Every finding on record at Genesis Care, LLC

Upon observation, there was no evidence of contracts/agreements with other facilities/agencies/hospices to receive patients in the event the hospice cannot provide care to their patients during an emergency.

Upon patient record review 5 of 14 (Patient #3,#4,#6,#7,#9) 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 #3,#4,#6,#7,#9: There is no evidence of an initial psychosocial comprehensive assessment being completed

Upon patient record review, 1 of 10 (Patient #9) 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 #9: The medication profile contained duplicate active orders on medication profile for the following medications: Colace 100mg 1 daily and for colace100mg twice a day; two identical orders for lorazepam 1 mg 1 tab every 4 hours prn; two identical orders for Quetiapine 100mg take one every evening; two identical orders for temazepam 30mg take 1 by mouth at bedtime. Corrected on site.

Upon patient record review, 6 of 14 (Patient #2,#4,#6,#7,#8,#9) 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 #2,#4,#6,#7,#9: There is no evidence of initial bereavement assessment on primary contact or other family member. Patient #8: Patient was admitted on 09/09/23. The initial bereavement assessment was completed on 06/08/24.

Upon patient record review, 9 of 14 (Patient #1,#2,#3,#4,#5,#6,#7,#9,#10) 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 #1: There is no evidence of the plan of care containing problems goals or interventions related to aspiration precautions, high risk of skin impairment, spiritual, or psychosocial needs of the patient. Corrected on site with exception of the spiritual and psychosocial. Patient #2: There is no evidence of the plan of care containing problems goals or interventions related to spiritual or psychosocial needs of the patient. Patient #3: There is no evidence of the plan of care containing problems goals or interventions related to respiratory, cardiovascular, high risk of skin impairment, or sleep. Corrected on site. There was also no evidence of plan of care containing problems goals or interventions related to spiritual or psychosocial needs of patient. Patient #4: There is no evidence of the plan of care containing problems goals or interventions for cardiovascular, respiratory, endocrine, sleep, gastro intestinal and fall precaution needs of patient. Corrected on site. There was also no evidence of plan of care containing problems goals or interventions related to spiritual or psychosocial needs of patient. Patient #5: There is no evidence of the plan of care containing problems goals or interventions related to cholecystostomy drain and care needs of the patient. Corrected on site. Patient #6: There is no evidence of the plan of care containing problems goals or interventions related to spiritual and psychosocial needs of patient. Patient #7: There is no evidence of the plan of care containing problems goals or interventions related to fall precautions needs of the patient. Corrected on site. There is no evidence of the plan of care containing problems goals or interventions related to spiritual needs of the patient. Patient #9: There is no evidence of the plan of care containing problems goals or interventions related to pain management, spiritual, or psychosocial needs for the patient. Corrected on site with exception of the spiritual and psychosocial. Patient #10: There is no evidence of the plan of care containing problems goals or interventions related to wounds, spiritual, or psychosocial needs of patient. Corrected on site with exception of the spiritual and psychosocial.

Upon patient record review, 2 of 14 (Patient #7,#8) 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 visit frequency order for social worker states one time visit then PRN. Order did not anticipate needs of patient. Corrected on site. Patient #8: The visit frequency order for nurse states per week but a number of visits is not indicated. The visit frequency for spiritual care and social work states one time and then PRN. There is no frequency for regular visit. Corrected on site.

Upon patient record review, 1 of 14 (Patient #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 medications and treatments. Patient #7: There is no evidence of frequency indicated on wound care order 0n 5/9/24. Corrected on site.

Upon patient record review, 3 of 14 (Patient #2,#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 #2: There is no evidence of order on plan of care for air mattress or bed. Corrected on site. Patient #5: There is no evidence of order on plan of care for nebulizer. Corrected on site. Patient #7: There is no evidence of order on plan of care for air mattress. Corrected on site.

Upon client record review, 2 of 14 (Patient #2,#8) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #2: The Social worker visit frequency was one time a month and one PRN. There is no evidence of a visit for the month of April. Patient #8: The social worker was going monthly, Spiritual made visit 11/11/23, nurse made visits weekly without scheduled frequency orders included in plan of care.

Upon observation, there was no evidence of involvement of the governing body and organizational leaders in the Quality Assessment/Performance Improvement (QAPI) program. There was no evidence of QAPI being discussed in the meeting. There is no evidence of governing body or leadership involvement.

Upon observation, there was no evidence the hospice's governing body is responsible for ensuring that the hospice-wide Quality Assessment and Performance Improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness. There is no evidence or documentation of meetings.

Upon observation, there was no evidence licensed professionals participate in the hospice's QAPI program. There is no evidence of documentation of a group meeting together.

Upon patient record review 1 of 14 (Patient #9) 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 #9: The aide visit frequency was for five times a week. The week of 6/30/24 there was only one visit documented. The week of 7/08/24 there were only four visits documented.

Upon observation, there was no evidence the hospice documents and demonstrates viable and ongoing efforts to recruit and retain volunteers. There is no evidence of a log of other documentation being kept for on these efforts. The agency was unable to recall specific efforts.

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. This agency is at 0% for 2023 however, agency does have volunteer on staff.

Upon patient client record review, 1 of 14 (Patient #6) did not have evidence that each patient record contains responses to medications, symptom management, treatments, and services. Patient #6: On RN visit 6/17/24 the patient report pain at a 4 out of 10. The nurse gave PRN tramadol as ordered. On RN visit 06/25/24 the patient complained of pain. The nurse gave PRN tramadol as ordered. There is no evidence of documentation on response to the medication for symptom management.

Upon patient client record review, 2 of 14 (Patient #3,#4) 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 #3: No visits documented since admission 07/12/24 as the clinician had not completed documentation. Per DPSC report agency policy is completion within 5 days. Corrected on site. Patient #4: No visits documented since admission 07/08/24 as the clinician had not completed documentation. Per DPSC report agency policy is completion within 5 days. Corrected on site.