Every finding on record at Gmg Hospice and Palliative Care, Inc

Upon patient record review, 2 of 5 (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 equipment and supply needs. Patient 1: During the home visit, it was observed that the patient has a walker, a cane, a shower chair, and an order for PRN oxygen. Patient records indicate the patient has urinary and bowel incontinence. No incontinence supplies listed on the POC. Patient 2: Patient record indicate the patient has urinary and bowel incontinence, uses a cane, and has a shower chair. No incontinence supplies or equipment listed on the POC.

Upon client record review, 5 of 5 (Patient #1,2,3,4,5) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 1: POC has orders for SC visits once weekly. The record indicates that one visit occurred on 09/12/2024, which was the initial spiritual visit. No evidence that any other visits occurred during the month of September. The record indicates that one visit occurred on 10/03/2024 for the month of October. No orders to discontinue or change the frequency of these visits noted. POC has orders for MSW visits once a month. The record indicates that one visit occurred on 09/12/2024, which was the initial psychosocial visit. No evidence that a visit for the month of October was completed. No orders to discontinue or change the frequency of these visits noted. POC has orders for SN 2-3 month. SN visited the patient on 10/10, 10/16, 10/23, 10/24, and 10/30. No orders to change the frequency of the SN visits. Patient 2: POC has orders for MSW visits once a month. No evidence that a visit for the month of October was completed. No orders to discontinue or change the frequency of these visits noted. POC has orders for SN visits weekly. SN visited the patient twice during the week of 10/06 (10/11, 10/12) and the week of 10/20 (10/25, 10/26). No orders to change the frequency of the SN visits. Patient 3: POC has orders for MSW visits once a month. No evidence that a visit for the month of October was completed. No orders to discontinue or change the frequency of these visits noted. POC has orders for SN visits 2-3 month. The LVN has visited the patient weekly for the month of October and the RN has visited the patient twice for the month of October. No orders to change the frequency of the SN visits for those weeks. Patient 4: POC has orders for MSW visits once a month. No evidence that a visit for the month of October was completed. No orders to discontinue or change the frequency of these visits noted. POC has orders for SN visits weekly. SN visited the patient twice during the week of 10/13 and 10/27. No orders to change the frequency of the SN visits for that week. Patient 5: POC has orders for MSW visits once a month. No evidence that a visit for the month of October was completed. No orders to discontinue or change the frequency of these visits noted. POC has orders for SN visits 2-3 month. The LVN has visited the patient weekly for the month of October and the RN has visited the patient twice for the month of October. No orders to change the frequency of the SN visits for those weeks.

Upon patient record review 14 of 14 (Patient #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14) 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. Patient #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 14: No evidence of an initial comprehensive SC assessment being completed, spiritual assessment in RN Admission assessment blank. Patient #13: No evidence of an initial comprehensive SC or Psychosocial assessment being completed.

Upon patient record review, 1 of 14 (Patient #2) 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: Initial POC dated 3/15/24 doesn't contain any medications.

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

Upon patient record review, 3 of 14 (Patient #1, 2, 5) 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 #1: Initial POC dated 3/21/24 ordered SN 2-3 time month and 5 PRN visits. Too many PRN visits ordered as a frequency. Patient #2: Initial POC dated 3/15/24 didn't contain frequency orders for SN and SC. Episode POC dated 7/5 didn't contain any frequency orders for SN, SC, and MSW. Patient #5: POC dated 7/4/24 doesn't contain frequency order for SN, SC, and MSW.

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 equipment and supply needs. Patient #1: During the home visit, it was observed that patient has hospital bed and hospital bed table. POC dated 3/21, 5/20 and 7/19 includes orders for Oxygen. Patient is incontinent per medical records. No supplies or equipment listed on any of the POC's. Patient #2: During the home visit, it was observed that the patient has a hospital bed, walker and a order for oxygen. Patient records indicate the patient has urinary and bowel incontinence. No supplies or equipment listed on any of the POC's.

Upon client record review, 14 of 14 (Patient #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14) did not have evidence that the IDG in collaboration with the attending physician reviewed, revised and documents the individualized plan as frequently as the patient's condition requires but no less frequently then every 15 calendar days. Patient #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 14: Initial IDG/POC and all subsequent IDG/POC doesn't contain the name or signature of the Chaplain. There is no evidence to support SC was present and participated in any IDG meeting and plan of care development. Patient #13: Initial IDG/POC and all subsequent IDG/POC doesn't contain the name or signature of the Chaplain. There is no evidence to support SC was included in the development of the POC and IDG meeting. Initial POC dated 1/19/2023 only signed by RN. No evidence the MD, MSW or SC participated in the development of the plan of care.

Upon patient record review, 6 of 14 (Patient #1, 2, 4, 5, 6, 12) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1: Initial POC dated 3/21/24 ordered SN 2-3 time month and 5 PRN visits. Patient was seen by the RN every 14 days and by the LVN 1 time every week. No evidence to support an order changing the frequency of SN visits. No evidence to support any of the visits were PRN. Initial POC didn't contain any orders for MSW. IDG/Update to POC dated 4/5 listed MSW frequency as "eval only for episode 3/21 - 5/19". MSW visit on 4/24. Narrative stated "MSW made her monthly follow up telephonic consultation services." No evidence of any orders for this service. POC dated 5/20 ordered MSW 1xmonth. No evidence of a visit made in July. June visit was conducted by phone/telehealth. No order for telehealth visits. Patient #2: POC dated 5/12/24 ordered MSW 1xwk. MSW saw patient 1xmo on 5/19, 6/19. POC dated 7/5 didn't contain any MSW frequency. MSW saw patient on 7/19. No order for this visit. POC dated 7/5 didn't contain any SN frequency. SN saw the patient on 7/8, 7/15, 7/19 and 7/22. No orders for these visits. Patient #4: POC dated 7/28/24 ordered SN 2-3xmonth. SN saw patient weekly on 8/6, 8/11, 8/13, 8/20, 8/25, 8/27, 9/3 and 9/8. No evidence to support an order for an increase in frequency. Patient #5: POC dated 3/13/24 ordered MSW 1xmo. No evidence of any visits after initial assessment on 3/15. POC dated 7/4 didn't contain any SN orders. SN saw patient on 7/9. No evidence of an order for this visit. Patient #6: POC dated 3/14/24 ordered MSW for eval only for episode 3/14-5/12. MSW saw patient 1xmo. No evidence of an order for these visits. Patient #12: POC dated 6/21/24 ordered MSW 1xwk. MSW only saw patient 1x a month in June, July and August. No evidence of an order to decrease the frequency.

Upon observation, there was no evidence the board of directors/governing body approves the frequency and detail of the data collection. No meeting minutes for any governing body meetings.

Upon observation, there was no evidence of involvement of the governing body and organizational leaders in the Quality Assessment/Performance Improvement (QAPI) program. No meeting minutes for any governing body meetings. No evidence to support that the governing body is involved in the QAPI program.

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. No meeting minutes for any governing body meetings.

Condition of Participation: Core Services.

Upon observation, there was no evidence Bereavement counseling services are available to the patient and family to assist the patient and family in minimizing the stress and problems that arise from the terminal illness, related conditions and the dying process. There is no evidence in any personnel file that a qualified person occupies the role of bereavement counselor. Agency reported that the MSW is the BC but there is no evidence the MSW is qualified to perform this role as evidenced by there is no job description, orientation, or skills checkoff in the personnel file and no evidence in any patient chart that the MSW is providing these services. Agency reported that the DPCS Designee oversees the bereavement and sends out the letters.

Upon personnel record review, 1 of 12 (Personnel # 5) did not have evidence that all bereavement services are provided by a qualified counselor in accordance with applicable laws and regulations, professional practice standards, the hospice's policies and procedures and/or job descriptions which includes experience or education in grief or loss counseling. There is no evidence in any personnel file that a qualified person occupies the role of bereavement counselor. Agency reported that the MSW is the BC but there is no evidence the MSW is qualified to perform this role as evidenced by there is no job description, orientation, or skills competency checkoff in the personnel file.

Upon patient record review, 14 of 14 (Patient #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13 14) did not have evidence of a spiritual comprehensive assessment, spiritual assessment in RN Admission assessment blank. No evidence to support that patient/caregivers were offered or provided with spiritual counseling. Initial POC and IDG notes don't include any information about the wishes or needs of the patient spiritually.

Upon patient record review, 2 of 14 (Patient #2,5) 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 #2: Initial POC dated 3/15/24 didn't contain frequency orders for the aide. Episode POC dated 7/5 didn't contain any frequency orders for the aide care plan it was left blank. Patient #5: POC dated 7/4/24 doesn't contain frequency order for the aide care plan it was left blank.

Upon patient record review 1 of 14 (Patient #5) 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 #5: POC dated 7/4/24 didn't contain any Aide orders. SN saw patient on 7/9. Aide saw patient on 7/8 and 7/11. No evidence of an order for these visits.

Upon observation, there was no evidence BOD/governing body minutes reflect the involvement in the hospice's management and administration of its resources to provide hospice services to patients and families. Agency does not have any meeting minutes for the Governing body. Office manager reports they do not document meeting minutes and only have a quarterly sign in sheet. Sign in sheet consisted of typed names but no signatures. No evidence to support who attended and what was discussed at the meetings. It is unclear who is on the Governing Body and what is discussed at the meetings. There is no evidence to support the governing body has oversight of the Administrator as no annual evaluation is present, no QAPI review, and no annual review of Policies and Procedures.

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. No evidence to support the governing body has oversight of the Administrator as evidenced by no annual evaluation of the Administrator, no review of the agency QAPI program and no annual review of Policies and Procedures.

Upon personnel record review, 4 of 12 (Personnel #1, 2, 5, 7) did not have evidence that the hospice employees have received orientation on their specific job requirements. Personnel #1: No evidence of orientation to Administrator or DPCS role Personnel #2: No evidence of orientation to alternate Administrator or alternate DPCS role Personnel #5: No evidence of orientation to Bereavement Coordinator role Personnel #7: No evidence of orientation to Volunteer Coordinator role

Upon personnel record review, 4 of 12 (Personnel #5, 7, 8, 9) 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 #5: No evidence of a skills competency for Bereavement Coordinator Personnel #7: No evidence of a skills competency for Volunteer Coordinator Personnel #8: No evidence of a skills competency for Volunteer Personnel #9: No evidence of a skills competency for Medical Director

Condition of Participation: Clinical Records.

Upon patient client record review, 12 of 14 (Patient #1,2,3,4,5,6,7,8, 9,10,11,12) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient #1: Patient notification of Hospice Non-Covered Items was left blank only contained the caregiver signature that they received a copy. Patient #2: Patient notification of Hospice Non-Covered Items was left blank only contained the patient signature that they received a copy. Patient #3: Patient notification of Hospice Non-Covered Items was left blank only contained the caregiver signature that they received a copy. Patient #4: Patient notification of Hospice Non-Covered Items was left blank only contained the caregiver signature that they received a copy. Patient #5: Patient notification of Hospice Non-Covered Items was left blank only contained the caregiver signature that they received a copy. Patient #6: Patient notification of Hospice Non-Covered Items was left blank only contained the caregiver signature that they received a copy. Patient #7: Patient notification of Hospice Non-Covered Items was left blank only contained the caregiver signature that they received a copy. Patient #8: Patient notification of Hospice Non-Covered Items was left blank only contained the caregiver signature that they received a copy. Patient #9: Patient notification of Hospice Non-Covered Items was left blank only contained the caregiver signature that they received a copy. Patient #10: Patient notification of Hospice Non-Covered Items was left blank only contained the caregiver signature that they received a copy. Patient #11: Patient notification of Hospice Non-Covered Items was left blank only contained the caregiver signature that they received a copy. Patient #12: Patient notification of Hospice Non-Covered Items was left blank only contained the caregiver signature that they received a copy.

Upon patient client record review, 1 of 14 (Patient #1) did not have evidence that each patient record contains Physician certification and recertification of terminal illness. Patient #1: CTI dated 3/21/2024 missing Attending physician name and there is not a returned signed copy.

Upon patient client record review, 5 of 14 (Patient #1, 3, 8, 12, 13) 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 #1: Page #1 of 2 of the Election of Medicare Hospice Benefit has spouses name written in the patient name spot "I choose" instead of the patient name being written in. Informed Consent form page 1 has spouses name written in the patient name spot. Patient was unable to sign consents themselves and spouse signed all forms. DPCS designee stated that she filled out the paperwork and entered the spouses name in error. In addition, the RN assessment dated 7/25 lists patient nutrition as difficulty swallowing, NAS, pureed and mechanical soft diet. It is unclear if the diet should be pureed or mechanical soft. Patient #3: Page #1 of 2 of the Election of Medicare Hospice Benefit has daughters name/daughter written in the patient name spot "I patients daughter choose" instead of the patient name being written in. Informed Consent form page 1 has (dtr name) written in the patient name spot. Patient was unable to sign consents and daughter signed all forms. Patient #8: Page #1 of 2 of the Election of Medicare Hospice Benefit has POA written in the patient name spot "I POA choose" instead of the patient name being written in. Informed Consent form page 1 has POA (dtr name) written in the patient name spot. Patient was unable to sign consents and POA signed all forms. Patient #12: Page #1 of 2 of the Election of Medicare Hospice Benefit has daughters name/daughter written in the patient name spot "I patients daughter choose" instead of the patient name being written in. Informed Consent form page 1 has (dtr name) written in the patient name spot. Patient was unable to sign consents and POA signed all forms. Patient #13: Page #1 of 2 of the Election of Medicare Hospice Benefit has patients son written in the patient name spot "I (son) choose" instead of the patient name being written in. Informed Consent form page 1 has "(son)" written in the patient name spot.