Every finding on record at Hospice at Lsmnj, Inc.

Upon patient record review, 2 of 5 (Patient #1,4) 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 #1: There is evidence in the medical record the patient was on Eliquis 2.5 mg 2x daily. The initial plan of care did not include Bleeding Risk. Patient #4: There is evidence in the medical record 9/18/24 initial nursing assessment noted "patient very restless and agitated. RN gave recommendation for Ativan, approved by the MD and given. The initial plan of care does not include Restlessness/Agitation.

Upon patient record review, 5 of 5 (Patient #1,2,3,4,5) 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 medications and treatments. Patient #1: There is evidence in the medical record of an order for Oxygen but Oxygen did not appear on the plan of care medications. Patient #2: There is evidence in the medical record nursing assessment 9/23/24 note "history of constipation controlled with Miralax and Senna QD. Senna was not on the plan of care. In addition, Miralax 17/gm/scoop powder one time daily as needed, did not indicate a diluent. Patient #3: There is evidence on the plan of care, Miralax 17/gm/scoop powder one time daily as needed, did not indicate a diluent. Patient #4: There is evidence on the plan of care, Tramadol 50 mg one tablet oral as needed for pain. Did not indicate how often to give Tramadol. Patient #5: There is evidence in the medical record nursing assessment 9/19/24 note redness in groin "skin protectant applied". There is no order for skin protectant.

Upon patient record review, 1 of 19 (Patient #19) 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 #19, No evidence of consents uploaded into chart. COS.

Upon patient record review, 1 of 19 (Patient #19) 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 #19, No evidence of consents uploaded into chart. COS.

Upon patient record review, 1 of 19 (Patient #19) did not have evidence of the appropriate documentation for release of confidential information. Patient #19, No evidence of consents uploaded into chart. COS.

Upon patient record review, 1 of 19 (Patient #19) did not have evidence that the patient received information about the services covered under the hospice benefit. Patient #19, No evidence of consents uploaded into chart. COS.

Upon patient record review, 1 of 19 (Patient #19) 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 #19, No evidence of consents uploaded into chart. COS.

Upon patient record review 1 of 19 (Patient #18) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient #18, MSW documents will complete assessment when son calls back. No evidence of initial assessment completed at the time of survey.

Upon patient record review, 9 of 19 (Patient #1,2,3,14,15,16,17,18,19) 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, Patient is taking pantoprazole 40mg every day. No evidence of medication listed on medication profile. Patient #2, Upon home observation, Comfort pack of medications had expired in the home. Morphine discard after 11/20/23. Bisacodyl, Tylenol suppository, prochlorperol, Hycosamine, discard after 2/7/24. In addition, patient is taking Mag oxide 400mg, no evidence of medication listed on medication profile. Patient #3, Medication profile states Flagyl 500mg, 1 tablet oral 1 time a day as needed for other symptoms. Order on bottle states crush 1 tablet and apply to wound base one daily with dressing changes as needed for wound odor control. Patient #14,15,16, No evidence of oxygen on medication profile. Patient #16,17,18,19, No evidence of home medications documented on medication profile. Medication profile only had hospice comfort pack medications documented.

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

Upon patient record review, 4 of 19 (Patient #6,12,16,17,) 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 #6, 12, Patient is full code. No evidence of initial care plan for patient being full code. Patient #16,17, No evidence of individualized care plans of problems/goals/interventions for each patient.

Upon patient record review, 6 of 19 (Patient #1,3,7,8,12,19) 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, LVN frequency 10 PRN every 90 days, no evidence of scheduled frequency. Patient #3, Order written for case manager (specific name) 1x/week and 9 PRN visits, prn frequency too high. Patient #7, Order written for case manager (specific name) 5x/week and 9 PRN visits, prn frequency too high. Patient #8, No evidence of frequency written for SN, visits completed on 11/26, 12/2. Patient #12, Order written for case manager (specific name) 1x/week and 9 PRN visits, prn frequency too high. Patient #19, SC frequency 1x/month with 6 PRN visit, prn frequency too high.

Upon patient record review, 6 of 19 (Patient #14,15,16,17,18,19) 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 #14, IDG note documents patient is now on 5l/nasal canula of oxygen. No evidence of written order to update oxygen on plan of care. Patient #14,15,16,17,18,19, No evidence of home medications added to medication profile. Medication profile only has hospice comfort medications.

Upon patient record review, 3 of 19 (Patient #2,14) 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 #2, Home visit completed, patient has wheeled walker in living room. No evidence of wheeled walker listed on DME list. Patient #14, Patient is oxygen dependent. No evidence of oxygen listed on Plan of Care.

Upon patient record review, 2 of 19 (Patient #14,15) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #14, MSW frequency 1x/month, visits completed 6/5 and 6/18, both routine visits. No evidence frequency was followed. Patient #15, SC frequency 1x/month, visit completed on 6/13 as telephone visit. No evidence of telephone visit order.

Upon observation, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient #1, RN displayed clean area with supplies, once the items (B/P cuff, pulse ox, thermometer) were used they were returned to clean area. Patient #2, RN washed hands then turned off faucet prior to drying her hands and then used paper towel to turn off faucet. Patient #3, LVN during wound care had removed dressing and had touched her glasses, removed gloves washed hands returned to patient with new pair of gloves, then used wound wash and sponge to clean wound, returned wound wash to clean area after use and then proceeded with dressing change without changing gloves.

Upon patient record review, 1 of 19 (Patient #5) 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 #5, Aide care plan states to "weigh cl monthly" or take arm circumference. No evidence of day identified to complete.

Upon patient record review 9 of 19 (Patient #1,3,4,5,12,16,17,18,19) 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, Aide care plan directed Aide to complete activity to chair, complete transfers, notify RN if no BM in 3 days, prepare meals. No evidence these tasks were completed on 8/9 and 8/12. Patient #3, Aide care plan directed Aide to complete activity to change bed linens, not completed, aide documented tomorrow. Assist with clothing, task was not completed on 8/12. Patient #4, Aide care plan directed Aide to complete activity to complete diet regular, puree, feeder and document food intake. No evidence this was completed on 8/12. Patient #5, Aide care plan directed Aide to complete activity to complete "weigh cl monthly" or take arm circumference. No evidence this was completed. No evidence this was taught to aide on 8/14. Patient #12, Aide care plan directed Aide to complete activity tasks of document last MB, incontinence, fluids, tasks were not completed. Patient #16, Aide frequency 5x/week effective 8/2 which is a Friday. No evidence of 5 visits completed in the first week. Patient #17, Aide frequency 5x/week effective 7/18. Aide visits completed on 7/8, 7/9, 7/12. Patient #18, Aide frequency 5x/week effective 7/30, Aide visits completed on 7/31, 8/1, 8/5, no evidence of 5 visit the first week. Patient #19, Aide frequency 5x/week effective 7/25, no evidence of 5 visits the first week.

Upon observation, there was no evidence the annual report documents the use of volunteers providing day to day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract personnel. No evidence of 5% of the total patient care hours of all paid hospice employees was met. 2023 year end was 3%.

Condition of Participation: Organization and Administration of Services.

Upon observation, there was no evidence that branch (multiple) locations share administration, supervision, and services with the parent hospice location. Parent and branch have their own Medical Director, Administrator and DPS.

Upon observation, there was no evidence that the lines of authority, professional and administrative control must be clearly delineated in the provider's organizational structure and in practice, and must be traced to the location issued the certification number. Organizational chart shows no evidence of the lines of authority with the branch office.

Upon observation, there was no evidence that the provider continually monitors and manages all services provided at all of its locations to ensure that services are delivered in a safe and effective manner and to ensure that each patient and family receives the necessary care and services outlined in the plan of care. Parent and branch both have Admin, Alt Admin, DPS, Alt DPS, Med Director, Alt Med Director.

Upon observation, there was no evidence the hospice designates a physician to serve as Medical Director which includes: • The Medical Director must be a doctor of medicine or osteopathy who is an employee or is under contract. • When the Medical Director is not available, a physician designated by the hospice assumes the same responsibilities and obligations as the Medical Director. Parent and Branch office each have their own Medical Director and Alt Medical Director.

Upon patient record review, 13 of 19 (Patient #1,2,3,4,5,6,7,8,9,10,11,12,13) 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 Patients #1,2,3,4,5,6,7,8,9,10,11,12,13 did not have evidence of an oral certification of the certifying physician stating that the patient is terminally ill with a prognosis of 6 months or less. The agency had order for admit and treat.

Upon patient client record review, 2 of 19 (Patient #15,19) 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 #15, No evidence of election date documented on consent for election of Medicare benefit. Patient #19, No evidence of consents uploaded into chart. COS.

Upon patient client record review, 4 of 19 (Patient #2,14,17,18) 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 #2, Prior to admission, patient listed as a number 2 for Disaster Plan, Disaster Acuity marked as N/A on the Plan of care after patient was admitted. RN documented oxy and script in note. No evidence these words are approved abbreviations. Patient #14, No evidence of Advance Directive was completed on the Admission consent. Patient #17,18, No evidence of POLST and DNR completed. Both yes and no boxes left empty.

Upon client record review, 1 of 19 (Patient #10) 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 #10, No evidence of discharge summary forwarded to attending MD.

Upon client record review, 2 of 19 (Patient #10,11) did not have evidence that the discharge summary includes all required information. Patient #10, Discharge summary only stated " no longer appropriate". No evidence of the summary documenting the patient's stay, treatments, symptoms and pain management. Patient #11, Discharge summary only stated "Revoked". No evidence of the summary documenting the patient's stay, treatments, symptoms and pain management.

Upon observation, there was no evidence a copy is provided of the hospice written policies and procedures on the management and disposal of controlled drugs to the patient or patient representative and family. Patient #19, No evidence of consents uploaded into chart. COS.

Upon observation, there was no evidence the hospice discussed the policies and procedures for managing the safe use and disposal of controlled drugs with the patient or representative and the family in a language and manner that they understand to ensure that these parties are educated regarding the safe use and disposal of controlled drugs. Patient #19, No evidence of consents uploaded into chart. COS.

Upon client record review, 2 of 19 (Patient #18,19) did not have evidence that the written policies and procedures for managing controlled drugs was provided and discussed. Patient #19, No evidence of consents uploaded into chart. COS.

Upon patient record review, 1 of 19 (Patient #4) did not have evidence that the hospice assumes responsibility for professional management of the resident's hospice services in accordance with the hospice plan of care. The hospice is responsible for providing all hospice services including: • Provision, in a timely manner, of all supplies, medications, and DME needed for the palliation and management of the terminal illness and related conditions Patient #4, Patient admitted to hospice program and lives in SNF; patient was on oxygen but no evidence oxygen was provided by the hospice agency; no contract for oxygen and hospice not paying for oxygen per hospice administrator.