Every finding on record at Health Care Connectors LLC

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 The hospice did complete an all hazards risk analysis. However the plan did not 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

Upon observation, there was no evidence 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 A Continuity of operation plan was started but not completed.

Upon observation, there was no evidence the hospice develops and maintains an emergency preparedness communication plan that complies with federal, state, and local laws and must be reviewed and updated every two years. Upon observation, the hospice did not have a communication plan only a call list of employees.

Upon observation, there was no evidence the Emergency Plan communication plan includes all of the following: • Patients' physicians • Other hospices Upon observation there was no contact information for patient's physicians or other hospices.

Upon patient record review, 2 of 6 (Patient #2,4) 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 #2: There was no evidence in the medical record the MSW or Chaplain signed the IDG notes on 12/17/24, 12/31/24 and 1/14/25. Patient #4: There was no evidence in the medical record the Chaplain signed the IDG notes on 12/17/24, 12/31/24 and 1/14/25.

Upon patient record review, 2 of 6 (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: There is evidence in the medical record in the initial comprehensive, the patient refused MSW and Chaplain. The patient did not have a funeral home, the RNCM did not include on the plan of care problems/goals/interventions for personal business.

Upon patient record review, 2 of 6 (Patient #1,2) 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: The initial plan of care on 10/28/24 with orders SN 1Xwk and 9 PRN for symptom management, no evidence of a routine frequency due to PRN visits. Patient #2: The initial plan of care on 9/11/24 with orders SN 2Xwk and 9 PRN for symptom management, no evidence of a routine frequency due to PRN visits.

Upon patient record review, 2 of 6 (Patient #2,4) 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 #2: There was no evidence in the medical record the MSW or Chaplain signed the IDG notes on 12/17/24, 12/31/24 and 1/14/25. Patient #4: There was no evidence in the medical record the Chaplain signed the IDG notes on 12/17/24, 12/31/24 and 1/14/25.

Upon patient record review, 1 of 6 (Patient #4) 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 #4: There is evidence in the medical record all care plans were discontinued 1/14/25. The patient had EOL Parkinson's and was on Oxygen. Problems/Interventions/Goals were not updated and active for Cognitive and Respiratory. (COS)

Upon personnel record review, 3 of 12 (Personnel #5,6,8) did not have evidence that a skills competency assessment, specific to each discipline had been conducted for all personnel including volunteers initially during orientation. Personnel #5, 6, 8: There was not an initial competency assessment for the MD, VC or volunteer.

Upon SNF/NF contract review, 1 of 2 (Civita) did not have a delineation of the responsibilities of the hospice and the SNF/NF to provide bereavement services to SNF/NF personnel. An addendum to the contract was created to include the responsibilities of the hospice and the SNF/NF to provide bereavement services to SNF/NF personnel.