Every finding on record at Hospice Partners of America Holding, LLC

Upon patient record review, 3 of 14 (Patient #4, 7, 10) 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 #4: Admitted Initial POC 1/19/23: SC 5 PRN for psychosocial support and spiritual support, with no baseline frequency until 4/17/23 Recertification POC. Patient #7: Patient admitted 10/6/22 Initial POC Volunteer frequency of 12 PRN. MD order was written 12/23/23 for Vol 1xwk. Patient #10: Patient admitted 8/26/22. Initial POC MSW frequency of MSW 2 prn. Frequency updated with 10/24/22 MD order for MSW effective 10/1/22 1m1 and 1PRN psychosocial and emotional support.

Upon patient record review, 2 of 14 (Patient #1, 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 #1: Initial POC 3/23/23 Medication order for Triple Antibiotic ointment 3.5 mg - 5000 unit-400 unit topical ointment packet. Apply to 3rd right toe after cleansing toe nail area to prevent infection. It is unclear what cleansing agent and what frequency for treatment. Patient #3: 4/13/23 MD Order - May insert Foley catheter to drainage bag. Change monthly and prn. The order is incomplete in that it does not specify catheter size and/or indications for prn change. Change monthly and PRN.

Upon client record review, 2 of 14 (Patient #7, 10) 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 admitted 10/6/22 Initial POC included Volunteer frequency of 12 PRN. Vol visits made Oct 17, 26, 28, Nov 3, 10, 18, Dec 2. There was an update to POC with 12/23/22 MD order for Volunteer 1xwk. Patient #10: Patient admitted 8/26/22. Initial POC MSW Frequency of MSW 2 prn. Patient was seen for eval visit and again, 9/12, 9/26/22. Frequency updated with 10/24/22 MD order for MSW effective 10/1/22 1m1 and 1PRN psychosocial and emotional support.

Upon client record review, 1 of 14 (Patient #4) did not have evidence that a written hospice plan of care is established and maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided is in accordance with this hospice plan of care. Patient #4: Admitted with Initial POC 1/19/23 SC frequency of SC 5 PRN for psychosocial support and spiritual support. SC visits made Jan 21, 27, Feb 8, 22, March 8, 22, 29. There was no baseline SC frequency order until subsequent POC (4/19/23) when SC Freq order was specific.

Upon observation there is no evidence the Hospice has a process for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of COVID–19, for all personnel who are not fully vaccinated for COVID–19. It is observed that agency has a contingency plan/process that includes masks for vaccine-exempt employees. During patient visits, it was observed that MSW, who has religious exemption, was not wearing mask per the agency policy.