Every finding on record at Hi-Top Hospice Care Inc.

Upon patient record review, 2 of 4 (Patients #1, #2) 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 #1: The medication record indicated acetaminophen 650 mg Suppository PRN fever. There is no evidence of a parameter for fever. Patient #2: The medication record indicated acetaminophen 650 mg Suppository PRN fever. There is no evidence of a parameter for fever. Additionally, Oxygen was listed as a DME item. The POC did not include Oxygen dose/frequency/route.

Upon patient record review, 3 of 4 (Patients #1,2,3) 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,#2,#3: The Social Worker and Spiritual Counselor Visit Frequency on the IDG/POC (11/27/24) indicated "As Needed". These frequencies did not include a baseline visit frequency for the Social Worker or Chaplain disciplines.

Upon patient record review, 2 of 4 (Patients #1,#2) did not have evidence the plan of care (POC) must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #1: The record indicated acetaminophen 650 mg Suppository PRN fever. There is no evidence of a parameter for fever. Patient #2: The record indicated acetaminophen 650 mg Suppository PRN fever. There is no evidence of a parameter for fever. Additionally, Oxygen was listed as a DME item. The POC did not include Oxygen dose/frequency/route.

Upon patient record review, 1 of 4 (Patient #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 #4: The last IDG meeting in patient record occurred on 10/4/24. There are no documented IDG meetings for this patient on 10/18/24, 11/1/24 or 11/15/24.

Upon patient record review 6 of 14 (Patient #1,#2,#5,#7,#8,#10) 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#1,5,#8: There is no evidence of an initial spiritual or an initial psychosocial assessment. Patient#2,#7,#10: There is no evidence of an initial spiritual or an initial psychosocial assessment.

Upon patient record review, 6 of 14 (Patient #2,#3,#6,#7,#9,#10) 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: The record indicates patient was using oxygen, nebulizer, and Calmoseptine topically. There is no evidence of these items on the medication profile. RN verified nebulizer use was documented on the plan of care but the patient is not using a nebulizer. During home visit, it was noted that the agency medication profile included losartan, hydralazine, Humalog, atorvastatin, and amlodipine. These medications were not in group home and were not on the group home medication list. RN indicated that Humalog is being reordered. RN indicated that losartan, hydralazine atorvastatin, and amlodipine were discontinued. Corrected on site. Patient#3: The record also indicates patient was using oxygen, however, this is also not on the medication profile. Corrected on site Patient#6,#7,#10: The record indicates that the patient was ordered oxygen. There is no evidence of oxygen on medication profile. Patient#9: The record indicates that the physician ordered oxygen. There is no evidence that this is on the medication profile.

Upon patient record review, 5 of 14 (Patient #1,#2,#3,#9,#10) 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,#2,#3: Upon review the record indicated the initial bereavement was completed. However, it was incomplete as there was no primary bereaved identified. Corrected on site Patient#9,#10: There is no evidence of an initial bereavement assessment being completed on primary contact or other family member.

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

Upon patient record review, 9 of 14 (Patient #1,#2,#3,#4,#5,#6,#7,#9,#10) 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: The record indicates the patient required a special diet and was receiving psychosocial services. There is no evidence the plan of care reflected patient goals and interventions related to these needs. Corrected on site. Patient#2: The record indicates patient diagnosed with dementia and diabetes. The record indicates patient was taking insulin, is incontinent, and is receiving wound care, and wound being debrided by wound pros. There is no evidence the plan of care reflected patient goals or interventions related to these needs. Corrected on site. Patient#3: The record indicates the patient is being treated for incontinence, sleep disturbance, and hypertension. There is no evidence that the plan of care reflected patient goals and interventions related to these needs. Corrected on site. Patient#4: The record indicates the patient requires special diet, and assistance with confusion/disorientation. There is no evidence that the plan of care includes goals and interventions related to these patient needs. Corrected on site. Patient#5: The record indicates the patient has needs related to aspiration precautions, incontinence, and is receiving spiritual counseling services. There is no evidence that the plan of care includes goals and interventions related to these patient needs. Patient#6: The record indicates the patient is taking metformin for diabetes, is on oxygen, and is being treated for constipation. There is no evidence that the plan of care includes goals and interventions related to these patient needs. Patient#7,#9,#10: The record indicates that the patient requires the use of oxygen. There is no evidence that the plan of care includes goals and interventions related to these patient needs.

Upon patient record review, 8 of 14 (Patient #2,#3,#4,#5,#6,#7,#9,#10) 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: The order for acetaminophen 650mg suppository PRN for fever. There is no evidence of a parameter for the fever. In addition, there was no evidence of wound care order of sacral wound. Corrected on site Patient#3: The record indicates an order for acetaminophen 650mg suppository PRN for fever. There is no evidence of a parameter for the fever. There is also an order for pepto-bismol PRN, however there is no evidence of an indication. In addition, there is not evidence of order for foley. Corrected on site Patient#4: The record indicates an order for acetaminophen 650mg suppository PRN for fever. There is no evidence of a parameter for the fever. Corrected on site Patient#5: The record indicates an order for Bacitracin 500units/gram apply 2 grams topically twice a day, and hydrocortisone 0.5% apply topically twice a day. There is no evidence of a specified area of application for these medications. Patient#6: The record indicates an order for acetaminophen 650mg suppository PRN for fever. There is no evidence of a parameter for the fever. Patient#7: The record indicates an order for Voltaren gel 2.32% to be applied every 6 hours PRN. There is no evidence of a specified area for application. The record indicates an order for acetaminophen 650mg suppository PRN for fever. There is no evidence of a parameter for the fever. Patient#9: The record indicates an order on 8/18 for Silvadene cream. There is no evidence of a dose or a route as the order only states "Silvadene cream". In addition, no evidence of an order for oxygen. Patient#10: The record indicates an order for Bacitracin zinc 500units apply once a day. There is no evidence of a specified area of application.

Upon patient record review, 9 of 14 (Patient #1,#2,#3,#4,#5,#6,#7,#9,#10) 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 indicates patient having oxygen, over the bed table, wheelchair, walker, wipes and incontinent supplies. There is no evidence of these items being included on plan of care. Corrected on site. Patient#2: The record indicates patient having wound care supplies, bed, table, diapers, chux, gloves, half rails, and mattress. There is no evidence of these items being included on plan of care. Corrected on site. Patient#3: The record indicates patient having oxygen, bed, table, and foley catheter. There is no evidence of these being included on plan of care. Corrected on site. Patient#4: The record indicates the patient having oxygen, wheelchair, walker, diapers, chux, and wipes. There is no evidence of these items being included on plan of care. Patient#5: The record indicates the patient has incontinence supplies. There is no evidence of these being included on plan of care. Patient#6,#7: The record indicates the patient having oxygen and hospital bed with rails. There is no evidence of these items being included on plan of care. Patient#9,#10: The record indicates the patient having oxygen and oxygen supplies. There is no evidence of these items being included on plan of care.

Upon client record review, 4 of 14 (Patient #1,#2,#4,#5) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient#1,#2: The record indicates spiritual visit frequency is 1 time per month. There is no evidence of any visits being made and no evidence of missed visit. Per conversation with RN spiritual services were declined. Corrected on site. Patient#4: The record indicates spiritual visit frequency is 1 time per month. There is evidence of only an initial spiritual assessment being made. No visits or missed visits are documented after the initial visit. The record indicates the daughter declined social worker services after the initial visit in March. There are no missed visits and no order to discontinue services found in record. The social worker resumed visits in July per family request. Corrected on site. Patient#5: The record indicates spiritual and social worker visit frequency is ordered 1 time per month. The social worker services were declined on admit per RN documentation. Social worker did make visit on September 15th. There is no documentation of visit for August and no indication or missed visit. Spiritual counseling did not make a visit until 10/11. There is no documentation of a visit or missed visit for August or September.

Upon patient record review 1 of 14 (Patient #4) did not have evidence that the IDG ensures that the care and services provided are based on all assessments of the patient and family needs. Patient#4: The record indicates that on initial social worker visit the social worker stated to caregiver that a podiatrist would follow up with the patient . There is no evidence that this was completed.

Upon patient record review, 2 of 14 (Patient #2,#8) did not have evidence that the IDG documents the sharing of information between all disciplines providing care and services in all settings, whether the care and services are provided directly or under arrangement. Patient#2: There is no evidence of coordination of care documented in IDG regarding care provided by wound pros. Patient#8: There is no evidence of coordination of care or sharing of information between hospice and the designated attending physician chosen by patient.

Upon patient record review 2 of 14 (Patient #1,#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 • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient#1: The Plan of care indicates the aide visit frequency is for 1 visit the first week of service and no visits after the first week. The record shows aide visits being made every week. Corrected on site. Patient#5: Upon review of patient record, it was indicated that aide services were declined on admit. However, starting March 8th the aide began seeing the patient every week. There is no evidence this was ordered by the interdisciplinary group. Corrected on site.

Upon contract review, 1 of 4 (Wound Pros contract) 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: • Authorized by the hospice • Furnished in a safe and effective manner by qualified personnel • Delivered in accordance with the patient's plan of care The agency did have a contract with Wound Pros that had been providing services to hospice patients however, there was no reference to administrative and financial oversight and the administrator stated Wound Pros was billing Medicare Part B and there was no documentation in the medical record whether wounds were or were not related to patient hospice stay.

Upon patient client record review, 1 of 14 (Patient #3) 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 #3: Upon review of record, it was noted that patient/family elected to receive the addendum. There is no evidence that this was provided to or received by patient/family.

Upon patient client record review, 5 of 14 (Patient #4,#5,#6,#8,#10) did not have evidence that each patient record contains Advance Directives. Patient #4: The record indicates that patient has advanced directives including POA. There was no evidence of these documents found in chart. Corrected on site Patient #5: The record indicates patient has a court approved conservator. There is no evidence of these documents found in chart. Corrected on site. Patient#6,#8,#10: The record indicates that patient has a designated POA. There was no evidence of these documents found in chart.

Upon patient client record review, 1 of 14 (Patient #9) 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#9: Upon review, record indicates patient is on a mechanical soft diet. The plan of care includes interventions for tube feedings and PEG tube care. RN confirmed patient was not on tube feedings.

Upon client record review, 4 of 14 (Patient #6,#7,#11,#12) did not have evidence that if a patient revokes the election of hospice care or is discharged from hospice in accordance with §418.26, the hospice must forward to the patient's attending physician: • A copy of the hospice discharge summary • The patient's clinical record, if requested Patient #6,#7: There is no evidence of hospice discharge summary being sent. There is no evidence of any coordination of care being communicated with a community physician as patient moved out of the service area. Patient#11: There is no evidence of hospice discharge summary being sent. There is no evidence of any coordination of care being communicated with hospital patient went to for aggressive treatment. Patient#12: There is no evidence of hospice discharge summary being sent. There is no evidence of any coordination of care being communicated to community physician as patient was discharged for extended prognosis.

Upon client record review, 3 of 14 (Patient #5,#6,#7) did not have evidence that the discharge summary includes all required information. Patient#5,#6,#7: There is no evidence of summary of patient's stay, treatment, symptoms, pain management, status at time of discharge, and no documentation of efforts or communication for continuity of care.

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 contract reviewed at the agency was not signed by the DME company. There was no evidence of DME provider being accredited. Corrected on site.

Condition of Participation: Personnel Qualifications.

Upon personnel record review, 1 of 14 (Personnel #14) did not have evidence that all Speech Therapy Services are provided by a qualified licensed Speech-Language Pathologist (SLP) or Audiologist in accordance with the state's Speech-Language Pathology Practice Act and the hospice's policies and procedures and/or job descriptions. There is no evidence of a file containing any information or an identified ST for this agency.

Upon personnel record review, 1 of 14 (Personnel #13) did not have evidence all Occupational Therapy Services are provided by a qualified licensed Occupational Therapist (OT) in accordance with the state's Occupational Therapy Practice Act and the hospice's policies and procedures and/or job descriptions. There is no evidence of a file containing any information or an identified OT for this agency.

Upon personnel record review, 2 of 14 (Personnel #13,14) did not have evidence the hospice obtained a criminal background check on all contracted individuals who have direct patient care and access to patient records. No OT or ST HR files presented.

Upon patient record review, 1 of 5 (Patient #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 Patient 4: The medical record contained information that the patient required oxygen. The oxygen was not included on the medication profile.

Upon patient record review, 1 of 1 applicable (Patient #4) 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 Patient 4: The aide care plane, dated 06.14.2021, did not contain evidence of a frequency for the tasks that the aide is to perform including the shower with chair, shampoo hair, and brush teeth.