Every finding on record at Holistic Hospice Care, Inc.

Observed in Emergency Management Session. The organization hazard vulnerability analysis utilizing an all-hazards approach failed to include emerging infections, this was observed and validated by the DPCS

Observed in Record Review. In 5 of 10 patient records reviewed, The organization failed to revise plan of care based on information from updates to the patient’s comprehensive assessment since SOC and address the patient’s progress toward goals or goals met as evidenced in the following records and SOC has been over 12 months ago: RRHV#1 for RRNHV#3: RRNHV#4: PCG is to express feelings of death, dying, and loss while expressing feelings of having adequate anticipatory grief support. RRHV#2: Cardiac goal: PCG will verbalize/express understanding of medication /treatment orders and side effects such as hypotension and fainting spells. RRHV#3: Gastro - Facilitate bowel elimination and comfort. -Pt/Family/PCG will verbalize understanding that symptom is a part of the disease process and the limitations of treatments. pt will have regular bowel movements. this was observed and validated by the DPCS

Observed in Record Review. In 10 of 10 patient records reviewed, The organization failed to provide a written plan of care based on the patient’s goals and the time frames as evidenced in RRHV#1 the neurological goal was : Pt/pcg will verbalize/express understanding of medication /treatment orders and side effects. pt will be comfortable with medications. RRHV#2: Cardiac goal - PCG will verbalize/express understanding of medication /treatment orders and side effects such as hypotension and fainting spells. RRHV#3: Cardiac -pt will be able to take the medication to control blood pressure for comfort. RRNHV#1: Resp goal: Pt will have early detection of URI, Pt will receive O2 treatments to achieve and maintain Pt comfort. RRNHV#2: GU goal: Pt. and pt. caregiver will verbalize having urinary elimination needs met at an acceptable level. RRNHV#3: Patient will maintain peripheral circulation for patient comfort throughout care with hospice/ RRNHV#4: Pain goal not specific: Keep patient's pain below SIT level for comfort genius Patient caregivers verbalize understanding of nonverbal signs of pain. RRNHV#5: Altered skin will heal for patient comfort. -Resolve wound status for comfort. rash will resolve for comfort. RRNHV#6: Patient will be monitored closely with early detection of possible and aneurysm throughout care with hospice. RRNHV#7: PCG will verbalize that patient needs will be met on a daily basis as communicated or tolerated, this was observed and validated by the DPCS

Observed in Record Review. In 7 of 10 patient records reviewed, The organization failed to identify the intervention needed when planning the patient’s care as evidenced in RRHV#2: Oxygen ordered 2-5 litres N/C continuous with no indication when to increase oxygen liters. RRHV#3, RRNHV#3: RRNHV#5, RRNHV#6, RRNHV#7: Oxygen ordered 2-4 liters PRN for shortness of breath but no indication when to increase liter flow. RRNHV#4: . Oxygen ordered 2-4 liters continuous via N/C , no indication as to what liter to use RRNHV#&: Patient is a type II diabetic and there is no interventions in plan of care, this observed and validated by the DPCS

Observed in Record Review. In 3 of 10 patient records reviewed, A registered nurse who prepares written patient care instructions for the hospice aide did not identify in RRNHV#2: special precautions for foley care in the HHA assignment . RRNHV#4:Patient has dysphagia on a pureed diet and aspiration precautions is not identified in HHA assignment, RRNHV#6: HHA assignment did not include aspiration precautions and patient is on a mechanical soft diet, this was observed and validated by the DPCS

Observed in Patient Home. In 1 of 3 patient records reviewed, The organization failed to coordinate the patient’s care, treatment, or services based on the patient’s needs as evidenced in RRHV#2: the hospice did not provide the SNF with a copy of the patients Election and consent forms, this was observed and validated by the DPCS

Observed in Competency Session. The organization failed to stipulate in the DME contract that they will complete criminal background checks on employees who provide direct patient care, this was observed and validated by the DPCS

Observed in Emergency Management Session. Identified during the review of the organization;s Emergency Preparedness Plan, there was no updated Alternate Meeting Site in the event the original site is incapacitated. There also was no succession plan that lists who replaces the key leaders nor a delegation of authority plan that describes what decisions and policies that authorized successors can implement. This was reviewed and validated with the Director of Patient Care Services.

Observed in Emergency Management Session. Identified during review of the organization's Emergency Preparedness Plan, there was no outline or description detailing the specific roles and responsibilities for staff and/or volunteers during an emergency. This was reviewed and validated with the Director of Patient Care Services.

Observed in Emergency Management Session. Identified during review of the organization's Emergency Preparedness Plan, the names and contact information for staff, physicians, volunteers, and vendors was not included in the plan in accordance with organizational Policy 2.3.1,2. This was reviewed and validated with the Director of Patient Care Services.

Observed in Record Review. In 2 of 8 active patient records reviewed, all services needed in the management of the terminal illness and related conditions were not included in the plan of care. For example, in HV#2, it was identified during the initial Comprehensive Psychosocial Assessment, approximately 4 months prior to the survey date, that the patient lacked funeral or burial plans. This need was not included in the patient's plan of care. In RR#4, the Registered Nurse indicated in the initial Comprehensive Assessment approximately 9 months prior to the survey date that the patient lacked Funeral/Burial plans, documented as TBD (to be determined) by the admitting Registered Nurse. To date this need has not been included in the patient's plan of care. This was reviewed and validated with the Director of Patient Care Services.

Observed in Record Review. In 1 of 8 active patient records reviewed it was identified that the Hospice Aide Supervisory Visit was not conducted every 14 days per requirements. For example during the record review of HV#1, the Registered Nurse conducted the initial hospice aide supervisory visit 17 days after the initial hospice aide visit. This was reviewed and validated with the Director of Patient Care Services.

Observed in Tracer Activities. Identified during the review of the Volunteer Program and during conversation with the Volunteer Coordinator, there was no documentation of volunteer recruitment or retention activity during the past three years: 2020, 2021, or 2022. This was reviewed and validated with the Director of Patient Care Services.

Observed in Tracer Activities. Identified during the review of the Volunteer Program, there was no documentation of cost savings achieved through the use of volunteers during 2020 and 2022. This was reviewed and validated with the Director of Patient Care Services.

Observed in Tracer Activities. Identified during the review of the Volunteer Program, there was no documentation of hours provided by volunteers in administrative or direct patient care roles during 2 of the last three years. For example in 2020 and 2022, there was no documentation of volunteer hours.. Therefore, the 5% equivalent hours was not achieved in those years. This was reviewed and validated with the Director of Patient Care Services.

Observed in Tracer Activities. There was no evidence that the governing body and leadership had established requirements to support patient care treatment and services as evidenced by policies and procedures were not followed for the 418.113 - Emergency Management Program or the 418.78 - Volunteer Services. This was reviewed and validated with the Director of Patient Care Services.