Every finding on record at Green Road Hospice Inc

Upon patient record review, 4 of 5 (Patients #2,3,4,5) did not have evidence the plan of care (POC) 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 Patients #2,3,4,5: The visit frequencies (SN 1x week, SW 1x month, SC 1xmonth) are not migrating over to IDG/POC from the Patient Dashboard> Edit Patient>Clinical Staff function. Agency called JN Cloud who assisted so these visit frequencies would populate onto the POC. Corrected on Site.

Upon patient record review, 9 of 14 (Patient #1,2,3,4,5,7,8,9,10) 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 1 (COS),5,8,9,10: Patient has an order for oxygen in treatment orders. There is no evidence of oxygen on the medication list. Patient 2: Patient has an order for oxygen in treatment orders. There is no evidence of oxygen on the medication list. COS Medication list contains order for Pronto-med HC 2.5percent 1cream Apply topically to affected area daily. There is no evidence of amount to apply or application site in this order. COS Patient 3: Patient has an order for oxygen in treatment orders. There is no evidence of oxygen on the medication list. COS Medication list contains order for albuterol solution 2.5mg/3ml 1film inhalation a single dose 1 vial via nebulizer every 406 hours as needed. There is no evidence of reason for PRN. There is no evidence of correct frequency (406 hours not correct). COS Patient 4: medication list contains order for Advair 250one every 4 hours as needed inhale 1 puff by mouth twice daily. There is evidence of conflicting orders for this medication with incorrect dosage. (250one is not a correct dose for this medication.) Medication list contains order for terbinafine 1percent mg 1 topical a single dose apply to affected area daily for fungal, itching. There is no evidence of correct dose (one percent mg is not a correct dose). There is no evidence of application site for this medication. There is no evidence of amount to apply per dose. Patient 7: Patient has an order for oxygen in treatment orders. There is no evidence of oxygen on the medication list. COS Medication list contains order for voltaren gel 1 percent. 2 grams topical twice daily as needed for pain. There is no evidence of application site for this medication. Medication list contains order for Motion Sickness 25mg 1 tab oral three times daily for nausea,dizziness,vomiting. There is no evidence of medication name in this order.

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

Upon patient record review, 6 of 14 (Patient #1,2,3,4,5,10) 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 1: Identified problems: respiratory, supplemental oxygen, cardiac, depression, high risk for skin breakdown. There is no evidence of these plans of care with problems, goals, or interventions. Patient 2: Identified problems: respiratory, supplemental oxygen. There is no evidence of these plans of care with problems, goals, or interventions. Patient 3: Identified problems: supplemental oxygen, use of anticoagulation medication. There is no evidence of these plans of care with problems, goals, or interventions. Patient 4: Identified problems: supplemental oxygen, high risk for falls. There is no evidence of these plans of care with problems, goals, or interventions. Patient 5: Identified problems: respiratory, supplemental oxygen. There is no evidence of these plans of care with problems, goals, or interventions. Patient 10: Identified problems: depression, high risk for skin breakdown. There is no evidence of these plans of care with problems, goals, or interventions.

Upon patient record review, 1 of 14 (Patient #6) 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 6: Physician’s order for SC visit frequency is once monthly and PRN. There is no evidence of the number of PRN visits for SC.

Upon patient record review, 9 of 14 (Patient #1,2,3,4,5,7,8,9,10) 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 1 (COS),5,8,9,10: Patient has an order for oxygen in treatment orders. There is no evidence of oxygen on the plan of care. Patient 2: Patient has an order for oxygen in treatment orders. There is no evidence of oxygen on the plan of care. COS Plan of care contains order for Pronto-med HC 2.5percent 1cream Apply topically to affected area daily. There is no evidence of amount to apply or application site in this order. COS Patient 3: Patient has an order for oxygen in treatment orders. There is no evidence of oxygen on the plan of care. COS Plan of care contains order for albuterol solution 2.5mg/3ml 1film inhalation a single dose 1 vial via nebulizer every 406 hours as needed. There is no evidence of reason for PRN. There is no evidence of correct frequency (406 hours not correct). COS Patient 4: plan of care contains order for Advair 250one every 4 hours as needed inhale 1 puff by mouth twice daily. There is evidence of conflicting orders for this medication with incorrect dosage. (250one is not a correct dose for this medication.) Plan of care contains order for terbinafine 1percent mg 1 topical a single dose apply to affected area daily for fungal, itching. There is no evidence of correct dose (one percent mg is not a correct dose). There is no evidence of application site for this medication. There is no evidence of amount to apply per dose. Patient 7: Patient has an order for oxygen in treatment orders. There is no evidence of oxygen on the plan of care. COS Plan of care contains order for voltaren gel 1 percent. 2 grams topical twice daily as needed for pain. There is no evidence of application site for this medication. Plan of care contains order for Motion Sickness 25mg 1 tab oral three times daily for nausea,dizziness,vomiting. There is no evidence of medication name in this order.

Upon patient record review, 7 of 14 (Patient #1,2,3,4,8,9,10) 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: Identified DME needs: rollator, hospital bed, oxygen, shower chair, raised toilet seat. DME listed in the plan of care: oxygen. There is no evidence of other DME listed in the plan of care. Patient 2: Identified DME needs: oxygen, alternating pressure pad, bedside commode, raised toilet seat, walker. DME listed in the plan of care: oxygen, walker. There is no evidence of other DME listed in the plan of care. Patient 3: Identified DME needs: oxygen, cane, walker. There is no evidence of DME listed in the plan of care. Patient 4: Identified DME needs: oxygen, cane, walker. There is no evidence of DME listed in the plan of care. Patient 8: Identified DME needs: oxygen. There is no evidence of DME listed in the plan of care. Patient 9: Identified DME needs: oxygen, shower bench, raised toilet seat, walker. There is no evidence of DME listed in the plan of care. Patient 10: Identified DME needs: oxygen, suction, cane, nebulizer. There is no evidence of DME listed in the plan of care.

Upon patient record review, 5 of 14 (Patient #1,7,9,10,13) 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: IDT dated 4/24/24 and 5/22/24, there is no evidence of notes entered by IDT disciplines. IDT dated 5/8/24, there is no evidence of notes entered by nursing or social worker. IDT dated 6/6/24 and 6/20/24, there is no evidence of MSW notes that include summary of care provided previous 2 weeks or plan for upcoming 2 weeks. Patient 7: There is evidence of copy/pasted notes for 5/9/24,7/4/24,7/18/24 RN notes are all identical. 5/21/24,6/26/24,7/4/24,7/11/24 MD notes are all identical. Patient discharged on 7/19/24. There is no evidence of discharge planning discussion in any of the IDTs leading to discharge. Patient 9: There is evidence of copy/pasted notes for 5/23/24,6/20/24,7/11/24 IDT contains identical SC and MSW notes from admission. Notes dated 5/6/24 (SC) and 5/7/24(MSW). 6/20/24,7/25/24 IDTs contain identical RN note from admission, dated 5/5/24. Patient discharged 7/31/24. There is no evidence of discharge planning discussion in any of the IDTs leading to discharge. Patient 10: Patient discharged 7/30/24. There is no evidence of discharge planning discussion in any of the IDTs leading to discharge. Patient 13: Patient discharged 1/7/24. There is no evidence of discharge planning discussion in any of the IDTs leading to discharge.

Upon patient record review, 7 of 14 (Patient #1,2,3,5,6,8,10) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 1: Physician’s order for SN visit frequency is weekly. There is no evidence of SN visit the week of 11/3/24 and 11/10/24. Patient 2: Physician’s order for SN visit frequency is weekly. There is no evidence of SN visit between 8/21/24 – 9/4/24 and 10/24/24 – 11/7/24. Patient 3: Physician’s order for SN visit frequency is weekly. There is evidence of SN visits on dates 9/3/24,9/17/24,9/23/24,10/1/24,10/15/24,10/29/24,11/10/24. Patient 4: Physician’s order for RN visit frequency is every 14 days. There is no evidence that the RN is visiting patient every 14 days with RN visits on 10/11/24, 10/24 /24 and 11/6/24. Patient 5: Physician’s order for SN visit frequency is weekly. There is evidence of SN visits: 10/6 and 10/8; 10/20 and 10/21; 10/27 and 10/28. There is no evidence of physician’s order for PRN nursing visits. Patient 6: Physician’s order for SN visit frequency is weekly. There is no evidence of SN visit since 11/9/24. Patient 8: There is documentation in the medical record, dated 6/20/24, that the SC services and the MSW services are declined. There are documented MSW visits: 7/24,8/24,9/23. There are documented SC visits: 7/17,8/15,9/18,10/1. There is no evidence of physician’s order for these visits. Patient 10: Physician’s order for SN visit frequency is weekly. There is evidence of SN visits 6/30/24 and 7/6/24. There is no evidence of physician’s order for both of these visit in the same Medicare week.

Upon patient record review, 1 of 14 (Patient #6) 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 6: There is evidence that the CTI physician narratives are copy/pasted; Physician’s certificate of terminal illness narrative for certification period 1 is identical to the RN admission narrative note.

Upon patient record review, 6 of 14 (Patient #1,2,3,5,6,7) 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 1: There is evidence that the CTI physician narratives are copy/pasted; All physician’s certificate of terminal illness narratives are identical from one benefit period to the next. Patient 2: There is evidence that the CTI physician narratives are copy/pasted; CTI narratives dated 04/30/2024,07/01/2024,08/30/2024 are all identical. Patient 3: There is evidence that the CTI physician narratives are copy/pasted; CTI narratives dated 05/27/2024,07/28/2024,09/26/2024 are all exact copies of the NP narratives from the face-to-face visit dated 05/27/2024. Patient 5: There is evidence that the CTI physician narratives are copy/pasted; Physician’s certificate of terminal illness narratives for certification periods 1 and 2 are identical. Certification period 3 physician’s certificate of terminal illness narrative is a direct copy of the NP narrative from the face-to-face visit for the same certification period. Patient 6: There is evidence that the CTI physician narratives are copy/pasted; Physician’s certificate of terminal illness narrative for certification period 1, 2, 3 are identical to the RN admission narrative note. Certification period 4 (dated 4/30/24) has no evidence of physician’s signature captured on the document. There is evidence of copy/pasted MD narrative on 4/30/24,7/2/24,8/31/24 with identical notes on these certificates of terminal illness. Patient 7: There is no evidence of CTI for 05/22/2024-07/19/2024 in the patient’s medical record. There is evidence of a face-to-face visit, dated 05/22/2024.

Upon SNF/NF contract review, 1 of 1 SNF contract (Windsor Care) did not have evidence of the manner in which the SNF/NF and the hospice are to communicate with each other and how each will document such communications to ensure that the needs of patients are addressed and met 24 hours a day.

Upon patient record review, 1 of 5 (Patient #4) did not have evidence that each patient record contains: • Signed election statement in accordance with 418.24 Patient #4: the election statement had an attending physician named. However, the form had a designated box to identify patient choice that was not check-marked on the form.