For example on HV 1 the LVN placed her equipment back into the bag with the blood pressure cuff placed into a dirty bag area (sharps container and paperwork located in this area. This was discussed with the LVN and confirmed by the Director of Clinical Practice and documented in the organizations Infection Prevention and Control Policy No 9-014.2.