Every finding on record at Holly Trinity Hospice Inc

Upon observation, there was no evidence that during the initial assessment visit in advance of furnishing care, the hospice provided the patient and/or family with verbal (meaning spoken) and written notice of the Patient's Rights and Responsibilities in a language and manner that the patient understands. Patient #11: Admission forms, including consent and hospice election are signed by patient with documented confusion and secondary diagnosis of dementia. Family was present during admission process, but only patient signed forms.

Upon patient record review, 1 of 14 (Patient #11) did not have evidence that the hospice informed and provided written information to the patient concerning its policies on advance directives, including a description of applicable state law. Patient #11: Admission forms, including consent and hospice election are signed by patient with documented confusion and secondary diagnosis of dementia. Family was present during admission process, but only patient signed forms.

Upon patient record review, 1 of 14 (Patient #11) did not have evidence that the hospice obtained the patient's or representative's signature confirming that they received a copy of the Patient's Rights and Responsibilities. Patient #11: Admission forms, including consent and hospice election are signed by patient with documented confusion and secondary diagnosis of dementia. Family was present during admission process, but only patient signed forms.

Upon observation, there was no evidence the patient has the right to voice grievances/complaints regarding treatment or care that is (or fails to be) furnished and lack of respect of property by anyone who is furnishing care/service on behalf of the hospice. Patient #11: Admission forms, including consent and hospice election are signed by patient with documented confusion and secondary diagnosis of dementia. Family was present during admission process, but only patient signed forms.

Upon patient record review, 1 of 14 (Patient #11) did not have evidence that if a state court has not adjudged a patient incompetent, any legal representative designated by the patient in accordance with state law may exercise the patient's rights to the extent allowed by state law. Patient #11: Admission forms, including consent and hospice election are signed by patient with documented confusion and secondary diagnosis of dementia. Family was present during admission process, but only patient signed forms.

Upon client record review, 1 of 14 (Patient #11) did not have evidence that the plan of care included IDG's documentation of the patient's or families level of understanding, involvement and agreement with the plan of care. Patient #11: Admission forms, including consent and hospice election are signed by patient with documented confusion and secondary diagnosis of dementia. Family was present during admission process, but only patient signed forms.

Upon patient record review, 1of 14 (Patient #11) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient #11: Admission forms, including consent and hospice election are signed by patient with documented confusion and secondary diagnosis of dementia. Family was present during admission process, but only patient signed forms.

Upon patient record review, 1 of 14 (Patient #11) did not have evidence of the appropriate documentation for release of confidential information. Patient #11: Admission forms, including consent and hospice election are signed by patient with documented confusion and secondary diagnosis of dementia. Family was present during admission process, but only patient signed forms.

Upon patient record review, 1 of 14 (Patient #11) did not have evidence that the patient received information about the services covered under the hospice benefit. Patient #11: Admission forms, including consent and hospice election are signed by patient with documented confusion and secondary diagnosis of dementia. Family was present during admission process, but only patient signed forms.

Upon patient record review, 1 of 14 (Patient #11) did not have evidence that the patient received information about the scope of services that the hospice will provide and specific limitations on those services. Patient #11: Admission forms, including consent and hospice election are signed by patient with documented confusion and secondary diagnosis of dementia. Family was present during admission process, but only patient signed forms.

Upon patient record review, 1 of 14 (Patient #4) 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 #4: Oxygen prescribed, but no related problem, goals, interventions specific to oxygen on initial or subsequent plan of care.

Upon home visit observation in 1 of the 3 visits, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient Visit #3: Upon observation, the RN placed nursing bag on barrier, but when preparing for closure of visit, lifted bag to gather barrier and placed the bag on the bare upholstered chair, before soon lifting and picking up/carrying with shoulder strap. (Policy 9-014.1) The bag will be placed on a clean dry surface (i.e. surface that can be easily disinfected) in the car and in the home

Upon personnel record review, 6 of 14 (Personnel #2, 3, 4, 6, 7, 8 ) did not have evidence that the hospice routinely provide substantially all core services directly by hospice personnel (The hospice issues a W-2 form for the employee). These services include: • Physician services (may contract for physician services) • Nursing • Medical social services • Counseling Personnel #2, 3: Personnel file included both W4 and W9 with same effective dates. (RN/Alt Admin/Alt DPCS #2 and RN #3) Personnel #6: The is no evidence of W4 or W9. W4 provided prior to end of survey. (MSW) Personnel #4, 7, 8: There is only evidence of aW9 in personnel file. (LVN #4, SC #7, BC/VC #8)

Upon personnel record review, 1 of 14 (Personnel #5) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) ·Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff. ·Reading and recording temperature, pulse, and respiration ·Safe transfer techniques and ambulation. ·Normal range of motion and positioning ·Appropriate and safe techniques in personal hygiene and grooming that include-- ·(A) Bed bath ·(B) Sponge, tub, and shower bath ·(C) Shampoo, sink, tub, and bed ·(D) Nail and skin care ·(E) Oral hygiene ·(F) Toileting and elimination The other subject areas in this section may be evaluated through written examination, oral examination or after observation of a Hospice Aide with a patient. Personnel #5: Specific types of shampoo are not validated, shampoo is generally listed.

Upon patient record review, 1 of 14 (Patient #14) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • 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 #14: Hospice Aide assignment for 2x/wk tub bath every visit with RN additional instructions for Hospice Aide may do a bed bath or bathe the patient in the bathtub/shower per RN assignment sheet. There is no qualifying statement regarding cognitive ability of patient and/or caregiver to verbalize choice. There is no evidence of separate assignment sheets.

Condition of Participation: Organization and administration of services. The hospice must organize, manage, and administer its resources to provide the hospice care and services to patients, caregivers and families necessary for the palliation and management of the terminal illness and related conditions.

Upon observation, there was no evidence the hospice is directed by a Board of Directors/governing body which assumes full legal authority and responsibility for the operation of the hospice. The governing body/Administrator did not provide Human resource management as evidenced by Personnel #1: There was no signed job description for administrator at time of personnel file review for comparison of qualifications; only alt DPCS job description was filed. Signed job description provided prior to end of survey and qualifications met. Personnel #2: There was no signed job description for Alternate Administrator. It was provided prior to end of survey. In addition, did not ensure core services are provided by employees.

Upon contract review, 2 of 4 (Dr. Soffwer and Dr Pines contracts) did not have evidence of a contract to fulfill the role of medical director or alternate medical director, if applicable. Both contracts presented as Medical Director. Dr. Soffwer is reported to be Medical Director and Dr. Pines is alternate.

Upon patient client record review, 1 of 14 (Patient #11) 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 #11: Admission forms, including consent and hospice election are signed by patient with documented confusion and secondary diagnosis of dementia. Family was present during admission process, but only patient signed forms.

Upon patient client record review, 1 of 14 (Patient #9) did not have evidence that each patient record contains Advance Directives. Patient #9: Patient SOC 7/14/23. Record identifies patient code status as Attempt CPR/Full Code in demographic information. MSW most recent assessment 9/5/24 identifies patient as full code. However, there is a POLST form dated 7/14/23, with option chosen as do not attempt CPR. There is no documented evidence of update at time of record review.

Upon client record review, 3 of 14 (Patient #10, 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 Patients #10, 11, 12: There is no documented evidence that patients' discharge summary was forwarded to attending physician following revocation.

Upon client record review, 4 of 14 (Patient #9, 10, 11, 12) did not have evidence that the discharge summary includes all required information. Patient 9, 10, 11, 12: Discharge Summary does not include a summary of the patient's stay, current plan of care, orders

Upon client record review, 1 of 14 (Patient #11) did not have evidence that the written policies and procedures for managing controlled drugs was provided and discussed. Patient #11: Admission forms, including consent and hospice election are signed by patient with documented confusion and secondary diagnosis of dementia. Family was present during admission process, but only patient signed forms.

Upon personnel record review, 3 of 14 (Personnel #12, 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. Personnel #12, 13, 14: No criminal background check prior to end of survey. (PT/OT/SLP)

Upon patient record review 1 of 11 (Patient #11) 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 #11, Patient refused chaplain visit, no spiritual assessment completed.

Upon patient record review, 1 of 11 (Patient #7) 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 #7, Oxygen 2l/nc cont ordered, no evidence of oxygen on medication profile.

Upon patient record review, 2 of 11 (Patient #8 and 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 #8 and 10: No evidence of initial bereavement risk assessment completed.

Upon client record review, 2 of 11 (Patient #7,11) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #7, Patient SN frequency 1x/week, nursing visits 4/12/22, 4/15/22, 4/16/22, 4/17/22, 4/18/22, no order to increase visit frequency. Patient #11, Patient SN frequency 2x/week, nursing visits 7/19/21, 7/20/21, 7/21/21, 7/22/21, 7/23/21, no order to increase visit frequency.

Upon patient record review, 1 of 7 applicable (Patient #6) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • 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 #6, Vital signs ordered on Plan of care without parameters for HHA to report to Case Manager.

Upon patient record review 1 of 7 applicable (Patient #6) 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 #6 Care Plan did not have direction for walker and w/c but was completed and checked off on HHA visit for 4/10/21.

Upon patient record review, 5 of 11 (Patient #5, 6, 7, 9 and 11) 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 #5, No CTI signed by primary MD or Medical Director for admission on 1/8/21. Patient #6, No CTI signed by primary MD or Medical Director for admission on 8/3/20. Patient #7, No CTI signed by primary MD or Medical Director for admission on 4/9/21. Patient #9, No CTI signed by Primary MD or Medical Director for admission on 6/4/21. Patient #11, No CTI signed by primary MD or Medical Director for admission on 6/23/21.

Upon patient record review, 1 of 4 applicable (Patient #9) 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 #9, No CTI for recertification on 8/25/21 and 11/15/21.

Upon patient client record review, 7 of 11 (Patient #4,5,7,8,9,10,11) 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 #4: Missing initials under Hospice Benefit for notification of covered or noncovered services, both were left blank. Patient #5: Initials signed under Hospice Benefit for notification for both covered and noncovered services without a check mark to identify which they wanted. Patient #7: Informed consent and treatment auth, missing patient name and effective date for hospice. Patient #8: Election of Hospice benefit both noncovered and covered initials on both without one being identified by check mark. Patient #9: Election of Hospice benefit both noncovered and covered initials on both without one being identified by check mark. Patient #10: Election of Hospice benefit both noncovered and covered initials on both without one being identified by check mark. Hospice Medicare Benefit , no effective date documented. Patient #11: Election of Hospice benefit both noncovered and covered initials on both without one being identified by check mark.

Upon patient client record review, 4 of 11 (Patient #4, 7, 10 and 11) 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 #4, incorrect documentation of error on printed medication profile Docusate 100mg daily, line drawn through daily and word twice written. No documentation of date or initials noted. Metoprolol 25mg twice a day with line drawn through twice a day and the word daily written. No documentation of date or initials noted on printed medication sheet. Hand written medication profile was not corrected. Patient #7: Informed consent and treatment auth, missing patient name and effective date for hospice. Patient consent for care and service agreement liability for payment was not identified by checking box of payor. Patient #10: Care and Service agreement, no identification by checking box for liability of payment. Patient #11: Patient consent for care and treatment, liability incomplete, no check mark for payor source.