Every finding on record at Good Samaritan Healthcare LLC

Upon observation, there was not evidence that the Emergency Preparedness Plan includes strategies for addressing those Emergency Events as identified by the Hazard Vulnerability Risk Assessment, that would affect the Hospice's ability to continue to provide care/services to their Hospice patients.

Upon patient record review, 1 of 6 (Patient #1) did not contain a current/comprehensive Medication Profile and/or evidence that a Drug Regimen Review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. Patient #1: Had Oxygen ordered at 4 lpm continuous. This was not included on the Medication Profile

Upon patient record review, 2 of 6 (Patients #1 and 3) did not contain evidence that the Plan of Care included all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments: Patient #1: Had Oxygen ordered at 4 lpm continuous. This was not included on the Hospice POC. Patient #3: A Physician order was obtained on 10/23/21 to suction secretions for patient as needed. It is not clear as to which device/supply should be used when suctioning. Additionally, a Physician order was obtained for 11/18/21 to 01/03/22 for, "Cleanse bilateral lower legs with wound cleanser, pat dry, apply Zero-form Gauze, then dry dressing. Complete 2x per week, and as needed till healed." It is not clear who is responsible for this wound care nor was there a reason for the as needed change.

Upon patient record review, 2 of 6 (Patients #4 and 5) did not contain evidence that the IDG had ensured that care/services were provided in accordance with the Plan of Care: Patient #4: The Hospice POC ordered Chaplain visits at a frequency of 1x per month. The Chaplain initially made a visit on 11/29/21 (SOC), and then no more visits were made/documented. Patient is still currently on service. Patient #5: SOC 09/16/21. An order was received on 09/17/21 for, "Left great toe lateral pressure ulcer. Cleanse with wound cleanser, apply Calcium Alginate/Silver, then dry dressing. Two times weekly and as needed if soiled." The patient lived in a Group Home. The order is not clear as to 'who' was to provide this dressing change, the Hospice RN or in-home caregiver. The next Hospice nurse home visit after this order was received was made on 09/20/21, wherein the nurse documented, "No skin issues observed or reported." The next SN visit on 09/28/21, there was no mention of such wound or wound interventions by either the Hospice nurse, or Group Home personnel. It did not appear that this wound order was ensured by the Hospice.

Upon patient record review 1 of 5 applicable (Patient #1) did not contain evidence that the Hospice Aide provided services that are ordered by the IDG and included in the plan of care. The Aide POC effective 11/27/21 assigned the following: 1) Shampoo Hair; 2) Comb Hair; 3) Clean Dentures; and 4) Encourage fluids. Shampoo Hair, Comb Hair, and Clean Dentures was not provided/documented on the 01/21/22 nor 01/25/22 home visits. Encourage fluids was not provided/documented on the 01/21/22 visit.

Upon patient record review, 6 of 6 (Patients #1, 2, 3, 4, 5, and 6) did not contain evidence that each patient record contained: A signed Election Of Hospice Benefit Statement, which includes all required content, in accordance with 418.24: Patient #4: The section of the EOB where the effective date of the election was to be entered had been left blank. Patients 1, 2, 3, 4, 5, and 6: Election of Hospice Benefit Statement used by the agency did not contained the additional requirements that went into affect Oct 2020.

Upon patient record review, 1 of 6 (Patient #3) did not contain evidence that all entries are clear/complete. A Physician order was obtained for 11/18/21 to 01/03/22 for "Cleanse bilateral lower legs with wound cleanser, pat dry, apply Zero-form gauze, then dry dressing. Complete 2x per week, and as needed till healed." On the 11/18/21 home visit, the nurse documented that she provided ordered wound care, but did not document the details of the wound care provided.

Upon in-patient contract review, 1 of 1 (PHF) did not contain verbiage that the Hospice must supply the in-patient provider with a copy of each patient's Plan of Care, which specifies the in-patient services to be furnished.

Upon in-patient contract review, 1 of 1 (PHF) did not contain verbiage requiring that a copy of the Discharge Summary must be provided to the Hospice at the time of the patient's discharge from such in-patient facility.

Upon personnel record review, 1 of 1 applicable (Personnel #4) did not contain evidence that the Hospice had obtained a Criminal Background Check (CBC) on all contracted individuals who have direct patient care and access to patient records, in accordance with Arizona-state requirements. Arizona Code Section 36-411requires a State and Federal Criminal Background Check. Personnel #4 had a Arizona-state-only CBC in their file. No Federal CBC had been conducted. This was conducted while Surveyor was yet on-site.

Upon personnel record review, 10 of 10 applicable (Personnel #1, 2, 3, 5, 6, 7, 8, 9, 10, and 11) did not contain evidence of Criminal Background Checks (CBC) having being obtained in accordance with Arizona-state requirements. Arizona Code Section 36-411 requires a State and Federal Criminal Background Check. All of these employees had a Arizona-state-only CBC in their files. No Federal CBC had been conducted.