Every finding on record at Grandview Hospice Inc

Upon patient record review, 2 of 5 (Patient #2, 3) 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 The medication profile for Nystatin and Voltaren reads "apply to affected areas." The medication profile does not specify where the medication should be applied. Patient #3 Upon inspection of patient medications during the home visit, it is noted that the patient has temazepam and ciclopirox that she currently utilizes that is not included in the medication profile.

Upon patient record review, 1 of 5 (Patient #5) 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 #5 There is no evidence that a bereavement assessment was completed within 5 days of admission or to date.

Upon patient record review, 1 of 5 (Patient #2) 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 #2 The plan of care does not include the problem, goals or interventions related to treatment and/or management of the patient wounds as identified in the comprehensive assessment.

Upon patient record review, 2 of 5 (Patient #2, 3) 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 #2 The orders for Nystatin and Voltaren read "apply to affected areas." The order is not specific to where the medication should be applied. The patient has a wound to her coccyx that is being treated by the nurse with no wound care orders listed. Patient #3 Medications found at the patient home include temazepam and ciclopirox that are not included in the plan of care.

Upon patient record review, 1 of 5 (Patient #2) did not have evidence that the IDG shares information on a on-going basis with non-hospice healthcare providers furnishing services unrelated to the terminal illness and related conditions. Patient #2 Upon home visit, surveyor received information that the patient receives homemaker & sitter services from a community program funded by her Medicaid benefit. There is no evidence in the patient record regarding the coordination or collaboration of care, and there is no evidence of communication with that agency or the staff to coordinate services.

Upon patient record review, 1 of 11 (Patient # 2) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient #2 has no documentation of election statement so unable to evidence the patient chose the attending physician.

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

Upon patient record review 1 of 11 (Patient # 7) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. #7: Patient admitted 9/13/21 with initial order for MSW 1x within 5 days. MSW did not complete assessment until visit on 9/20/21.

Upon patient record review, 1 of 11 (Patient # 7) 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 #7: RN PRN Visit Note 9/16/21 reported anxiety and Ativan SL 0.5ml every 6 hrs. Medication not included in med profile.

Upon patient record review, 8 of 11 (Patient #1, 2, 3, 6, 7, 8, 10, 11) 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 #1, 2, 3, 6, 7, 8, 10, 11: There is no evidence that an initial bereavement assessment occurred.

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

Upon patient record review, 2 of 11 (Patient # 6, 9) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. #6-RN Visit Note 10/9/21 states "She has wounds to sacrum." There was no documented description/assessment of the wound, treatment or coordination with physician regarding the wound. 10/10/21 SN visit did not address wound. #9-Patient was admitted 10/13/21. SN assessment included that "Patient is sitting in recliner in tripod position. Patient noted to be dyspneic. He is on O2 at 3l/nc. Sats at 88%.... edema lower extremities .. 4+... Patient taking Torsamide 20 mg for edema..." No follow up RN visit until death note 10/18/21.

Upon patient record review, 11 of 11 (Patient #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11) 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, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11: All admitting orders include SN Visit Freq of 1xwk and 3xwk prn for changes in condition. The prn frequency is excessive and would indicate need to update standing frequency, if this level of PRN was indicated. Patient #10, #11 IDG/POC orders include SN Visit Freq update of SN 1wk 13 and 13 PRN and SN 1wk12 and 12 PRN, respectively. The PRN is excessive and would indicate need for update to standing frequency, if this level of PRN was indicated.

Upon patient record review, 2 of 11 (Patient #6, 9) 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 #6 RN Visit Note 10/9/21 states "She has wounds to sacrum." There was no documented description, treatment or coordination with physician. 10/11 SN Visit Note "Wounds on sacrum being cleaned daily with soap and water and pat dry by caregiver. They have a cream that is being applied to wound". There was no documented evidence of an order for this wound care. Patient #9 Medications Ativan, Morphine and Atropine were identified as injectables, when they should have read sublingual. RN stated that meds received were sublingual. A clarification order was written on site before end of survey.

Upon patient record review, 1 of 11 (Patient #6) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient #6: RN PRN Visit Note 9/16/21 reported anxiety and Ativan SL 0.5ml every 6 hrs. Medication not included in med profile or POC update. Also: RN Visit Note 10/9/21 states "She has wounds to sacrum." There was no documented description, treatment or coordination with physician. 10/10/21 SN visit did not address wound. 10/11 SN Visit Note "Wounds on sacrum being cleaned daily with soap and water and pat dry by caregiver. They have a cream that is being applied to wound". There was no documented description, treatment cream not specified and no coordination with physician regarding status and orders was noted. There was no update to IDG Plan of Care.

Upon client record review, 7 of 11 (Patient #1, 3, 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. Patients 1, 6, 7, 8, 10: Initial / Admitting order include MSW 1x within 5 days of admission and the same frequency for SC. These records have no evidence that a visit was made or that the patient was contacted, in an attempt to make visits, within 5 days of admission. Patient #1 was admitted 8/24/21 with symptoms of bloating, constipation and back pain. Patient had a history of colon cancer. She had been seen in ER a few times per record. SN frequency was set at RN 1x / week and 3x/wk prn for changes in condition. There was no evidence of a visit made the week of 8/29/21. There was no documentation of any SN communication until the death visit 9/6/21. Patient #3: Patient was admitted 12/22/21. RN visit schedule 1xwk adn 3xwk prn for changes in condition. RN was reportedly out of work last week of December rt illness, but made a virtual visit 12/29/21. There was no order for a virtual visit. No documented evidence that MSW and/or SC made any attempt to contact patient within 5 days although ordered frequency was MSW 1 visit within 5 days of admission and Spiritual Counselor Coordinator 1 visit within 5 days of admission. The patient passed away 01/03/22. Patient #9: No documented evidence that MSW and/or SC made any attempt to contact patient to schedule visits within 5 days, in spite of ordered frequency (MSW 1 visit within 5 days of admission and Spiritual Counselor Coordinator 1 visit within 5 days of admission.) The patient passed away 10/18/21 with no documented follow up between admission visit and date of death.

Upon patient record review, 1 of 11 (Patient #7) did not have evidence that Social work services are based on the patient's psychosocial assessment and the patient/family's needs and acceptance of these services. Patient #7: Patient admitted 9/13/21 with initial order for MSW 1x within 5 days of admission. MSW made visit 9/20/21. MSW note stated "Patient's spouse is currently primary and only caregiver. He expressed how he is struggling to take care of patient. SW from a community personal care agency was present during my assessment and indicated will be processing a referral. No concerns or SW interventions required at this time. Will continue to follow." There was no order for additional SW visits. There is no evidence the agency ensured that the caregiver received additional support from MSW. Patient passed away 10/15/21.

Upon patient record review, 5 of 6 applicable records (Patient #1, 3, 4, 7, 9) did not have evidence the hospice offers bereavement counseling that includes: • Making bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. Bereavement counseling also extends to residents of a SNF/NF or ICF/IID when appropriate and identified in the bereavement plan of care • Ensuring that bereavement services reflect the needs of the bereaved • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery Patients# 1, 3, 4, 7, 9 passed away while under care of hospice. Patient Records 1, 3, 4, 7, 9 had no documented evidence of offering bereavement services subsequent to death.

Upon personnel record review, 1 of 1 applicable record (Personnel #4 ) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient including all required tasks. Personnel File #4: The competency skills validation list utilized by the agency does not include · Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff. ·Safe transfer techniques and ambulation. ·Normal range of motion and positioning ·Appropriate and safe techniques in personal hygiene and grooming that include-- ·(B) tub bath ·(C) Shampoo, sink, tub, and bed.

Upon patient record review 2 of 6 applicable records (Patient #1, 11) 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 #1: Aide visit notes dated 8/26/21, 8/31/21 and 9/2/21 are signed by the aide, but no tasks are documented as complete. Patient #11: Aide Freq 3x/wk. Visit notes 3x/wk, (including but not limited to visits 8/23/21, 8/25/21, 8/27/21, 8/30/21, 9/1/21, 9/4/21 and all others through 10/20/21), were signed and dated by aide, but all tasks were blank, lacking evidence that assigned tasks were completed. Leadership aware and had implemented corrective action for subsequent visits, with tasks documented appropriately beginning 10/22/21.

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 as evidenced by personnel with no competency assessment at the time of hire, personnel with no orientation to hospice philosophy, and that care plans are individualized for the patient and that care is being provided according to the needs of the patient and the plan of care.

Upon contract review, 1 of 4 (Mayamax) did not have evidence the agreement to furnish any services under arrangement included that the hospice must retain administrative and financial management, and oversight of staff and services for all arranged services, to ensure the provision of quality care. Arranged care/services are supported by written contract/agreement that requires all care/services are authorized by the hospice.

Upon personnel record review, 7 of 7 applicable (Personnel #1, 2, 3, 4, 5, 6, 7) did not have evidence the hospice employees and contract employees have received orientation on the hospice philosophy. Patient 1, 2, 3, 4, 5, 6, 7- There is no documented evidence of hospice philosophy education included in the personnel file.

Upon personnel record review, 6 of 6 applicable (Personnel #1, 2, 3, 5, 6, 7) did not have evidence that a skills competency assessment was conducted initially, specific to each discipline, for all personnel including volunteers initially during orientation.

Upon patient record review, 1 of 11 (Patient #10) 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 #10 Admitted 7/1/21 for (3) benefit periods thus far. For Benefit Period 7/1/21-9/28-21, the CTI is completed, but benefit period identified on form as 6/30-9/27/21.

Upon patient record review, 2 of 3 applicable (Patient # 10, 11) 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 10-For Benefit Period 9/29/21-12/27/21 and Benefit Period 12/28/21-2/5/22, there was no evidence a CTI was completed. Patient 11- For Benefit Period 11/21-2/18/21, there was no evidence a CTI was completed.

Upon patient record review, 1 of 11 (Patient #2) did not have evidence that each patient record contains: • Signed election statement in accordance with 418.24 Patient #2 has no documentation of a Hospice election statement being completed.

Upon personnel record review, 4 of 4 applicable (Personnel #7, 8, 9, 10 ) did not have evidence the hospice obtained a criminal background check on all contracted individuals who have direct patient care and access to patient records.