Every finding on record at Gentle Care Services Hospice, Inc.

Upon patient record review, 2 of 5 (Patient #3, 5) 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: The RN visited the patient on 11.10.2024 and performed an update to the comprehensive assessment. The next RN visit and update to the comprehensive assessment was performed on 11.26.2024, which exceeded the 15 day requirement. Patient 5: The RN visited the patient on 11.07.2024 and performed an update to the comprehensive assessment. The next RN visit and update to the comprehensive assessment was performed on 11.23.2024, which exceeded the 15 day requirement.

Condition of Participation: Initial and Comprehensive Assessment of the Patient.

Upon patient record review, 2 of 14 (Patient #9,10) 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: Observed during home visit, medication on the agency medication profile, Andrographis, was not available in the home. Patient #10: Observed during home visit, medications on the agency medication profile, Trazodone and Donepezil, were not available in the home.

Upon patient record review, 10 of 14 (Patient #1,2,3,4,5,6,7,8,9,10) 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 #1: There is no evidence of an RNCM visit after 9/26/24. Patient #2: There is no evidence of an RNCM visit after 9/23/24. Patient #3: There is no evidence of an RNCM visit after 9/11/24. Patient #4,5,6: There is no evidence of an RNCM visit after 9/24/24. Patient #7: There is no evidence of an RNCM visit after 9/16/24. Patient #8: There is no evidence of an RNCM visit after 9/27/24. Patient #9: There is no evidence of an RNCM visit after 9/24/24. Patient #10: There is no evidence of an RNCM visit after 8/19/24.

Upon client record review, 10 of 14 (Patient #1,2,3,4,5,6,7,8,9,10) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1: There is evidence in the medical record, visit frequency SN 1Xwk. The last SN visit was 9/26/24. No SN visit week of 9/29,10/6, 10/13, 10/20 Patient #2: There is evidence in the medical record, visit frequency SN 1Xwk. The last SN visit was 10/3/24. No SN visit week of 10/6, 10/13, 10/20 Patient #3: There is evidence in the medical record, visit frequency SN 1Xwk. The last SN visit was 10/15/24. No SN visit week of 10/20 Patient #4,6,9: There is evidence in the medical record, visit frequency SN 1Xwk. Last SN visit was 9/24/24. No SN visit week of 9/29,10/6, 10/13, 10/20 Patient #5: There is evidence in the medical record, visit frequency SN 1Xwk. The last SN visit was 10/16/24. No SN visit week of 10/20 Patient #7: There is evidence in the medical record, visit frequency SN 1Xwk. The last SN visit was 10/14/24. No SN visit week of 10/20 Patient #8: There is evidence in the medical record, visit frequency SN 1Xwk. The last SN visit was 9/27/24. No SN visit week of 9/29,10/6, 10/13, 10/20 Patient #10: There is evidence in the medical record, visit frequency SN 1Xwk. The last SN visit was 9/26/24. No SN visit week of 9/29,10/6, 10/13, 10/20

Upon patient record review, 10 of 14 (Patient #1,2,3,4,5,6,7,8,9,10) did not have evidence that the IDG documents the sharing of information between all disciplines providing care and services in all settings, whether the care and services are provided directly or under arrangement. Patient #1,2,3,4,5,6,7,8,9,10: There is no evidence the IDG meeting on Oct 2 and Oct 16, 2024, included the Social Worker at the meeting. The Social worker did not sign the IDG notes also, there was not a sign-in sheet to provide evidence of attendance.

Upon personnel record review, 1 of 13 (Personnel # 3) did not have evidence in the hospice aide personnel file 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. Personnel #3: There is no evidence the Aide had an annual on-site visit.

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. The administrator did not provide oversight to ensure the proper operation of the of the hospice as evidenced by, the medical director commented it is not his role to supervise other physicians however, all other hospice physicians must function under the supervision of the medical director. In addition, several CTI's remain unsigned by the medical director or other hospice physicians. The DPS indicated he recently asked the medical director to "catch up" on his paperwork. Patients were not being seen as ordered by physician and RN's not providing continuous assessment of patient/family needs. RN's not providing LVN supervision. Several IDG meetings without evidence of all core disciplines attending.

Upon observation, there was no evidence the hospice designates a physician to serve as Medical Director which includes: • The Medical Director must be a doctor of medicine or osteopathy who is an employee or is under contract. • When the Medical Director is not available, a physician designated by the hospice assumes the same responsibilities and obligations as the Medical Director. Medical director commented it is not his role to supervise other physicians however, all other hospice physicians must function under the supervision of the medical director. In addition, several CTI's remain unsigned by the medical director or other hospice physicians.

Upon patient record review, 6 of 14 (Patient #2,3,4,5,6,7) 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 #2,3,4,5,6,7: There is no evidence the medical director or any other hospice physician signed the initial certification of terminal illness.

Upon patient record review, 8 of 14 (Patient #2,3,4,5,6,7,8,10) 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 #2,3,45,6,7,8,10: There is no evidence in the medical record that the medical director or any other hospice physician signed the recertification of terminal illness