Every finding on record at Hospice for You Inc.

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

Upon patient record review, 1 of 2 (Patient #1) 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 - No interventions or goals related to wound.

Upon patient record review, 2 of 2(Patient #1, 2) 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: SOC 3/19/25. SW and SC frequency 1x/initial assessment and prn 1x/month. No evidence of a routine frequency. Patient #2: SOC 3/19/25. SW and SC frequency 1x/initial assessment and prn 1x/month. No evidence of a routine frequency.

Upon client record review, 2 of 2 (Patient #1, 2) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1 - SOC 3/19/25. SW and SC frequency 1x/initial assessment and prn 1x/month. No evidence of visits. Patient #2 - SOC 3/19/25. SW and SC frequency 1x/initial assessment and prn 1x/month. No evidence of visits.

Upon patient record review 2 of 2 (Patient #1, 2) 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 #1: SOC 3/19/25. SW frequency 1x/initial assessment and prn 1x/month. There is no documented contact by MSW, no documented patient refusal of visits, and no documented visit being made. Patient #2: SOC 3/19/25. In referral section of RN comprehensive assessment, noted referred to SW and SC. There are no documented communications/visits by MSW or SC

Upon patient record review 2 of 2 (Patient #1 2) 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 - Effective 04/25/25 Aide seeing patient 1 x week but no visit frequency order in system. Patient #2 - Effective 04/22/25 Aide seeing patient 2 x week but not visit frequency order in system.

Upon patient client record review, 1 of 2 (Patient #1) 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 #1 - SN visit made on 04/29/25 "wound care changed during visit" did not specify wound care procedure. Visit note on 05/06/25 incomplete and not signed or dated by the RN.

Upon patient record review, 3 of 5 (Patient #1, 4, 5) did not have evidence that the patient chooses a health care provider, including an attending physician Patient #1: Choose or don't wish to choose physician is blank all forms. Patient #4 Choose or don't wish to choose physician is blank all forms. Patient #5: Choose or don't wish to choose physician is blank all forms.

Upon patient record review 1 of 5 (Patient #1) did not have evidence that the hospice Registered Nurse must complete an initial assessment within 48 hours after the election of hospice care in accordance with §418.24 Patient #1: SOC identified as 3/28/25. There is no initial assessment/comprehensive assessment by RN.

Upon patient record review 1 of 5 (Patient #1) 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: SOC identified as 3/28/25. There is no initial assessment/comprehensive assessment for any disciplines.

Upon patient record review, 1 of 5 (Patient #1) 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: SOC identified as 3/28/25. There is no initial bereavement assessment.

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

Upon patient record review, 3 of 5 (Patient #2, 3, 5) 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 #2: Primary diagnosis of cardiac disease and related medications with no related cardiac and/or respiratory problems/goals/interventions. Patient c/o pain on the initial comprehensive nursing assessment with no related problems/goals/interventions. Patient has stool softener and GERD medication with no related problems/goals/interventions. Patient #3: Medications include Naproxen, Tramadol and Oxycodone ordered with no documented problems/goals/interventions. Respiratory problem identified with intervention that includes oxygen as ordered via __ at __/liter, there are no complete problems/goals/interventions for oxygen. Patient #5: Medications include Eliquis with no related problems/goals/interventions.

Upon patient record review, 4 out of 5 (Patient #1, 2, 3, 5) 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: 3/28/25 orders for SC 1/for initial assessment and as needed 1x/month for spiritual needs and support. SN 1/xwk and PRN 3x/week for ... SW 1x/wk for initial assessment and PRN 1x/month. No evidence of a routine frequency. Patient #2: 3/19/25 orders SW 1x/ for initial assessment and PRN 1x/month; SC 1x for initial and as needed 1x/month .... SN 1x/wk and (blank) PRN. No evidence of a routine frequency. Patient #3: 3/27/25 IDG Plan of Care frequency of MSW (blank space) per week and 3 prn visits … SC 1x/for initial assessment and as needed 1x/month. No evidence of a routine frequency. Patient #5: 3/17 orders SW 1x initial assess and prn 1/month for .... SC 1x/for initial assessment and as needed 1x/month for needs and support. No evidence of a routine frequency.

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 equipment and supply needs. Patient #2: SOC 3/19/25. RN comprehensive noted patient needs new hospital bed, it is not included in the current Plan of Care Summary for DME. Patient #4: SOC 3/18/25. RN comprehensive noted patient needs wheelchair, it is not included in the current Plan of Care Summary for DME.

Upon patient record review, 5 of 5 (Patient #1, 2, 3, 4, 5) 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 #1: SOC 3/28/25. IDG Meeting Note 3/27/25 (prior to SOC) is set up and is totally blank. No other notes/reference to IDG review/meeting. Patient #2, 3: IDG 3/27/25, exceeding 15 days since last meeting; there is no documented IDG since 3/27/25 noted at the time of survey. Patient #4, 5: IDG 3/18 and 3/27/25, exceeding 15 days since last meeting; there is no documented IDG since 3/27/25 noted at the time of survey.

Upon patient record review, 4 of 5 (Patient #1, 2, 3, 4) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1: SOC 3/28/25. SN 1/wk and PRN 3x/wk. SW 1x/wk. for initial assessment and PRN1/mo.; SC 1/for initial assessment and as needed 1x/month for spiritual needs and support. There were no documented assessments by RN, MSW, SC and no visit notes. There was no documentation visits were declined. Patient #2: SOC 3/19/25. SW frequency 1x/initial assessment and prn 1x/month.... RN assessment documented need for MSW visit. There is no documented psychosocial assessment or any visits made by the MSW. No documented patient refusal of visits. Patient #3: 3/19/25 RN initial comprehensive assessment, the RN documented SC declined. SC documented making visit 3/22/25. Patient #4: SOC 3/18/25. SW and SC frequency 1x initial assessment. Initial RN assessment documented need for SC and MSW visits. There is no documented contact by either discipline, no initial comprehensive and no visit note documented and no documented patient refusal of visits.

Upon patient record review 2 of 5 (Patient #2, 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 #2: SOC 3/19/25. SW frequency 1x/initial assessment and prn 1x/month. There is no documented contact by MSW, no documented patient refusal of visits, and no documented visit being made. Patient #4: SOC 3/18/25. In referral section of RN comprehensive assessment, noted referred to SW and SC. There are no documented communications/visits by MSW or SC

Upon patient 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: No hospice election effective date (blank). Choose or don't wish to choose physician is blank on all forms. Patient #2: No hospice election effective date (blank). There are no dates for Docu-signed signatures. Patient #4, 5: No hospice election effective date (blank). There are no dates for Docu-signed signatures. Choose or don't wish to choose physician is blank on all forms.

Upon patient record review, 1 of 5 (Patient #5) did not have evidence that each patient record contains Advance Directives. Patient #5: Upon observation of consents/election, noted that patient signed blank DNR form

Upon patient record review, 2 of 5 (Patient #2, 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 #2: 3/27/25 IDG psychosocial narrative note reads: Social worker initial assessment conducted with patient. However, there is no documented psychosocial assessment and there is no documented psychosocial contact, assessment or visit note for the MSW. 4/2/25 RN note incomplete, including no narrative and no signature/credential. 4/6/25 RN triage note is totally blank except date and time 6-630, no signature/credential. Patient #3: SOC 3/19/25, RN initial comprehensive assessment, (the psychosocial section), the RN documented SW visit declined. 3/27/25 IDG psychosocial narrative entry note reads: This MSW evaluation was conducted on patient. However, there is no documented psychosocial contact, assessment, visit documented for the MSW.

Upon patient record review 8 of 15 (Patient #1,4,5,6,7,10,12,14) 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. There is no evidence of initial spiritual assessment in the medical record. There is no evidence of initial psychosocial assessment in the medical record. There is no evidence of initial psychosocial or spiritual assessment in the medical record. Patient 1,12,14: There is no evidence of initial psychosocial assessment in the medical record. Patient 4,6,7: There is no evidence of initial spiritual assessment in the medical record. Patient 5,10: There is no evidence of initial psychosocial or spiritual assessment in the medical record.

Upon patient record review, 3 of 15 (Patient #1,8,15) 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: Medication list shows fluticasone 50mcg 1-2 puffs nasal daily for allergies. There is no evidence of application site for this medication in the medication list. Patient 8: Medication list shows fluticasone 50mcg/actuation 2 puffs nasal daily for allergies. There is no evidence of application site for this medication in the medication list. Medication list with shows refresh tears 0.5% lubricant eye drops. 1 drop ophthalmic daily as needed for eye irritation/redness. There is no evidence of application site for this medication in the medication list. Medication list shows for Neupro transdermal patch 3mg/24hr. Apply one patch transdermal every 24 hours. There is no evidence of on/off instructions in the medication list. Patient 15: Medication list shows lidocaine 3% topical cream, 1 cream topical 2-3 times daily for muscle pain. There is no evidence of application site for this medication in the medication list.

Upon patient record review, 9 of 15 (Patient #1,3,4,5,8,10,11,14,15) 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 1,3,4,5,8,10,11,14,15: There is no evidence of initial bereavement assessment in the medical record

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

Upon observation, there was no evidence the hospice has an interdisciplinary group (IDG) or groups composed of individuals who work together to meet the physical, medical, psychosocial, emotional, and spiritual needs of the hospice patients and families facing terminal illness and bereavement. Interdisciplinary group members must provide the care and services offered by the hospice, and the group, in its entirety, must supervise the care and services. Patient 1,2: IDG dated 2/27/25: No evidence of MD or MSW participation. Patient 3: IDG dated 9/19,10/3/24,2/27/25: No evidence of MSW participation. Patient 4: IDG dated 2/27/25: No evidence of MD signature.

Upon patient record review, 10 of 15 (Patient #1,2,3,4,5,7,8,9,10,15) 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: Identified needs with no evidence of problems, goals, interventions on the plan of care: high risk for falls; nutritional needs including aspiration precautions; oxygen use; weakness; pain. Patient 2: Identified needs with no evidence of problems, goals, interventions on the plan of care: high risk for falls; decreased appetite; high risk for skin breakdown; weakness; pain. Patient 3: Identified needs with no evidence of problems, goals, interventions on the plan of care: oxygen use; nutritional needs including aspiration precautions; high risk for falls; cardiac needs including bleeding precautions. Patient 4: Identified needs with no evidence of problems, goals, interventions on the plan of care: oxygen use. Patient 5: Identified needs with no evidence of problems, goals, interventions on the plan of care: anxiety, weakness, patient has no caregiver. Patient 7: Identified needs with no evidence of problems, goals, interventions on the plan of care: high risk for falls; nutritional needs including aspiration precautions. Patient 8: Identified needs with no evidence of problems, goals, interventions on the plan of care: oxygen use; high risk for skin breakdown; wound care for active wound. Patient 9: Identified needs with no evidence of problems, goals, interventions on the plan of care: oxygen use. Patient 10: Identified needs with no evidence of problems, goals, interventions on the plan of care: oxygen use and dyspnea; hypertension with documented elevated blood pressures. Patient 15: Identified needs with no evidence of problems, goals, interventions on the plan of care: oxygen use and dyspnea; nutritional needs including aspiration precautions; pain.

Upon patient record review, 12 of 15 (Patient #1,2,4,6,7,8,9,11,12,13,14,15) 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 1,4,8,12,13: Physician’s SC visit frequency order is initial and PRN. MSW visit frequency order is initial and PRN. This is not a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs. Patient 2: SC visit frequency order is initial and monthly PRN. MSW visit frequency order is initial and monthly PRN. This is not a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs. Patient 6,11,14: SC visit frequency order is initial and then on recert. Physician’s MSW visit frequency order is initial and then on recert. This is not a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs. Patient 7,9: SC visit frequency order is initial, on recert, and PRN. MSW visit frequency order is initial, on recert, and PRN. This is not a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs. Patient 15: SN visit frequency order is per week, 3PRN. SC visit frequency order is initial and PRN. MSW visit frequency order is initial and PRN. This is not a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs

Upon patient record review, 3 of 15 (Patient #1,8,15) 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: Plan of care with order for fluticasone 50mcg 1-2 puffs nasal daily for allergies. There is no evidence of application site for this medication in the plan of care. Patient 8: Plan of care with order for fluticasone 50mcg/actuation 2 puffs nasal daily for allergies. There is no evidence of application site for this medication in the plan of care. Plan of care with order for refresh tears 0.5% lubricant eye drops. 1 drop ophthalmic daily as needed for eye irritation/redness. There is no evidence of application site for this medication in the plan of care. Plan of care with order for Neupro transdermal patch 3mg/24hr. Apply one patch transdermal every 24 hours. There is no evidence of on/off instructions in the plan of care. Patient 15: Plan of care with order for lidocaine 3% topical cream, 1 cream topical 2-3 times daily for muscle pain. There is no evidence dosage amount or application site for this medication in the plan of care.

Upon patient record review, 4 of 15 (Patient #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 6,10: DME not on plan of care, despite identified need: oxygen. Patient 7: DME not on plan of care, despite identified need: hospital bed, wheelchair, nebulizer, suction. Patient 9: DME not on plan of care, despite identified need: hospital bed.

Upon client record review, 4 of 15 (Patient #1,2,3,5) 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 1,2,3: IDG dated 1/16,1/30,2/13,2/27/25 has no evidence of SC signature for attendance or review/revision of plan of care although actively involved visiting patient. IDG dated 2/27/25: No evidence RN signature or attendance or review/revision of plan of care although actively involved visiting patient. Patient 5: SOC 12/12/2024. Medical record has IDGs dated 9/13,10/31,11/14,11/21, 12/5/24 present, which are all prior to SOC date. There is no evidence of an IDG between 1/2/25 and 1/30/25. IDGs dated 12/19/24, 1/ 2,1/30, 2/13/25 are blank, including signatures therefore no IDG meetings are evidenced for these dates. IDG dated 2/27/25 contains only RN admission note and no evidence of signatures from IDG members, therefore no evidence of meeting.

Upon client record review, 7 of 15 (Patient #1,2,3,4,7,10,15) 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: SC visit frequency order is initial and PRN. There is evidence of scheduled recertification visit made 1/6/25. Patient 3: SC visit frequency order is initial and monthly PRN. There is evidence of scheduled recertification visit made 12/15/2024. Patient 4: MSW visit frequency order is initial and PRN. There is evidence of scheduled recertification visit made 2/10/25. Patient 7: MSW visit frequency order is initial, recert, and PRN. There is no evidence of recertification visits made. SN visit frequency order is once weekly. There is evidence of routine RN visit 2/6/25 and routine LVN visit 2/7/25. Patient 10: SN visit frequency order is once weekly and 3PRN. There is no evidence of SN visit 10/24/24-11/4/24. Patient 15: SC visit frequency order is initial and PRN. There is evidence of scheduled recertification visit made 12/30/24.

Upon patient record review, 1 of 15 (Patient #8) 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 8: Aide tasks on care plan without evidence of frequencies: turn/reposition; record bowel movements; change patient’s linens. Patient is on oxygen. No evidence of oxygen precautions or dose on the aide care plan.

Upon patient record review 1 of 15 (Patient #8) 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 8: Physician’s aide visit frequency order is 3 times weekly. During weeks of 2/16/25 and 3/2/25, there is one documented aide visit in the medical record. On 2/27/25, bathing/hygiene section of care plan not complete. There is no documentation of refusal or other reason for incomplete tasks.

Upon patient record review 1 of 15 (Patient #8) 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 8: There is no evidence of aide supervisory visits in the medical record.

Upon patient record review, 1 of 5 (Patient #2) 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 2: The certification of terminal illness, signed by the MD on 01.07.2022, indicates that the patient has a primary diagnosis of Alzheimer's disease, is a high fall risk, is confused at all times, and requires continuous caregiver support for safety. The initial comprehensive assessment, dated 01.07.2022, indicates the patient is fully dependent for care and support, is a high fall risk, requires maximal assist for all ADLs, and is continually confused. Subsequent nursing visit notes indicate ongoing fall risk and dependence for ADLs. However, at no time has a care plan been developed relating to safety in the home/fall prevention. An individualized care plan must be developed related to all identified concerns, including the patient's personal safety and fall prevention. (corrected onsite)

Upon patient record review and home visit observation, 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 equipment and supply needs. Patient 3: The comprehensive initial assessment, dated 01.05.2022, and subsequent nursing visit notes indicate the patient is ambulatory with walker. During the home visit, it was observed that the patient had a walker present at chairside. However, the plan of are did not include the walker. All DME utilized by the patient must be included on the plan of care. (corrected onsite)