Every finding on record at Gamma Hospice Inc.

Upon personnel record review, 1 of 8 (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: DPCS conducted a joint visit with aide to observe patient care delivery on 11/30/23 which included observation of a bed bath. No direct observation with a patient or pseudo patient of aide's appropriate and safe techniques in delivery of (B) sponge, tub, and shower bath has been done by agency. However, the updated competency form dated 11/30/23 indicated that all levels of bathing (bed bath, sponge, tub and shower) had been observed during joint visit. Interview with DPCS revealed that patient received a bed bath only. The sample of patients receiving Aide services included 3 with shower assigned and 1 with bed bath assigned to be delivered by the aide.

Upon patient record review, 2 of 5 (Patient #1,4) 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 & 4: The POC has orders for deep oral suction for patient PRN. There is no suction equipment on the DME POC list.

Upon client record review, 1 of 5 (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: The POC 11/6/23 has orders for RN 1 time for initial assess and a separate order for SN once a week. The medical record contains evidence of the RN initial assessment but there are no other visits documented by the SN for that SOC week.

Condition of Participation: Hospice Aide and Homemaker Services. L607

Upon personnel record review, 1 of 12 (Personnel #6 ) 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 6: The aide competency was all verbal and conducted with an LVN to check off. There was no evidence of a hands on competency performed with a pseudo patient or patient.

Upon patient record review 4 of 5 (Patient #1,2,3,4) did not have evidence documentation in the patient record that a hospice aide provides services that are: Patient 1: The POC 3/16/23 contains orders for aide 2x a week. IDG meetings 11/9/23 and 10/26/23 and 10/12/23 have orders for aide 3 times per week but none of the IDG's contain a physician signature. There is evidence the aide was seeing the patient 3 times a week up until 10/30/23 then there are no further visits documented. Patient 2: The aide was ordered to perform aspiration precautions each visit. This was not completed on 10/20/23. The POC contains orders for aides 3 times per week. There is no evidence of aide visits being performed after 10/30/23. Patient 3: The POC 5/27/23 contains orders for aide 5 times per week. There is no evidence the aide saw the patient past 10/31/23. Patient 4: The POC 11/6/23 contains an order for aide 1x per week. The first week 11/5/23-11/11/23 there is no evidence the aide has visited the patient.

Upon personnel record review, 1 of 12 (Personnel #12) did not have evidence the individual who supervises volunteers is qualified by meeting the hospice's policies and procedures and/or job description criteria and is a designated hospice employee. Personnel 12: The volunteer coordinator does not have 2 years of experience in a health care setting, hospice and or volunteer experience preferred as required in the job description.

Condition of Participation: Organization and Administration of Services.

Upon personnel record review, 1 of 12 (Personnel #1) did not have evidence that the administrator is a hospice employee and possesses the education and experience required by the governing body. Personnel 1: The Owner/Administrator does not have 3-5 years of health care administration experience per agency job description.

Upon personnel record review, 7 of 12 (Personnel #2,3,4,10,11,12) 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 2,3,4,10,11,12: These personnel's competencies are all marked verbal, there is no evidence a skills competency was performed other than verbally.

Upon client record review, 1 of 5 (Patient #3) did not have evidence that the hospice plan of care identifies the care and services that are needed and specifically identify which provider (nursing facility or hospice) is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care. Patient 3: The POC 11/13/23 contains orders for wound care to left foot, left heel, right foot. The order does not state who will be performing the care.

Upon personnel record review, 10 of 13 (Personnel#1,#2,#3,#4,#5,#6,#7,#8,#9,#10) did not have evidence Emergency Preparedness training including: • Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles • Demonstrate staff knowledge of emergency procedures • Provide emergency preparedness training at least annually • Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others • Maintain documentation of all emergency preparedness training

Upon patient record review 1 of 14 (Patient #2) 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 2:The patient was admitted on 6/15/23. The psychosocial assessment was completed on 7/3/23.

Upon patient record review 1 of 14 (Patient #3) 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. Patient3: The patient was admitted on 6/13/23. There is no evidence that a spiritual assessment was completed.

Upon patient record review, 3 of 12 (Patient #6,#12,#13) 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 6:Upon admission, the patient's medication administration record with entry of Oxygen at 2 liters per minute. Oxygen therapy was not included on the medication profile. Patient 12:Upon admission, the patient's medication administration record with entry of Oxygen at 2 liters per minute. Oxygen therapy was not included on the medication profile. The medication profile entry for Volataren gel does not indicate the location for application Patient 13:Upon admission, the patient's medication administration record with entry of MiraLAX powder 17 grams daily as needed. There was no evidence on the medication administration record of the type and amount of diluent needed for MiraLAX administration

Upon patient record review, 1 of 14 (Patient #3) 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: No Bereavement Risk assessment.

Upon patient record review, 4 of 14 (Patient #1,#3,#7,#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. Patient1:Upon admission the nurse documentation included evidence that the patients death was imminent. There is no evidence of problems, goals and interventions for imminence on the plan of care. Patient 3:There is documentation of antibiotic therapy initiated on 6/27/23. There is no evidence of problems, goals and interventions for infection on the plan of care. Patient 7:Upon admission the nurse documentation included oxygen therapy at 2 liters per minutes via nasal cannula intermittently related to shortness of breath. There is no evidence of problems, goals and interventions related to oxygen therapy on the plan of care. Patient 11:Upon admission the nurse documentation included evidence that the patients death was imminent. There is on evidence of problems, goals and interventions for imminence on the plan of care.

Upon patient record review, 1 of 14 (Patient #7) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient 7:The medical record contained an order for Social Work to visit PRN only.

Upon patient record review, 2 of 14 (Patient #1,#2) 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 1:The patient record indicated that the patient had a foley catheter upon admission. The plan of care does not include the catheter size or the amount used to inflate balloon. Patient 2:On 7/3/23 the record indicated an order to cleanse with wound cleanser and pat dry, apply mupirocin ointment and cover with calcium alginate and ABD pad. The order did not include who is to perform care.

Upon patient record review, 5 of 14 (Patient #1,#2,#3,#5,#7) 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:The patients medical record contains documentation upon admission that patient utilized an air mattress and heel protectors. There is no evidence that an air mattress and heel protectors are present on the plan of care. Patient 2:The patients medical record contains documentation upon admission that patient utilized a walker. There is no evidence that a walker is present on the plan of care. Patient 3:The patients medical record contains documentation upon admission that patient utilized a hospital bed. There is no evidence that a hospital bed is present on the plan of care. Patient 5:The patients medical record contains documentation upon admission that patient utilized a wheelchair and hospital bed. There is no evidence that a wheelchair and hospital bed are present on the plan of care. Patient 7:The patients medical record contains documentation upon admission that patient utilized a wheelchair. There is no evidence that a wheelchair is present on the plan of care.

Upon client record review, 1 of 13 (Patient #5) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 5:On admission, nurse documentation included to clean ulcer with cleanser and apply hydrogel and cover with dressing. There is no indication that an order was obtained from the physician.

Upon patient record review, 4 of 14 (Patient #2,#7,#10,#11) did not have evidence the hospice offers bereavement counseling that includes: • Making bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. Bereavement counseling also extends to residents of a SNF/NF or ICF/IID when appropriate and identified in the bereavement plan of care • 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 2&7:bereavement POC to include sympathy card, 1, 3 6 9 month letter, no evidence of bereavement activity. Patient 10&11:Bereavement POC includes post Death card, and Condolence call, no other interventions listed. No documentation to support that card or call had been given.

Condition of Participation: Hospice Aide and Homemaker Services. L607

Upon personnel record review, 1 of 13 (Personnel #7) 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.

Upon patient record review, 1 of 14 (Patient #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 12: There is documentation in the record on admission that patient uses oxygen at 2 liters per minute via nasal cannula as needed for shortness of breath. There is no evidence that aspiration and oxygen precautions are included on the aide plan of care.

Upon patient record review 6 of 14 (Patient #3,#5,#7,#12,#13,#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 3 and 14:The visit frequency on the aide plan of care was indicated at 2x/week. There is no evidence of visits completed on week 1. Patient 5 and 7:The visit frequency on the aide plan of care was indicated at 2x/week. There documentation to support 1 visit on week 1. Patient 12: The visit frequency on the aide plan of care was indicated at 5x/week. There is no evidence of visits completed on week 1 and documentation to support only 4 visits on week 2. Patient 13:The visit frequency on the aide plan of care was indicated at 3x/week. There is documentation to support 2 visits on week 1.

Upon personnel record review, 1 of 13 (Personnel #10) did not have evidence the individual who supervises volunteers is qualified by meeting the hospice's policies and procedures and/or job description criteria and is a designated hospice employee.

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 which assumes full legal authority and responsibility for the operation of the hospice. There is no evidence of complete personnel files to include verification of qualifications of the bereavement coordinator, volunteer coordinator, no competencies for several personnel, no credentialing, or verification of employment for several of the employees.

Upon personnel record review, 10 of 13 (Personnel #1,#2,#3,#4,#5,#6,#7,#8,#9,#10) did not have evidence the hospice employees and contract employees have received orientation on the hospice philosophy.

Upon personnel record review, 7 of 13 (Personnel #2,#4,#6,#7,#8,#9,#10) did not have evidence that the hospice employees have received orientation on their specific job requirements.

Upon personnel record review, 8 of 13 (Personnel #2,#3,#5,#6,#7,#8,#9,#10) did not have evidence that a skills competency assessment, specific to each discipline had been conducted for all personnel including volunteers initially during orientation.

Upon patient record review, 3 of 14 (Patient #12,#13,#14) 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 12:For the benefit period beginning 8/25/23, there is no evidence that a certification of terminal illness narrative was completed and signed by the hospice physician. Patient 13:For the benefit period beginning 8/20/23, there is no evidence that a certification of terminal illness narrative was completed and signed by the hospice physician. Patient 14:For the benefit period beginning 9/12/23, there is no evidence that a certification of terminal illness narrative was completed and signed by the hospice physician.

Upon client record review, 1 of 14 (Patient #7) did not have evidence that the hospice plan of care identifies the care and services that are needed and specifically identify which provider (nursing facility or hospice) is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care. Patient 7: On admission, the record indicated an order to cleanse left heel wound with normal saline, pat dry, apply hydrogel and cover with collaged particles, calcium alginate and cover with ABD. The order does not indicate who is to perform wound care.

Upon personnel record review, 1 of 13 (Personnel #7) did not have evidence that personnel credentialing activities are conducted to verify qualifications of all credentialed/licensed personnel in the positions they hold at the time of hire, at renewal or in accordance with specific state practice act requirements.

Upon personnel record review, 1 of 13 (Personnel #13) did not have evidence that all Speech Therapy Services are provided by a qualified licensed Speech-Language Pathologist (SLP) or Audiologist in accordance with the state's Speech-Language Pathology Practice Act and the hospice's policies and procedures and/or job descriptions.

Upon personnel record review, 1 of 13 (Personnel #12) did not have evidence all Occupational Therapy Services are provided by a qualified licensed Occupational Therapist (OT) in accordance with the state's Occupational Therapy Practice Act and the hospice's policies and procedures and/or job descriptions.

Upon personnel record review, 1 of 13 (Personnel #11) did not have evidence all Physical Therapy Services are provided by a qualified licensed Physical Therapist (PT) in accordance with the state's Physical Therapy Practice Act and the hospice's policies and procedures and/or job descriptions.

Upon personnel record review, 3 of 13 (Personnel #11,#12,#13) did not have evidence the hospice obtained a criminal background check on all contracted individuals who have direct patient care and access to patient records.

Upon personnel record review, 3 of 13 (Personnel #7,#9,#10) did not have evidence of criminal background checks being obtained in accordance with state requirements. In the absence of state requirements, criminal background checks are obtained within three months of the date of employment for all states that the individual has lived or worked in the past 3 years.