Every finding on record at Health Link Hospice Services

Upon patient record review, 2 of 19 (Patient #4,11) 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 had a "Bereavement Risk Assessment Note" dated 2/10/25 that stated "voicemail left to complete bereavement assessment." There was no further documentation of any Bereavement risk assessment. Patient #11 There was no evidence of a Bereavement risk assessment completed at the time of survey.

Upon patient record review, 6 of 19 (Patient #4,6,11,14,17,19) did not have evidence the hospice offers bereavement counseling that includes: • Ensuring that bereavement services reflect the needs of the bereaved • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery Patient #4 did not have evidence of the developing bereavement plan of care since admission. Patient #6 did not have evidence of the developing bereavement plan of care since admission. Patient #11 did not have evidence of the developing bereavement plan of care since admission. Patient #14 did not have evidence of the developing bereavement plan of care since admission. Patient #17 did not have evidence of the developing bereavement plan of care from admission to post death. The post death assessment was noted as a phone call stating "left voice mail. Will remain available and mailings will be sent." (mailings are documented.) Patient #19 did not have evidence of the developing bereavement plan of care from admission to post death. The post death assessment was noted as a phone call stating "left voicemail, mailings only as Edith is UCC, and was not interested in chaplain support". (mailings are documented)

Upon patient record review, 1 of 11 records (Patient #7) 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 7: The record indicated that bed and half rails were present during admission but was not in the plan of care. Corrected on site.

Upon observation during home visit, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Visit 2: RN placed dirty thermometer in the clean area with clean equipment.

Upon patient record review, 7 of 9 applicable records (Patient #1,#2,#3,#5,#6,#7,#9) the aide plan of care included as needed or as tolerated. • 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 1: The aide plan of care included task to assist in ambulation as needed. Patient 2: The aide plan of care included task make bed if needed Patient 3: The aide plan of care included task assist in transfer as needed. Patient 5: The aide plan of care included task as needed/tolerated for ambulation, as needed for changing linen, assisting in transfer, turning or reposition. Patient 6: The aid plan of care included task change linen as needed. Patient 7: The aide plan of care included task change linen as needed. Patient 9: The aide plan of care included tasks as needed for light housekeeping, change linen, assist with bedside commode.

Upon observation, there was no evidence the hospice documents and demonstrates viable and ongoing efforts to recruit and retain volunteers.

Upon patient record review, 1 of 11 records (Patient #1) 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 1: The medical record contained a written CTI signed 1/6/22 for the admitting benefit period starting 12/26/21. There was no evidence of a verbal certification received timely. The verbal certification dated 12/26/21 states for benefit period 3/26/22. According to the Hospice Medicare Billing manual, for the first 90-day period of hospice coverage, the hospice must obtain, no later than 2 calendar days after hospice care is initiated, (that is, by the end of the third day), oral or written certification of the terminal illness by the medical director of the hospice or the physician member of the hospice IDG, and the individual’s attending physician if the individual has an attending physician. For the subsequent periods, recertifications may be completed up to 15 days before the next benefit period begins and the hospice must obtain, no later than 2 calendar days after the first day of each period, a written certification statement from the medical director of the hospice or the physician member of the hospice’s IDG.

Upon patient record review, 2 of 7 applicable records (Patients #1,#2) 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: The medical record contained a written CTI signed 6/25/22 for benefit period starting 5/25/22. There was no evidence of a verbal certification received timely. The verbal certification dated 5/25/22 states for benefit period starting 7/24/22. The record also contained a CTI signed 2/24/22 for benefit period starting 3/26/22, outside of allowable time frame with no evidence of a verbal certification. The CTI for benefit period starting 9/27/22 does not contain a digital signature and date despite MD narrative being included. Patient 2: There was no evidence of a CTI for benefit period starting 1/31/22. For the subsequent periods, recertifications may be completed up to 15 days before the next benefit period begins. For subsequent periods, the hospice must obtain, no later than 2 calendar days after the first day of each period, a written certification statement from the medical director of the hospice or the physician member of the hospice’s IDG.

Upon patient client record review, 4 of 11 records (Patients #1,#2,#3,#8) 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 record inaccurately indicated that F2F conducted on 9/13/22 was for certification 7/24/22-9/21/22, 7/12/22 was for certification 5/25/22-7/23/22, and 5/17/22 was for certification 3/26/22-5/24/22. Patient 2: The record inaccurately indicated that F2F conducted on 9/2/22 was for certification 7/13/22-9/10/22. Patient 3: The record inaccurately indicated that F2F conducted on 7/6/22 was for certification 4/24/22-7/22/22, and 9/14/22 was for certification 7/23/22-9/20/22. The record contained physician order for foley catheter to be changed monthly and prn. The nursing documentation on 10/7/22 indicated that there was no foley catheter change since 8/20/22 despite LVN documentation on 9/24/22 that foley catheter was changed during the visit. Patient 8: The record inaccurately indicated that F2F conducted on 5/10/22 was for certification 3/9/22-6/6/22, and F2F conducted on 7/31/22 was for certification 6/7/22-8/5/22.

Upon SNF/NF contract review, 1 of 1 applicable (GH) did not have a provision stating that the hospice reports all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by anyone unrelated to the hospice to the SNF/NF administrator within 24 hours of the hospice becoming aware of the alleged violation. The provision acknowledging report of alleged mistreatment was reversed and stated it was facility responsibility to notify hospice administrator within 24 hours. Corrected on site with signed addendum by facility.