Every finding on record at Global Hospice Care, Inc.

Observed in Record Review. In 1 of 6 patient records reviewed, the organization failed to ensure the hospice aide provide services that were ordered by the physician per the plan of care. for example, in RRDC#1, the HA POC had check vital signs every visit; however, the HA had not documented any vital signs in 4 visits. This observation was reviewed with the Administrator.

Observed in Record Review. In 2 of 6 patient records reviewed, with hospice aide services, the organization failed to ensure the RN assess the quality of care and services provided by the hospice aide (HA) to ensure the services meet the patient's needs no less frequently that every 14 days. In RRNHV#1, there had been a missed HA supervisory visit for the first 14 days of May. In RRDC#1, there had not been a documented HA supervisory visit after the 2nd week of April until the patients passing the first week of May. This observation was reviewed with the Administrator/DPCS.

Observed in Record Review. In 1 of 6 patient records reviewed, the organization failed to ensure the patient record is complete, promptly and accurately documented. For example, In RRNHV#1, the patient had been missing a documented HA supervisory visit. The HCO brought in a note stating the HA supervisory visit had been made, on a date where no nursing visit had occurred. The RN visit made the following day had a blank supervisory note. These observations were reviewed with the Administrator

Observed in Record Review. In 1 of 8 patient records reviewed, the organization failed to ensure the patient-specific comprehensive assessment identify the needs of the patient's family and other individuals focusing of the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. On review of RRNHV#5 there was no documentation that a initial bereavement risk assessment was conducted. This observation was reviewed with the Administrator/DPCS and RN Supervisor.

Observed in Record Review. In 7 of 8 patient records reviewed, the organization failed to ensure the plan of care was established with goals that were specific, measurable and time-bound. On review of the clinical records there was a pattern of goals that were not specific, measurable and time-bound. In RRHV#1 and example was: Pt will have adequate food and fluids as tolerated or desired. Pt will have adequate food and fluids to maintain comfort as exhibited by expressed. In RRHV#2 a goal read Will have adequate food and fluids as tolerated. In RRNHV#4 an example was Facilitate bowel elimination and comfort. Reduce discomfort with improved bowel elimination status. In RRNHV#5 and example was Maintain mobility and independence. Further examples can be seen in RRNHV#6, RRNHV#7, and RRNHV#8. Throughout the record it was also noted that most all achieve by dates were set the end of the benefit period. These observations were reviewed with the Administrator/DPCS and the RN Supervisor.

Observed in Record Review. In 5 of 8 patient records reviewed, for active records, the organization failed to ensure the plan of care include all services needed for the palliation and management of the terminal illness and related conditions. On review of RRHV#3 there was documentation of the patient having an allergic reaction with the addition of a Medrol dosepak, yet there was no care plan established to guide the care. In RRNHV#4 there was documentation of being seen by the social worker monthly yet there was no psychosocial care plan to guide the care. In RRNHV#5 there was documentation of issues with hypertension with parameters for medication administration but hypertension was not reflected in the care plan. In RRNHV#6 the patient was being seen by the social worker but no psychosocial care plan was established. Further, the patient had an ostomy, and the nurse documented providing passive range of motion exercises yet neither were reflected in the care plans. In RRNHV#8 the patient was on 2 different anticoagulants but there were no bleeding precautions reflected in the plan of care. These observations were reviewed with the Administrator/DPCS and RN Supervisor.

Observed in Record Review. In 4 of 8 patient records reviewed, for active records, the organization failed to ensure the pan of care include all services needed for the palliation and management of the terminal illness and related conditions to include a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs. On review of RRHV#2 the patient was being seen by the hospice aide per documentation yet there were no orders noted on the plan of care for the aide's frequency. On review of RRHV#3 the frequency order for the Medical Social Worker (MSW) read 1 time initial and as needed for psychosocial needs and support yet there was no indication how many as needed visits were ordered. Similar order was noted for the spiritual counselor (SC). Volunteer frequency was as needed and based on availability and patient/caregiver preference. There was no indication of a specific volunteer frequency. In RRNHV#4 there were similar non-specific frequency orders for the MSW, SC, and Volunteer. Further there was no specific order for the RN, the order read initial assessment, supervisory visit and ongoing comprehensive assessment, recertification and as needed for change in condition. Similar non specific frequency for the RN was noted in RRNHV#5. These observations were reviewed with the Administrator/DPCS and RN supervisor. Observed in Record Review. In 3 of 3 patient records reviewed, the organization failed to ensure the plan of care include all services needed for the palliation and management of the terminal illness and related conditions. On review of RRDC#1, RRDC#2, and RRDC#3 who were discharged live, there was no documentation of a discharge order noted on the clinical record. This observation was reviewed with the Administrator/DPCS and RN Supervisor.

Observed in Record Review. In 3 of 8 patient records reviewed, the organization failed to ensure the plan of care include all services needed for the palliation and management of the terminal illness an related conditions. On review of RRHV#3 there was an order for Medrol dose Pak that had instructions that stated as per pack instructed yet the order did not have specific instructions for use. In RRNHV#4 blood glucose test strips and lancet devices yet there was no specific physician order for blood glucose monitoring. In RRNHV#8 the patient had a foley catheter yet the plan of care noted to change monthly and prn. The order was incomplete as it lacked type, size of catheter and what situation to change as needed. These observations were reviewed with the Administrator/DPCS and RN Supervisor.

Observed in Record Review. In 3 of 8 patient records reviewed, The organization failed to ensure care was provided according to the patient's individualized plan of care. On review of RRNHV#4 the hospice aide frequency was specified as every other day yet the aide was seeing the patient 3 days a week. The Medical Social Worker (MSW) was ordered 1 time initial and as needed yet was documenting scheduled visits monthly. In RRNHV#5 the MSW documentation noted monthly visits yet the order was for 1 visit as needed and at recert. The Chaplain frequency was for 1 visit as needed and at recert but there was no documentation of a Chaplain visit documented at recert. In RRNHV#6 the MSW was ordered 1 time only yet documented monthly visits. These observations were reviewed with the RN supervisor and Administrator/DPCS.

Observed in Record Review. In 2 of 3 patient records reviewed, for bereavement records, the organization failed to ensure a bereavement plan of care that specified the type of bereavement services to be offered and frequency of service delivery was developed. In review of RRBR#1 there was no documentation that a bereavement plan of care was developed. In RRBR#3 there was documentation that bereavement services were declined prior to the patient death, yet there was documentation the bereaved was receiving bereavement letters but no bereavement plan of care. These observations were reviewed with the Administrator/DPCS and RN Supervisor.

Observed in HR File Review. In 1 of 1 HR files reviewed, for the hospice aide, the organization failed to ensure the staff competence was assessed and documented. On review of HR#2 for the hospice aide there were computer generated competency forms noted in the HR file that were uniform and all looked alike each year the forms specified as Ongoing Competency Assessment were checked that competency was assessed on-site and along with multiple areas checked as competent in such as patient rights, agency complaint mechanism, respect of patient property, basic home property, infection control, etc. There was another section that noted Care observed the included: Venipuncture, Wound care, Foley insertion, IV start, Blood Glucometer, and Vital Signs. The competencies in the aide's file noted the aide was competent to perform skills even though the aide was not qualified to perform the procedures. There was an identical form in the file for all years the clinician had been with the organization dating back to 2017. There were multiple other competency checklists noted in the files each signed by the aide and a supervisor. On discussion with the CEO, Administrator/DPCS, and RN Supervisor they noted that the forms were computer generated and signed but not following the process for competency assessment per policy.

Observed in Record Review. In 3 of 8 patient records reviewed, for active records, the organization failed to ensure the RN provide written patient care instructions for the hospice aide. On review of RRHV#2 there was no documentation of an aide plan of care, the plan of care was established yet it was blank with no tasks assigned. On review of RRHV#1 the aide was ordered to record vital signs yet there were no parameters provided to guide the aide as to when to report. In RRNHV#8 the patient was on Clopidogrel, Eliquis and Oxygen yet there were no bleeding precautions or oxygen precautions listed on the aide plan of care. These observations were reviewed with the Administrator/DPCS and RN supervisor.

Observed in Record Review. In 1 of 8 patient records reviewed, for active patients, the organization failed to ensure the hospice aide provide services that were ordered by the physician per the plan of care. In review of RRHV#2 the aide had documented three visits where the documentation noted patient tolerated bath care yet there were no aide tasks assigned as all tasks were blank on the plan of care. This observation was reviewed with the Administrator/DPCS and RN Supervisor.

Observed in Record Review. In 1 of 6 patient records reviewed, with hospice aide services, the organization failed to ensure the RN assess the quality of care and services provided by the hospice aide to ensure the services meet the patient's needs no less frequently that every 14 days. On review of RRNHV#4 the last documented RN aide supervisory visit was mid January with no further documentation of aide supervisory to date of survey. This observation was reviewed with the RN Supervisor and Administrator/DPCS.

Observed in Tracer Activities. Upon review of all tracer activities, it was noted that there was a pattern of staff failing to follow established organization policy and the governing body/leadership did not ensure that the Conditions of Participation for 418.100, 418.102, 418.104, 418.114, 418.116, and 418.56, and 418.76 were met per policy as determined through observations, documentation, and staff interviews.

Observed in HR File Review. In 6 of 9 HR files reviewed, the organization failed to ensure the skills and competence of all individuals furnishing care, including volunteers furnishing services. On review of HR#1, HR#3, HR#4, HR#5, HR#6, and HR#8 there were computer generated competency forms noted in the HR file that were uniform, and all looked alike each year. The forms specified as Ongoing Competency Assessment were checked that competency was assessed on-site and along with multiple areas checked as competent such as patient rights, agency complaint mechanism, respect of patient property, basic home property, infection control, etc. There was another section that noted Care observed that included: Venipuncture, Wound care, Foley insertion, IV start, Blood Glucometer, and Vital Signs. In all HR files except the Chaplain all care skills items were checked as observed and the clinician was competent even if the clinician was not qualified to perform the procedures. There was an identical form in the file for all years the clinician had been with the organization some dating back to 2017. There were multiple other competency checklists noted in the files each signed by the clinician and a supervisor. On discussion with the CEO, Administrator/DPCS, and RN Supervisor they noted that the forms were computer generated and signed but not following the process for competency assessment per policy. Observed in HR File Review. In 1 of 1 HR files reviewed, for new employees, the organization failed to ensure the staff competence was initially assessed and documented as part of orientation. In review of HR#7 for the volunteer, there was a computer generated competency form noted in the HR file specified as Ongoing Competency Assessment where checks noted that competency was assessed on-site and along with multiple areas checked as competent in such as patient rights, agency complaint mechanism, respect of patient property, basic home property, infection control, etc. There was another section that noted Care observed that included: Venipuncture, Wound care, Foley insertion, IV start, Blood Glucometer, and Vital Signs. In the HR files for the volunteer all care items were checked as observed and that the clinician was competent even though the volunteer was not qualified to perform the procedures. There were multiple competency checklists noted in the files each signed by the volunteer and a supervisor. On discussion with the CEO, Administrator/DPCS, and RN Supervisor they noted that the forms were computer generated and signed but not following the process for competency assessment per policy.

Observed in Record Review. In 1 of 8 patient records reviewed, for active records, the organization failed to ensure the Medical Director provide written certification that the patient's life expectancy was six months or less if the illness runs its normal course to include all required elements such as current subjective and objective findings. On review of RRHV#2 the physician's narrative on the Certificate of Terminal Illness (CTI) stated Patient meets LCD Medical Guidelines to receive hospice service, signed Certification of Terminal Illness. Patient is admitted to hospice care under routine level of care. Patient is certified for hospice and is appropriate for hospice admission with a terminal prognosis of 6 months or less if disease process follows its normal course. The statement lacked all required elements as it lacked related diagnosis and current subjective and objective medical findings. This observation was reviewed with the Administrator/DPCS, CEO, and RN supervisor.

Observed in Record Review. In 2 of 14 patient records reviewed, the organization failed to ensure that before the recertification period the medical director or physician designee review the patient's clinical information. On review of RRDC#2 it was noted it was noted the started hospice on benefit period (BP) #3. The certificate of terminal illness was signed by the physician for recertifications in BP #4, 5, 6, and 7. For BP's number 8, 9, 10 an 11 the CTI was noted to not be signed by the physician and was noted in the signature line to have signature on file/verified by ****,***RN. When asked for the signatures on file the leadership was unable to produce. Further the physician narrative lacked any current subjective and objective clinical information. In RRNHV#4 the recertification CTI had similar lack of current subjective and objective findings. This observation was reviewed with the Administrator/DPCS and RN Supervisor.

Observed in Record Review. In 1 of 8 patient records reviewed, the organization failed to ensure the patient record contain all information to reflect the patient's care, treatment, and services. On review of RRNHV#4 there was a noted 27 day gap in RN comprehensive assessment documentation. On discussion with the Administrator/DPCS and RN Supervisor in was verified through a route sheet that the visit was made as ordered yet the documentation was not entered into the record as required by policy. This observation was reviewed with the Administrator/DPCS and RN Supervisor. Observed in Record Review. In 1 of 3 patient records reviewed, the organization failed to ensure the patient record contain all information to reflect the patient's care, treatment, and services. On review of RRBR#3 there was no documentation in the record of a patient visit at the time of death and who attended the patient death. This observation was reviewed with the Administrator/DPCS and RN Supervisor. Observed in Record Review. In 1 of 3 patient records reviewed, for live discharge, the organization failed to ensure the patient record contain all information to reflect the patients care, treatment, and services. On review of RRDC#2 who was discharged for extended prognosis, there was no documentation noted in the record to support that the patient was no longer terminally ill. There were two nursing visits and a social worker visit documented in the days leading to discharge date yet the documentation did not indicate that the patient was being discharged. This observation was reviewed with the Administrator/DPCS and RN Supervisor.

Observed in Record Review. In 7 of 8 patient records reviewed, the organization failed to ensure all entries to the clinical record are authenticated per policy. Throughout the clinical record it was noted that the entries to the record were not authenticated as required. In review of RRHV#1 an example was all LVN visit notes were in review status in the EMR and not signed and dated in the EMR by the clinician. In RRHV#2 the last 2 LVN notes were in review status and not signed/dated, and all but one hospice aide notes had been submitted by the nurse on behalf of the aide and not signed and dated by the clinician. In RRNHV#4 all of the Aide visit notes were not properly authenticated by the aide as they were either submitted on behalf of the aide by the RN or not fully submitted in the system. Further examples can be seen in RRHV#3, RRNHV#5, RRNHV#6, and RRNHV#7. These observations were reviewed with the Administrator/DPCS and RN Supervisor.

Observed in Record Review. In 2 of 3 patient records reviewed, for live discharges, the organization failed to ensure the receiving facility was provided with a copy of the hospice discharge summary and , if requested, a copy of the patient's clinical record. On review of RRDC#1 and RRDC#3 the patient's revoked care to enter a hospital yet there was no documentation that a discharge summary was sent to the receiving facility. This observation was reviewed with the Administrator/DPCS and the RN Supervisor.

Observed in Record Review. In 3 of 3 patient records reviewed, for live discharge, the organization failed to ensure the discharge summary was provided to the patient's attending physician as required. On review of RRDC#1, RRDC#2, and RRDC#3 there was no documentation that the discharge summary was provided to the patient's attending physician. These observations were reviewed with the Administrator/DPCS and RN Supervisor.

Observed in Record Review. In 3 of 8 patient records reviewed, for active patients, the organization failed to ensure the patient record is complete, promptly and accurately documented. On review of RRHV#1 the medical record number on the patient consents and admission documents was different that the number listed in the EMR as the patient medical record number. On discussion with the Administrator/DPCS it was acknowledged that the medical record number written on the admission paperwork was an error. In RRNHV#4 there was documentation of a spiritual counselor visit/assessment prior to the patient admission. The Administrator/DPCS and RN Supervisor noted that the spiritual documentation was likely submitted in error. In review of RRNHV#5 the hospice aide services were declined and no aide services were being provided, yet in each RN comprehensive assessment there was a Aide supervisory visit documented. These observations were reviewed with the Administrator/DPCS and RN Supervisor.

Observed in HR File Review. In 9 of 9 patient records reviewed, the organization failed to ensure criminal background checks were obtained on all hospice employees who have direct patient contact or access to patient records. On review of all HR files it was noted the organization utilized a computer site to obtain background checks that clearly stated you may not use this information when evaluating a person for employment, reassignment, promotion, or retention. This observation was reviewed with the CEO, and Administrator/DPCS.

Observed in Record Review. In 7 of 8 patient records reviewed, the organization failed to ensure compliance with all applicable federal, states and local laws and regulations related to the health and safety of patients. On review of all active records except RRNHV#6 there was no documentation that the Patient Notification of Hospice Non-Covered Items, Services, and Drugs was addressed with the patient/patient representative. Discussion with the Leadership noted the organization was using an outdated election of benefits form that lacked the information, but had updated the form. When the new form was used the section to elect or decline the Notification addendum was left blank. This observation was reviewed with the Administrator/DPCS and the RN Supervisor.

Observed in Individual Tracer. HV1, during the home visit, the surveyor noted the organization failed to demonstrate it implemented its use of standard precautions, including the use of personal protective equipment, to reduce the risk of infection. For example, during HV1, the aide failed to change gloves or perform hand hygiene prior to direct contact with the patient. The aide was observed to don gloves, then proceed to conduct all the bath set up, including handling supplies, moving equipment, touching the faucet etc., however, did not change gloves or conduct hand hygiene prior to direct contact with the patient. This was not compliant with the organization's Hand Hygiene Policy and validated by the Nursing Supervisor.

Observed in Individual Tracer. In 1 of 1 home visits conducted, The surveyor noted the organization failed to orient and train the aide on specific job duties, particularly those within the scope of practice. For example, HV1, during the home visit, while the aide demonstrated compliance with the assignment sheet and stated she would contact the nurse if she noted any change in condition, she also stated that if she noted the patient was not feeling good or appeared to have respiratory distress, she would obtain vital signs and a pulse oximeter. She stated she had this equipment in her bag and was competent in the use of the equipment. The personnel file reflected the aide had demonstrated competency with obtaining vital signs, however did not have documented training or competence on the use of a pulse oximeter. This was brought to the attention of the Nursing Supervisor who stated that obtaining a pulse oximeter was not compliant with organization policy or an expectation however the aide should have been oriented on scope of practice.

Observed in Record Review. In 3 of 3 patient records reviewed, that had wounds, the organization failed to ensure that the patient receive a patient-specific comprehensive assessment and reassessment to identify patient needs. For example: during review for RR#5 it was documented in a progress note that the patient sustained a fall and obtained a skin tear/laceration. There is no indication in the clinical record that an assessment took place after the fall and injury to assess for patient needs related to the change in status. This patient fall and injury was documented on 11/5 however there is no further mention in the record of the fall and there is no comprehensive wound assessment noted in the record until done by a wound care consult on 11/23. There has been no weekly wound care assessment by the SN to date. Similar lack of wound care comprehensive by the SN can also be seen in HV#2 and RR#9. This observation was reviewed with the CEO and the QAPI Assistant.

Observed in Record Review. In 4 of 11 patient records reviewed, The organization failed to update the comprehensive assessment as frequently and the patient's condition requires but no less than 15 days. For example: in HV#3 there was a noted 32 day gap in RN comprehensive assessment visits. In RR#5 there were gaps of 33 days, and a gap to date of survey of 26 days since an RN comprehensive assessment. Example 2: In RR#6 it was noted that the RN IDG summary documented was the same over 6 IDG meetings. In HV#1 there were multiple IDG meetings where no RN summary/update was included in the meeting documentation for the last 2 IDG meetings. This observation was reviewed by the CEO, and the QAPI Assistant.

Observed in Record Review. In 8 of 8 patient records reviewed, active clinical records reviewed, the organization did not ensure that the individualized plan of care reflected goals based on the patients needs, nor that the plan of care was individualized, specific, and measurable. For example: Throughout all active records reviewed many of the goals were noted to not be measurable and almost all were set to a time frame of 2 weeks. For example in HV#3 examples of established goals were ADL needs will be met for the next two weeks of hospice care. In RR#7 a goal states maintain optimum peripheral circulation for the next 2 weeks and prevent potential skin problems for comfort for the next 2 weeks, another states minimize complications due to impaired mobility Similar non-specific, non-measurable goals can be see throughout all records reviewed. These observations were reviewed with the CEO, and QAPI Assistant.

Observed in Record Review. In 9 of 11 patient records reviewed, the organization failed to provide care per the detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs. For example: upon review of HV#2 the LVN was ordered visits 2 times a week. There was a gap in SN visits from week 13 of benefit period 1 to week 4 of benefit period 2. There is also only one visit for week 8 of benefit 2. Further the hospice aide was scheduled a frequency of 1 time a week yet no aide visit was made for week 11 of benefit 1. Further in was noted that in all record except RR#6 and RR#7, the RN was not assigned a frequency as order states RN for initial assessment, supervisory visit, and ongoing comprehensive assessment, recertification and as needed. There observations were reviewed with the CEO and QAPI assistant.

Observed in Record Review. In 9 of 11 patient records reviewed, the organization failed to ensure that the plan of care was revised and updated based on the patient's comprehensive assessment and did not note the patient's progress toward outcomes and goals. For example: noted as a pattern throughout all records reviewed with the exception of short length of stay discharge records, there was a lack of documentation of progress toward outcomes and goals, nor changes in interventions and/or goals to account for changes in patient status or response to implementation of established interventions. The care plan goals and interventions remained the same from IDG to IDG with only the dates changing for each IDG period. This observation was reviewed with the CEO and the QAPI Assistant.

Observed in Record Review. In 2 of 5 patient records reviewed, that were receiving hospice aide services, the organization failed to ensure that the care and services were provided in accordance with the plan of care. For example: in HV#1 the hospice aide assignment specifies a shower for the patient's bath, however on 1/10/22 and 3/28/22 the aide documented at the patient was given a bed bath. Similar findings of documenting a bed bath when a shower was ordered was noted in RR#8. There is no indication that the RN was notified of the change in the bath type. This observation was reviewed with the CEO and QAPI Assistant.

Observed in Record Review. In 1 of 11 patient records reviewed, the organization failed to ensure the ongoing sharing of information between all disciplines providing care and services. For example: in RR#5 there is a communication note documenting a report that there was a patient fall resulting in an injury while the hospice aide was providing care for the patient. There is no indication in the record that the fall was reported by the HA to the RN, and further there is no documentation that the fall was reported to the physician or the IDG team. This observation was reviewed with the CEO, and the QAPI Assistant.

Observed in Patient Home. In 1 of 3 home visits conducted, the LVN failed to follow organization policy to prevent the transmission of infections and communicable diseases as during home observation in HV#1 the LVN dropped the box of gloves on the floor at the beginning of the visit and did not pick them up but continued to access the gloves for use from the box on the floor. This observation was reviewed with the Director of Nursing.

Observed in Record Review. In 1 of 8 patient records reviewed, that were receiving hospice aide services, the organization failed to ensure that the aide had written patient care instructions to guide the patient care provided. For example: in HV#2 the patient had wound dressings yet there were no instructions for how the aide was to handle the dressings during a bath. This observation was reviewed with the QA assistant.

Observed in Record Review. In 1 of 8 patient records reviewed, where aide services were ordered, the organization failed to ensure the HA provided care that was consistent with the hospice aide training. For example: upon review of HV#2 the hospice aide documented Assisted with dressing. Pressure ulcer noted on scarococcyx and right malleolus. All covered with clean and dry dressing. Negative for infection and wound is improving. During the home observation along with the aide for this patient, when asked what she does with the dressings during the bath, the aide responded that she never changes a dressing but if the outer portion gets wet she will replace the wet to make she the patient stays dry. This observation was reviewed with the CEO and QAPI Assistant.

Observed in Record Review. In 5 of 5 patient records reviewed, where HA supervisory visits were due, the organization failed to document supervisory visits for the hospice aide to assess the quality of care and services provided and to ensure that services ordered by the hospice IDG meet the patient's needs. For example: In HV#1 the last hospice aide supervisory documented dated back three months from the date of survey. In HV#2 there was also a noted gap in documentation of hospice aide supervisory for a greater than a 3 month period, from early January to mid March of 2022. Further many supervisory visits conducted by the RN were done via telecommunication an not on-site. Similar gaps greater than 14 days in hospice aide supervisory visit by the RN can be found in RR#5, RR#8, and RR#4, where no supervisory visits have been documented to date. This observation was reviewed with the CEO and QAPI Assistant.

Observed in Record Review. In 1 of 8 patient records reviewed, that were receiving hospice aide services, the organization failed to conduct an on-site visit when an area concern was noted. For example: in RR#5 it was reported that the patient sustained a fall with injury during the aides visit yet no on-site supervisory was conducted to observe and assess the aide while he or she was performing care. This observation was reviewed with the CEO and the QAPI Assistant.

Observed in Leadership Session. The governing body/leadership did not ensure that the following Conditions of Participation were met as determined through observations, documentation, and staff interviews:  - §418.100 and 418.104, 418.56, 418.54, and 418.76.

Observed in Record Review. In 6 of 11 patient records reviewed, the organization failed to ensure the physician's narrative for hospice certification contained all of the required elements to include the primary terminal condition, current subjective and objective medical findings, current medication and treatment orders, and information about the conditions unrelated to the terminal prognosis. For example in HV#2 in the certification for terminal illness the physician's narrative lacks all of the required elements as it states the the patient meets LCD Medical guidelines to receive hospice service, signed certificate of terminal illness. Patient is certified for hospice and is appropriate for hospice admission with a terminal prognosis of 6 months or less if disease follows its normal course. Similar findings can be seen in RR#9, RR#10,RR#11, RR#7, RR#6. Additionally RR#6 benefit period #2 has not been completed by the physician. This observation was reviewed with the CEO and the QAPI Assistant.

Observed in Record Review. In 7 of 11 patient records reviewed, The organization failed to ensure that the clinical record contained complete and accurate patient records. For example in HV#1, and HV#2 the RN comprehensive visits were conducted via telecommunication and not face to face in the patient home, however the record for these visits contained documentation of assessments such as lung sounds, edema levels, pulses, bowel sounds, skin turgor, along with O2 sat and vital signs. Similar findings were noted for telephonic visits completed for the initial assessment for HV#3, and multiple telephonic visits completed for RR#4, RR#5, and RR#6. Further there is noted conflicting information noted in the record. In HV#2 the documentation on 1/24 states the patient's wounds are stage 2 yet further down in the narrative in notes the wounds as stage 3 and 4. In the skin assessment for 3/21 the RN documents 3 stage 2 wounds yet the LVN's documentation the next day notes 2 stage 4 wounds with marked differences in measurements. Additional examples of conflicting documentation is noted in RR#4 where each IDG meeting states the HA is declined yet there is an order for HA services and the visits were beings made. In HV#3 upon recertification the recertification order specifies the patient's diagnosis was Colon Ca, however the patient's terminal diagnosis is Cancer of the Larynx. In RR#10 the RN documented a aide supervisory visit two weeks prior to the aide beginning services. These observations were reviewed with the CEO and the QAPI Assistant.

Observed in Record Review. In 6 of 11 patient records reviewed, the organization failed to ensure the record contained pertinent information to reflect the patient's care treatment and services. For example: many of the RN visits were documented as being accomplished via telehealth, however the documentation lacked platform used and consent of the patient/caregiver as required. These observations were reviewed with the CEO and the QAPI Assistant.

Observed in Record Review. In 1 of 11 patient records reviewed, the organization failed to ensure the patient medical record included information that reflects the patient's care, treatment, and services. For example: in HV#1 the patient was prescribed diclofenac gel and the medication profile failed to specify to what location the medication was to be applied. Further the instructions for Calcium supplement note that the medication is included in the comfort pack and to be used as a suppository, yet the medication is not a comfort medication and is not a suppository. This observation was reviewed with the Director of Nursing and the QAPI Assistant.