Every finding on record at Home of St Theresa Hospice LLC

Upon patient record review, 5 of 5 (Patient #1, 2, 3, 4, 5) did not have evidence in the patient record that the comprehensive assessment takes into consideration the imminence of death.

Upon patient record review, 2 of 5 (Patient #2, 3) 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 - Medication profile contained Zinc oxide to buttocks and elbows PRN - no frequency or modifier for PRN. Patient #3 - Medication profile did not contain Zyrtec 10mg 1 tab every day for seasonal allergies.

Upon patient record review, 2 of 5 (Patient #3, 4) 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 #3 - POC dated 04/28/24 MSW visit frequency PRN. Patient #4 - POC dated 05/10/24 MSW and SC visit frequency PRN.

Upon patient record review, 1 of 5 (Patient #3) 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 #3 - POC 04/28/24 did not contain Zyrtec 10mg 1 tab every day for seasonal allergies.

Upon patient record review, 2 of 5 (Patient #3, 5) 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 #3 - Hospital bed was not noted on POC dated 04/28/24 Patient #5 - CPAP was not noted on POC dated 05/04/24.

Upon patient record review, 3 of 5 (Patient #3, 4, 5) 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 #3 - IDT dated 06/04/24 and 06/18/24 did not have evidence that the SN documented the patient progress towards goals from the plan of care. Patient #4 - IDT dated 06/04/24 and 06/18/24 did not have evidence that the SN documented the patient progress towards goals from the plan of care.

Upon patient client record review, 1 of 5 (Patient #3) 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 #3 - Illegible name and credentials on visit notes 04/24/24 and 05/22/24 completed by SC.

Upon client record review, 1 of 5 (Patient #1) 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 #1 - No evidence that the discharge summary was sent to the PCP.

Upon patient record review, 4 of 5 (Patient ##2, #3, #4, #5) 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 nurse note dated 1/5/24, 1/25/24, and 1/29/24 indicated the patient was using Tylenol PRN for pain. Tylenol is not on the medication profile. Patient#3:MiraLAX is listed on the medication profile as 16 grams of powder PO daily without evidence of a diluent. Patient#4:On 9-7-23 the RN documented "provide O2 supplement". There was no evidence of O2 on the medication profile. Patient#5:On 8-24-23, an order for Lidocaine patch, Voltaren gel and Melatonin was written without evidence of the medications being added to the medication profile.

Upon patient record review, 2 of 5 (Patient #3, #5) 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. Patient #3: There was no evidence of a bereavement assessment completed within 5 days of admission. Patient#5: There was no evidence of a bereavement assessment completed within 5 days of admission.

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

Upon patient record review, 2 of 5 (Patient #2, #4) 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 nurse note dated 1/5/24, 1/25/24 and 1/29/24 indicated the patient was using Tylenol PRN for pain. There was no order for Tylenol. Patient#4: The nurse documented on 9-7-23 to "provide O2 supplement". There is no order for O2.

Upon patient record review, 5 of 5 (Patient #1, #2, #3, #4, #5) 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#1, #2, #3, #4, #5: The plans of care were updated every 14 days using a "Case conference" template which addressed "Barriers: related to Communication, non-compliance, behavioral dysfunction, and resistive physician"; "Obstructions to meet goals" and "suggestions to move forward". There was no evidence the plan of care addressed progress toward outcomes as determined in the individualized comprehensive plan of care, changes that had taken place since the initial assessment, or reassessment of the the patient's response to care. In addition, there were no frequency updates to the plans of care.

Upon client record review, 5 of 5(Patient #1, #2, #3, #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: The comprehensive plan of care dated 5/10/23 indicated SW visits were 1 wk. 12, however, there were no SW visits and the RN completed the SW Comprehensive Assessment. In addition, the Volunteer frequency was 1 wk12, and there was no evidence of a visit by the volunteer. Patient #2: The comprehensive plan of care dated 7-15-23 indicated SW frequency of 1 wk. 12, however, there was evidence of only one visit on 7-15-23. Additionally, the SCC frequency was documented as 1 wk. 12, but there were notes for the SCC visit every 2 weeks, on 12/13/23, 12/27/23, 01/10/24, 01/24/24, and 02/07/24, Also, the volunteer frequency was documented as 1 wk. 12 and there was no evidence of a volunteer visit. Patient #3:The plan of care dated 10-31-23 indicated RN visits were 1 wk. 12. There was no evidence of a visit made between the dates of 1/5/24 and 2/11/24. Patient #4:The plan of care dated 9-2-23 documented RN visit frequency 14 wk.12, Visits were made 2 x day on 9/2/23, 9/3/23, 9/4/23, 9/6/23, 9/7/23, and 9/8/23.The volunteer frequency was documented as 1 wk. 12, but there was no evidence of volunteer visits. Additionally, the SC visits were documented as 1 wk. 12 and there were 3 visits on 9/3/23, 9/4/23 and 9/8/23. Patient #5:The plan of care indicated the volunteer visits were 3 wk. 12, but there was only evidence of 2 total visits by the volunteer during the admission.

Upon patient record review, 1 of 5 (Patient #4) did not have evidence the hospice offers bereavement counseling that includes: • Making bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. • 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: The bereavement plan of care was incomplete without evidence of interventions and frequencies.

Condition of Participation: Hospice Aide and Homemaker Services. L607

Upon patient record review, 3 of 5 (Patient #2,#3,#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#2: The interdisciplinary plan of care dated 7-15-23 indicated aide visits were 2 x week. On the aide care plan dated 9-15-23, the RN indicated aide visits were 3 days a week. The aide continued to visit the patient 2 x week. In addition, the RN assigned "ambulation" which was not given as an option on the aide's visit document so was not completed by the aide. The aide's documentation sheet was inconsistent with the assignment sheet. Supervisory visits were completed q 2 weeks and the RN documented "Yes" to the questions of aide following the plan of care. Patient#3: On 10-30-23, the IDT plan of care indicated the aide visits were 2 x week. On the aide care plan of 10-31-23, the RN documented the aide visits were 3 x week. In addition, on the aide care plan dated 10-31-23, the RN ordered Bathing tasks of complete bath, 2 days a week and sponge bath 1 day a week, but the aide only visited 2 days a week throughout the patient's admission. Supervisory visits were completed every 2 weeks by the RN, who indicated "yes" to the question of whether the aide followed the plan of care. Patient#4: On the aide plan of care dated 9-2-23, the RN ordered "shower", "complete bed bath" and "sponge bath."

Upon patient record review 4 of 5 (Patient #2,#3,#4,#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 Patient#2:Beginning 11-11-23 and all weeks through week of 2-10-23, the aide care plan indicated "shower" was ordered and the aide documented "complete" indicating bed bath. "Nail care" was ordered and the aide documented, "none;" "Ambulation" was ordered, but was not an option on aides document tool and was not documented as done by the aide; Care plan indicated "diaper change" and aide documented "assist to bathroom". Patient#3:Aide care plan indicated "Complete bed bath 2 x week" and "sponge bath" 1 x week. Aide did not complete any bath on 1/3/24 and 1/5/24, aide documented completion of "bed bath" and "shower" on 1/22/24 and 2/9/24. There were no sponge baths given throughout admission. Additionally, the aide documented "shave" on every visit During January-February of 2024, but the RN did not order "shave" as part of the plan of care. The care plan indicated "change linens" and "tidy care area" was part of the plan of care, but there was no evidence of the tasks being completed from 1/12/24 through 2/16/24. Patient#4:The aide care plan dated 9-2-23 indicated "nail care", "Shampoo", "change linens", "clean patient area", and "companion" were ordered, but the aide did not complete any of these tasks throughout the patient's admission. The IDT care plan dated 9-2-23 ordered 5 visits per week for the aide. The aide visited 6 times during the week of 9-2-23. In addition, the patient died on 9-8-23 and the aide documented a visit on 9-10-23 due to the aide documentation tool showing the care week as Monday through Sunday, when the agency has indicated Sunday through Saturday as the care week. Patient#5:The aide documented completion of of Nutrition, Feeding, Companion, Socialization and Safety tasks on the weeks of 8-18, 8-26, 9-1, 9-9, 9-11, but there was no indication that these tasks were part of the aide care plan. In addition, the interdisciplinary care plan indicated aide visits were 0 frequency beginning 8-20-23, but the aide continued to visit 2 x week. The plan of care dated the 8-14-23 indicated the CNA visits decreased to "0" on 8-20-23, however, the CNA continued to visit 2x/week .

Upon patient record review 3 of 5 (Patient #2, #3, #5) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs. Patient#2:Supervisory visits completed every 14 days indicated CNA was following plan of care, "yes", despite care plan indicating "shower", "nail care", "ambulation" and "diaper change" and aide documenting, "complete bed bath", no nail care, no ambulation and "assist to bathroom." Patient#3: Supervisory visits documented on 1/18/24 and 2/2/24 indicated aide was following plan of care, "yes", despite aide never giving "sponge bath" as ordered 1 x week, and providing a "shave" on visits 1/12/24, 1/15, 1/22, 1/24, 1/26, 1/29, 1/31, 2/2, 2/5, 2/7, 2/9, 2/12. 2/14, and 2/16 which was not ordered as part of the plan of care. Patient#5:Supervisory visits on 8/26/23 and 9/10/23 indicated aide was following plan of care; "yes" despite aide not, "making bed", "changing linens", "tidying patient care area", and "housekeeping" as assigned and instead on dates 8/18/23, 8/26, 9/1, 9/9, and 9/11 performing, nutrition, feeding, companion, socialization and safety tasks despite not being assigned on the plan of care.

Upon patient record review, 3 of 5 (Patient #1,#2, #3) 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: There is no evidence of a narrative explanation of clinical findings for Benefit Period 2 or benefit Period 4. Patient #2: There is no evidence of a narrative for Benefit Period 2 or the 3rd Benefit Period. Patient #3: There is a no evidence of a narrative for the the 2nd Benefit Period dated 1/29/24.

Upon patient client record review, 4 of 5 (Patient #1, #2, #4, #5) 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#1:The Consent to Care dated 5/10/23 was incomplete without evidence of payment amount required by patient. In addition, the chosen attending physician documentation did not include the NPI or address of the physician. Patient#2:Patient Financial Authorization dated 7/15/23 is incomplete without evidence of "primary insurance to be billed" completed. In addition, on the Medicare Hospice Election, dated 7/15/23, the patient's representative signed without evidence of the relationship of signature or reason the patient was unable to sign. Patient#4:On "Right to Choose Physician documentation dated 9/2/23 there is no evidence of NPI or address for chosen physician. Patient#5::On "Right to Choose Physician documentation dated 8/14/23 there is no evidence of NPI or address for chosen physician.