Every finding on record at H & A Hospice

Condition of Participation: Patient’s Rights. L500

Upon observation, there was no evidence that during the initial assessment visit in advance of furnishing care, the hospice provided the patient and/or family with verbal (meaning spoken) and written notice of the Patient's Rights and Responsibilities in a language and manner that the patient understands. Cannot abate condition level as there have been no admissions since previous survey.

Upon patient record review, there was no evidence that the hospice informed and provided written information to the patient concerning its policies on advance directives, including a description of applicable state law. Cannot abate condition level as there have been no admissions since previous survey.

Upon patient record review, there was no evidence that the hospice obtained the patient's or representative's signature confirming that they received a copy of the Patient's Rights and Responsibilities. Cannot abate condition level as there have been no admissions since previous survey.

Upon patient record review, there was no evidence that if a state court has not adjudged a patient incompetent, any legal representative designated by the patient in accordance with state law may exercise the patient's rights to the extent allowed by state law. Cannot abate condition level as there have been no admissions since previous survey.

Upon patient record review, there was no evidence that the patient chooses a health care provider, including an attending physician. Cannot abate condition level as there have been no admissions since previous survey.

Upon patient record review, there was no evidence of the appropriate documentation for release of confidential information Cannot abate condition level as there have been no admissions since previous survey.

Upon patient record review, there was no evidence that the patient received information about the services covered under the hospice benefit. Cannot abate condition level as there have been no admissions since previous survey.

Upon patient record review, there was no evidence that the patient received information about the scope of services that the hospice will provide and specific limitations on those services. Cannot abate condition level as there have been no admissions since previous survey.

Upon patient record review, there was no 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. Cannot abate as there has been no patients with non-hospice healthcare providers furnishing services to the patients.

Condition of Participation: Clinical Records.

Upon patient client record review, there was no 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 Cannot abate condition level as there have been no admissions since previous survey.

Upon client record review, there was no evidence that the hospice forwarded a summary and a copy of the patient record, if requested, to a facility when transferring the patient to that facility. Cannot abate this condition as there has been no patient's transferred since previous survey

Condition of Participation: Patient’s Rights. L500

Upon observation, there was no evidence that during the initial assessment visit in advance of furnishing care, the hospice provided the patient and/or family with verbal (meaning spoken) and written notice of the Patient's Rights and Responsibilities in a language and manner that the patient understands. Patients 4, 5, 6, 7, 11, 12, 13, 14: Admission documents including consents, acknowledgements and election were not available to surveyor upon request Day 1 and was requested multiple times from first day of survey, but available late am of Day 2. The documents/consents were not part of the medical record and were not uploaded to the EMR.

Upon patient record review, 8 of 16 (Patient #4, 5, 6, 7, 11, 12, 13, 14) did not have evidence that the hospice informed and provided written information to the patient concerning its policies on advance directives, including a description of applicable state law. Patients 4, 5, 6, 7, 11, 12, 13, 14:Admission documents including consents, acknowledgements and election were not available to surveyor upon request Day 1 and was requested multiple times from first day of survey, but available late am of Day 2. The documents/consents were not part of the medical record and were not uploaded to the EMR.

Upon patient record review, 8 of 16 (Patient #4, 5, 6, 7, 11, 12, 13, 14) did not have evidence that the hospice obtained the patient's or representative's signature confirming that they received a copy of the Patient's Rights and Responsibilities. Patients 4, 5, 6, 7, 11, 12, 13, 14: Admission documents including consents, acknowledgements and election were not available to surveyor upon request Day 1 and was requested multiple times from first day of survey, but available late am of Day 2. The documents/consents were not part of the medical record and were not uploaded to the EMR.

Upon patient record review, 8 of 16 (Patient #4, 5, 6, 7, 8, 11, 12, 13, 14) did not have evidence that if a state court has not adjudged a patient incompetent, any legal representative designated by the patient in accordance with state law may exercise the patient's rights to the extent allowed by state law. Patients 4, 5, 6, 7, 11, 12, 13, 14: Admission documents including consents, acknowledgements and election were not available to surveyor upon request Day 1 and was requested multiple times from first day of survey, but available late am of Day 2. The documents/consents were not part of the medical record and were not uploaded to the EMR.

Upon patient record review, 8 of 16 (Patient #4, 5, 6, 7, 11, 12, 13, 14) did not have evidence that the patient chooses a health care provider, including an attending physician Patients 4, 5, 6, 7, 11, 12, 13, 14: Admission documents including consents, acknowledgements and election were not available to surveyor upon request Day 1 and was requested multiple times from first day of survey, but available late am of Day 2. The documents/consents were not part of the medical record and were not uploaded to the EMR.

Upon patient record review, 8 of 16, (Patient #4, 5, 6, 7, 11, 12, 13, 14) did not have evidence of the appropriate documentation for release of confidential information. Patients 4, 5, 6, 7, 11, 12, 13, 14: Admission documents including consents, acknowledgements and election were not available to surveyor upon request Day 1 and was requested multiple times from first day of survey, but available late am of Day 2. The documents/consents were not part of the medical record and were not uploaded to the EMR.

Upon patient record review, 8 of 16 (Patient #4, 5, 6, 7, 11, 12, 13, 14) did not have evidence that the patient received information about the services covered under the hospice benefit. Patients 4, 5, 6, 7, 11, 12, 13, 14: Admission documents including consents, acknowledgements and election were not available to surveyor upon request Day 1 and was requested multiple times from first day of survey, but available late am of Day 2. The documents/consents were not part of the medical record and were not uploaded to the EMR.

Upon patient record review, 8 of 16 (Patient #4, 5, 6, 7, 11, 12, 13, 14) did not have evidence that the patient received information about the scope of services that the hospice will provide and specific limitations on those services. Patients 4, 5, 6, 7, 11, 12, 13, 14: Admission documents including consents, acknowledgements and election were not available to surveyor upon request Day 1 and was requested multiple times from first day of survey, but available late am of Day 2. The documents/consents were not part of the medical record and were not uploaded to the EMR.

Upon patient record review, 10 of 16 (Patient #1,2,3,4,5,6,7,8,10,15) 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. Patients 1, 2, 3 , 4, 5, 6, 7, 8, 10, 15: Initial bereavement assessment has no name, relationship or contact information for person assessed.

Upon patient record review, 1 of 16 (Patient #3) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual's attending physician, if any) • Changes that have taken place since the initial assessment • Information on the patient's progress toward desired outcomes • Reassessment of the patient's response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days Patient 3: SN frequency 1x/week and 2 prn. There are no documented RN visits 11/05/25 -12/3/25.

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

Upon patient record review, 1 of 16 (Patient #11) 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. Patient 11: Patient was hospitalized on 12/10/24 with no explanation of circumstance and no documented follow-up until MD ordered discharge on 12/26/24. The IDG note from 12/16/24 states patient was hospitalized and will continue to monitor. There was no documented evidence by the nurse of follow up and continuous assessment of the patient and family's needs.

Upon patient record review, 5 of 16 (Patient #3, 4, 5, 6, 8) 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. Patients 3, 8: Spiritual counselor visits were phone calls without problems, goals and interventions in the plan of care. Patients 4: Patient admitted with cardiac pacemaker according to CTI and diagnoses. There is no reference to pacemaker in problems, goals and interventions. Patients 5, 6: Diagnosis of seizure disorder listed with no related problems, goals and interventions.

Upon patient record review, 16 of 16 (Patient #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16) 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. Patients 1, 2, 3, 4, 5, 6, 9, 10, 11, 12, 13, 14, 15, 16: Patient admitted with orders for MSW and SC 1x/month. Patients declined services on initial assessment visits by each discipline, with no updated frequency orders to the plan of care. Patients 7, 8: Patient admitted with orders for MSW 1x/month. Patient declined additional visits during initial MSW assessment visit. Frequency orders were not updated to reflect patient choice.

Upon client record review, 3 of 16 (Patient #3, 8, 14) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 3: 10/10/25 assessment visits describe home visit, but that patient declined. 10/20/25 IDG SC noted Chaplain made contact with patient by phone to offer and explain SC services and schedule an initial visit.....not interested in the SC services at this time... Chaplain will not schedule. However 11/11/25 note states spiritual phone call provided and plan to continue monthly calls. In addition, SN frequency 1x/week and 2 prn. There are no documented visits 11/05/25 -12/3/25. Patient 8: Spiritual counselor visits were phone calls and no order documented in the record. Patient 14: Patient documented as passed away 8/16/25 related to lethal food allergy, but there is documentation of 8/21/25 SN visit 100-300 pm, describing the patient as alert, oriented, restless, including vital signs.

Upon patient record review, 1 of 16 (Patient #11) 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 11: Patient was hospitalized on 12/10/24 with no explanation of circumstance and no documented follow-up until MD ordered discharge on 12/26/24. The IDG note from 12/16/24 states patient was hospitalized and will continue to monitor. There was no evidence of sharing of information or communication with the hospital.

Upon personnel record review, 1 of 12 (Personnel #6) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) ·Appropriate and safe techniques in personal hygiene and grooming that include-- (C) Shampoo, sink, tub, and bed Personnel 6: Form utilized by agency does not specify shampoo types of sink, tub, and bed

Upon patient record review, 1 of 16 (Patient #10) 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 10: Hospice aide frequency 1x/week. Tasks assigned have no specified frequency. Oxygen flow rate included, but not safety precautions. (applicable to both care plans both benefit periods.)

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. This lack of oversight is demonstrated by the hospice's inability to provide complete and readily accessible medical records at the start of survey. During the survey process the hospice failed to provide requested documentation in a timely manner, reflecting a lack of administrative organization, lack of record management, and effective oversight. Hospice agencies are expected to maintain organized, complete, accurate, and readily accessible clinical records to demonstrate compliance with regulations.

Upon patient record review, 1 of 16 (Patient #1) did not have evidence that there is a physician's brief narrative explanation of the clinical findings that supports a life expectancy of 6 months or less as part of the certification forms, or as an addendum to the certification forms. Patient 1: There is no physician narrative for the initial CTI 10/23/25 benefit period.

Condition of Participation: Clinical Records.

Upon patient record review, 14 of 16 (Patient #1,2,3,4,5,6,7,9,11,12,13,14,15,16) 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 Patients 1, 2, 3, 4, 5, 6, 7, 9, 11, 12, 13, 14, 15, 16: Patient chose to receive notice of non covered items. No documented evidence it was provided.

Upon patient record review, 3 of 16 (Patient #7, 11, 14) 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 7: 7/5/24 SC initial assessment notes that patient was finding it difficult to receive news that she has cancer. There was no other reference to cancer for this patient in the record. Patient 11: End of Care summary notes that patient was hospitalized 12/10/25. The 12/16/25 IDG notes that patient was hospitalized 12/8/25. Patient 14: 2/16/26 Bereavement support call scheduled for 2/16/26 was inadvertently marked done. (but was not actually completed when opened).

Upon observation, there was no evidence the organization follows their policies and procedures to maintain the the patient's clinical record in confidential manner. Surveyor is informed that clinical records are kept in locked cabinet in administrator's office, located different level of building than the office space available to surveyor, labeled as Suite B. Alt Administrator prohibits surveyor from observing that space, as administrator has COVID and has occupied the space in past 24 hours.

Upon client record review, 1 of 16 (Patient #13) did not have evidence that the hospice forwarded a summary and a copy of the patient record, if requested, to a facility when transferring the patient to that facility. Patient 13: Upon discharge record review, there is no evidence of any information provided to receiving organizations. The patient chose to transfer to another hospice.

Upon client record review, 2 of 16 (Patient #11, 12) did not have evidence that the discharge summary includes all required information. Patient 11: Discharge summary does not address any change in patients condition and/or signs/symptoms resulting in hospitalization. There is no evidence of hospice notification/coordination of care with hospital where patient had been hospitalized (12/10-12/26/25 date of hospice discharge). There is also no documented evidence of communication/coordination with hospital related to discharge date. Patient 12 Upon discharge record review, there is no evidence of any information provided to receiving organizations. The patient chose to "search for another hospice, with no additional info provided."

Upon observation, there was no evidence the patient record, whether hard copy or in electronic form, is made readily available on request by an appropriate authority. Upon observation, EMR access was not readily available to surveyor. There were (3) computer changes before one was functional. By 1:25 pm (pacific time) when computer was functional, there were obstacles with user ID/Password set up.

Upon observation, there was no evidence the Emergency Plan communication plan must includes a primary and alternate means for communicating with hospice's employees and Federal, state, tribal, regional, and local emergency management agencies. Upon observation of the hospice's emergency plan there was no evidence of an alternate means for communicating with the agency’s employees.

Upon patient record review, 6 of 11 (Patient #4, #5, #6, #7, #10, #11) 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 #4: There is documentation of an order for Lasix 20 mg for 14 days on 7/20/22. Lasix remained on the medication profile until 9/22/22. Patient #5, 6, 7, 11: There is documentation that the patient was using oxygen. Oxygen therapy was not included on the medication profile. Patient #10: There is documentation that the patient was using oxygen. oxygen therapy was not included on the medication profile. There is documentation of an order for Azithromax for 4 days on 5/12/22. Azithromax remained on the medication profile until 9/22/22. Patient #11: The medication profile did not include the albuterol nebulizer.

Upon patient record review, 5 of 11 (Patient #5, #6, #7, #8, #9) 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 #5: The visit frequency for the spiritual care provider was indicated at 1x/ month. There was no evidence of problem statements with goals, interventions, and progress toward outcomes related to the spiritual aspect of the patient. Patient #6: The visit frequency for the medical social worker was indicated at 1x/ month. There was no evidence of problem statements with goals, interventions, and progress toward outcomes related to the psychosocial aspect of the patient. Patient #7: The medical record contained a visit frequency for the spiritual care provider and medical social worker were indicated at 1x/ month. There was no evidence of problem statements with goals, interventions, and progress toward outcomes related to the spiritual or psychosocial aspect of the patient. Patient #8: The medical record contained a psychosocial evaluation performed 4/16/22 indicated "MSW will assist with funeral planning, advance directives, help create peaceful home environment, and validate emotions and feelings". There was no evidence of problem statements with goals, interventions, and progress toward outcomes related to the spiritual or psychosocial aspect of the patient. Patient #9: The visit frequency for the spiritual care provider was indicated at 1x/ month. There was no evidence of problem statements with goals, interventions, and progress toward outcomes related to the spiritual aspect of the patient.

Upon patient record review, 1 of 11 (Patient #11) 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 #11: The plan of care dated 9/14/22 did not include the albuterol nebulizer.

Upon patient record review, 3 of 11 (Patient #1, #10, #11) 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: The medical record contained nursing documentation dated 4/22/22 stating the patient had a cane and shower chair. There is no evidence of a cane or shower chair included for DME on the plan of care. Patient #10: Observed in the home the patient had a walker and cane. There is no evidence of a walker or can included for DME on the plan of care. Patient #11: The plan of care dated 9/14/22 did not include the albuterol nebulizer DME.

Upon client record review, 9 of 11 (Patient #2, 4, 5, 6, 7, 8, 9, 10, 11) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #2: The medical record contained a discrepancy regarding the discharge date. The order for discharge was effective 6/23/22. Patient was discharged 7/8/22. Patient #4: The medical record contained an order dated 7/20/22 for a psychosocial evaluation. There was no evidence of social work visit completed. Patient #5: The medical record contained an order dated 4/3/22 for a psychosocial evaluation. There was no evidence of social work visit completed. Patient #6: The medical record contained an order dated 4/21/22 for a psychosocial evaluation. There was no evidence of social work visit completed. Patient #7: The medical record contained an order dated 4/20/22 for a psychosocial evaluation. There was no evidence of social work visit completed. Patient #8: The medical record contained documentation by the medical social worker dated 4/16/22 that indicated follow up visits would be made to assist with funeral planning, advance directives, help create peaceful home environment, and validate emotions and feelings. There was no evidence of social work visit completed. Patient #9: The medical record contained an order dated 4/10/22 for a psychosocial evaluation. There was no evidence of social work visit completed. Patient #10: The medical record contained an order dated 4/1/22 for a psychosocial evaluation. There was no evidence of social work visit completed. Patient #11: The medical record contained an order dated 3/28/22 for a psychosocial evaluation. There was no evidence of social work visit completed.

Upon observation, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient 2 During home visit, the clinician did not use proper handwashing technique; after handwashing clinician turned the faucet off with his clean hands and proceeded to dry his hands after and pick up his equipment.

Upon patient record review 2 of 6 applicable (Patient #7, #8) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group Patient #7: The aide visit frequency was ordered 2 x week. On the weeks of 4/20/22 and 5/16/22 indicated only 1 visit was made. Patient #8: The aide visit frequency was ordered 2 x week. On the week of 4/13/22 indicated only 1 visit was made.

Upon patient client record review, 4 of 11 (Patient #1, #8, #10, #11) 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: The medical record contained the comprehensive nursing assessment dated 4/22/22 that was not signed by the nurse. The record contains documentation by the nurse dated 5/4/22 documenting the patient went to hospital 5 days ago and documentation dated 5/12/22 that also documents patient went to hospital 5 days ago. The patient went to the hospital 4/29/22. Patient #8: The medical record contained psychosocial and spiritual care visit notes that were not signed by the clinicians completing the visits. Patient #10: The medical record contained spiritual care visit notes that were not signed by the chaplain completing the visits. Patient #11: The medical record contained spiritual care visit notes that were not signed by the chaplain completing the visits.