Every finding on record at Healing Hands Hospice

Upon patient record review, 5 of 7 charts reviewed (Patient #1, #4, #5, #6, #7) 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 #1,4,5,6,7: There was no evidence a bereavement assessment was fully completed, there was no mention of the bereaved person and there was no bereavement risk score.

Upon patient record review, 1 of 7 charts reviewed (Patient #1) 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 #1: The record indicated on 5/16/24 the patient reported "complaints of back pain but Tylenol does not help. Dr. Chang made aware and advised to start Ibuprofen 600mg po Q8hours prn. There was no evidence of RN follow up. There was no follow up until 5/20/24.

Upon patient record review, 5 of 7 records reviewed (Patient #1, #2, #3, #4, #5) 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 record indicated an MD order on 2/20/24 for a hospital bed with half side rails, wheel chair and Oxygen concentrator. There was no evidence of these items in the initial plan of care. COS. Patient #2: The record indicated an MD order on 10/23/24 for a hospital bed, wheel chair and oxygen. There was no evidence of these items in the initial plan of care. COS. Patient #3: The record indicated an MD order on 10/24/24 for a hospital bed with half side rails, wheel chair, walker, oxygen concentrator. There was no evidence of these items in the initial plan of care. COS. In addition, a hoyer lift was in the plan of care but there was no MD order. Both were COS. Patient #4: The record indicated an MD order on 02/18/24 for a hospital bed with half side rails and an oxygen concentrator. There was no evidence of these items in the initial plan of care. COS. Patient #5: The record indicated an MD order on 02/17/24 for a hospital bed with half side rails, APP mattress, wheel chair and oxygen concentrator. There was no evidence of these items in the initial plan of care. COS.

Upon patient record review, 1 of 7 records reviewed (Patient #2) 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 Patient #2: The record indicated the patients start of hospice care was on 03/22/24. There was no evidence of the effective date on the election form.

Upon observation, there was no evidence the hospice complies with all applicable federal, state, and local emergency preparedness requirements by establishing and maintaining an emergency preparedness program that meets the requirements of 42 CFR 418.113. COS.

Upon observation, there was no evidence the Emergency Preparedness plan: • Is based on and includes a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach • Includes strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. COS.

Upon observation, there was no evidence the The Emergency Preparedness plan addresses patient population, including, but not limited to: • The type of services the hospice has • The ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans COS.

Upon observation, there was no evidence the Emergency Preparedness plan includes a process for cooperation and collaboration with local, tribal, regional, state, and federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. COS.

Upon observation, there was no evidence of contracts/agreements with other facilities/agencies/hospices to receive patients in the event the hospice cannot provide care to their patients during an emergency. COS.

Upon observation, there was no evidence the Emergency Plan communication plan includes all of the following: • Names and contact information for the following: • Hospice employees • Entities providing services under arrangement • Patients' physicians • Other hospices COS.

Upon observation, there was no evidence the Emergency Plan communication plan must include a primary and alternate means for communicating with hospice's employees; in addition, it must include contact information for Federal, state, tribal, regional, or local emergency preparedness staff. COS.

Upon observation, there was no evidence the Emergency Plan communication plan includes: • A method for sharing information and medical documentation for patients under the hospice's care, as necessary, with other health care providers to maintain the continuity of care • A means, in the event of an evacuation, to release patient information as permitted under 45 CFR 164.510(b)(1)(ii) • A means of providing information about the general condition and location of patients under the facility's care as permitted under 45 CFR 164.510(b)(4) COS.

Upon personnel record review, 9 of 12 (Personnel #1,2,3,7,8,9,10,11,12) did not have evidence Emergency Preparedness training including: • Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles • Demonstrate staff knowledge of emergency procedures • Provide emergency preparedness training at least annually • Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others • Maintain documentation of all emergency preparedness training Agency prepared a completed EPP plan during this survey and has initiated training with staff. Partial COS.

Upon patient record review, 5 of 5 (Patients #1,2,3,4,5) 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 #1,2,3,4,5: The POC indicated Bereavement Coordinator (BC) frequency "one as needed". There was no baseline visit frequency for the BC. Agency provided late entry clarification orders. COS.

Upon patient record review, 5 of 5 (Patients #1,2,3,4,5) did not have evidence in the patient record that hospice aide assignments and duties are: • 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 Patients #1,2,3,4,5: These Aide assignments indicated 3 x weekly and PRN. This PRN frequency did not identify if the patient/caregiver is cognitively and functionally able to make a choice of the PRN determination. Agency obtained clarification of orders. COS.

Upon patient record review 3 of 5 (Patients #1,3,5) 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 Patient #1: The POC listed Aide visit frequency of, 3 X's per week. For first Benefit Week there were no visits provided by the Aide. Patients #3 and #5: The POC listed Aide visit frequency of, 3 X's per week. For first Benefit Week, there were only 2 visits on 2/21/24 and 2/23/24.

Upon contract review, 3 of 6 (contract PT/OT/ST) 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: • Delivered in accordance with the patient's plan of care not included in contract.

Upon patient record review, 2 of 5 (Patients #4, 5) did not have evidence that the discharge summary (DC) includes all required information. Patients #4, 5: Did not include that the patients current plan of care was included in DC Summary