Every finding on record at Haven Healthcare LLC

Upon patient record review 5 of 5 (Patient #1,2,3,4,5) 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: There is no evidence that initial comprehensive psychosocial assessment included all required components such as: Depression and suicide risk; Substance abuse; Coping mechanisms; ability and style of expressing emotions, thoughts and needs; feelings regarding loss and grief; Role changes and family dynamics; The patient's involvement with social and community resources; Communication strengths and barriers; Literacy and language skills; Response to previous loss; Legal concerns and other issues related to life closure as appropriate. The documentation was unclear as to what was assessed or questions asked to patient for the nurse to formulate her narrative statements. Patient 3,5: There is no evidence that initial comprehensive spiritual assessment included all required components such as: The nature and scope of spiritual concerns or needs includes, but is not limited to: Loneliness, Despair, Fear, Guilt, Anger, Forgiveness, Reconciliation, Inner strengths or weaknesses, as appropriate. The documentation was unclear as to what was assessed or questions asked to patient for the nurse to formulate her narrative statements.

Upon patient record review, 1 of 5 (Patient #4) 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 4: There is no evidence of an initial bereavement assessment in patient's medical record.

Upon patient record review, 1 of 5 (Patient #1) 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 needs: cardiac, edema, pain, constipation, skin, wound, respiratory with oxygen as an intervention, fall, bleeding precautions. No evidence of problems, goals, interventions on the plan of care: constipation, oxygen as an intervention.

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. During all 3 home visits, the six listed deficiencies were observed: 1.Nursing bag was a cloth, grocery-style bag with an open top. Per hospice's bag technique policy, the nursing bag is to remain closed during the visit. The only time the bag is to be opened is when retrieving equipment. The observed bag during home visits had no closure available. 2.There was no handwashing performed before, during, or after any of the home visits. Per hospice's bag technique policy, hands are to be washed before opening nursing bag. Hands are also to be washed at the end of the visit. 3.There was no hand sanitizer used during visits (when entering nursing bag, entering or exiting homes, etc.) 4.There was no cleansing of the equipment used for assessment purposes, before or after any of the uses. 5.During home visit 1, nursing bag was placed on patient's floor. 6.There were no barriers used during any of the home visits. No barriers were used for the nursing bag, equipment, or for designation of clean vs. dirty areas.

Upon patient record review, 1 of 5 (Patient #4) 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 4: There is no evidence of written certification of terminal illness in patient's medical record, patient admitted 09/27/2024 and was discharged 10/24/2024.

Upon patient client record review, 2 of 5 (Patient #1,5) 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: Patient admitted to hospice 1/17/25. Admission narrative note states, "chaplain requested 6/10/24." Patient 5: Patient on service 8/29/24-9/12/24. Initial comprehensive RN assessment dated 6/8/24. Corrected assessment uploaded to patient's chart during evening hours between survey day 1 and 2.

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. The Staff Roster/Emergency phone plan in the Emergency preparedness plan did not include all staff and did not include primary or alternate means of communication to all staff.

Upon patient record review, 1 of 5 (Patients #2) did not have evidence that the patient has received effective pain management and symptom control from the hospice for conditions related to the terminal illness. Patient #2: This patient describes constant pain in her back and lower extremities. Upon admission, she was assessed with pain being described as sharp, stabbing, ache with numbness and tingling. The patient stated she was taking Motrin but not able to use due to taking Xarelto. She states she is using Tylenol 500mg, taking 4 tablets each morning and often three more tablets at night. There was no discussion in the RN assessment regarding her pain and current descriptors. There were no additions or changes made to her current pain regimen or plan of care despite weekly visits which showed continued issues with pain.

Upon patient record review, 2 of 5 (Patients #2, 3) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient #2: The patient verbalized during the visit that his attending physician was Dr. Nadu. The EOB has it selected that the patient did not choose an attending physician and was being followed by the hospice medical director. This patient states he sees his local doctor on a regular basis and had just been there the day before and had several medication changes. Patient #3: The patient, when asked who she chose as her attending physician, stated that she chose Dr. Gundara. The record lists that she did not choose an attending and was being followed by the hospice medical director.

Upon patient record review, 3 of 5 (Patient #2,3,4) 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: Patient taking Tylenol but it was not on medication list. Medication list states patient on Meloxicam but patient said she has never had that due to Xarelto. Patient #3:Medication list states patient on Gabapentin 300mg daily. Patient states that Gabapentin is 1500mg daily. His prescription in the home states Gabapentin is 1500mg daily. Insulin was not included on medication list, despite the fact patient has been a long time diabetic. Patient #4: Medication list in patient record does not include Senna, Loperamide, Omeprazole, or Tamsulosin. All of these medications were in the patient home and patient stated he was taking them.

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

Upon patient record review, 3 of 5 (Patients #2, 3, 4) 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: This patient is on Xarelto for active DVT's in lower extremities. There is no mention on the plan of care of DVT's problems/goals/interventions or need for precautions with Xarelto. Patient #3: Patient is on service for heart disease. He has comorbidities that include diabetes for which he is on insulin. There is no evidence of problems/goals/interventions for diabetes. Patient #4: Patient is extreme hard of hearing and has a cochlear implant. There is no evidence of problems/goals/interventions related to the cochlear implant or hearing impairment of patient.

Upon patient record review, 3 of 5 (Patients #2, 3, 4) 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: Patient taking Tylenol but there is no evidence of an order. Patient #3: Upon home visit, patient states that Gabapentin is 1500mg daily. His prescription in the home states Gabapentin is 1500mg daily however, no evidence of an order for 1500mg of Gabapentin. No evidence of insulin order. Patient #4: There is no evidence of orders for Senna, Loperamide, Omeprazole, or Tamsulosin.

Upon patient record review, 4 of 5 (Patient #1,2,3,4) 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: The IDG plan of care meeting and notes from 08/30/24 and 09/13/24 are signed only by the DPCS. There is no other evidence of involvement of other disciplines. This is not signed by the medical director. Patient #2: The initial IDG meeting held on 09/09/24 is not signed by any team member except the DPCS. There is no evidence of involvement from other disciplines, and are not signed by the medical director. Patient #3: The initial IDG meeting held on 09/27/24 is not signed by any team member except the DPCS. There is no evidence of involvement from other disciplines and is not signed by the medical director. Patient #4: The Initial and subsequent IDG meeting and plan of care from 08/30/24 and 09/13/24 are signed only by the DPCS. There is no evidence of involvement from other disciplines and are not signed by the medical director.

Upon observation, there was no evidence the hospice documents and demonstrates viable and ongoing efforts to recruit and retain volunteers. There was no evidence in the records of recruitment and retention efforts for volunteers.

Upon observation, there was no evidence the hospice documented the cost savings achieved through the use of volunteers. Documentation must include the following: • The identification of each position that is occupied by a volunteer • The work time spent by volunteers occupying those positions • Estimates of the dollar costs that the hospice would have incurred if paid employees occupied the positions identified in paragraph (d)(1) of CFR 418.78 for the amount of time specified in paragraph (d)(2) of CFR 418.78 The agency did have record templates in place for this tracking, however, these files have not been updated since 04/25/23. There is no monthly reports available even if the total cost or hours for each month is zero.

Upon observation, there was no evidence that when the hospice provides durable medical equipment under contract, then the DMEPOS provider is accredited by a CMS approved accreditation organization. The agency did not have proof of accreditation for their contracted DME provider.