Every finding on record at Huntington Hospice Care Inc

Upon observation, there was no evidence the agency has conducted exercises to test the emergency plan every two years. The agency does not have evidence of a full scale exercise being performed in the past 3 years.

Upon patient record review 2 of 14 (Patient 8,9) 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 8: Admitted 8/2/23. The psychosocial comprehensive assessment was completed on 8/14. The RN did not complete the psychosocial component of the comprehensive assessment. Patient 9: Admitted 8/8/23. The psychosocial comprehensive assessment was completed on 8/14. The RN did not complete the psychosocial component of the comprehensive assessment.

Upon patient record review 1 of 14 (Patient 3) 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 3: Admitted 10/10/22. The RN comprehensive assessment indicated SW is needed, the RN did not complete the psychosocial assessment and there is no evidence the MSW ever saw the patient. There is no evidence of pt refusal.

Upon patient record review, 6 of 14 (Patient 1,3,4,8,11,14) did not have evidence in the patient record that the comprehensive assessment takes into consideration the imminence of death. Patient 1,3,4,8,11,14: The comprehensive assessment did not contain evidence of imminence of death was taken in to consideration.

Upon patient record review, 2 of 14 (Patient 8,10) 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: Patient 8: The medication profile contains Miralax with no diluent. Corrected on site. Patient 10: The medication profile contains an order for Prednisone 5mg PO daily listed twice. Corrected on site.

Upon patient record review, 5 of 14 (Patient 3,6,7,8,12) 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: Patient 3 The POC contains an order for "SC to update as needed after eval". Patient 6 and 7: The POC contains an order for SN 1 time a week and prn for pain and symptom management. There is no order for number of PRN visits. Patient 8: The POC had conflicting aide orders for starting 8/6/23 2 times per week and also 1 time per week starting SOC week and then 3 times per week. The POC has conflicting orders for SN starting 8/2 2-3 times per week and 1-2 times per week. Patient 12: The POC contains orders for SN 2 times a week and PRN and Aide 2 times a week and PRN. There is no order for a number of PRN visits that can be completed.

Upon patient record review, 5 of 14 (Patient 1,3,4,8,10) 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 medications and treatments. Patient 1: The POC does not contain diet orders. The POC has orders for wound care to the left heel with no frequency. Corrected on site. Patient 3: The nurse documents on the recertification 6/30/23 "GT intact and patent, so s/sx of infection at stoma site". There is no evidence of an order for g tube care. Patient 4: The POC does not contain diet orders. Corrected on site. Patient 8: The POC contains Miralax with no diluent. Corrected on site. Patient 10: The POC contains an order for Prednisone 5mg PO daily listed twice.

Upon patient record review, 1 of 14 (Patient 13) 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 13: The nurse documented on 7/21/22 that the patient has a walker. There is no walker listed on the POC.

Upon client record review, 8 of 14 (Patient 1,3,5,6,7,8,10,12) 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 POC contains orders for SN 2 times a week. The week of 7/23-7/29 SN saw pt 1 time on 7/26/23. The week of 8/13-8/19 the pt was seen by the nurse one time on 8/16/23. The week of 8/20-8/26 the pt was seen by the nurse 8/23/23. There is no evidence of missed visit documentations or pt refusals. Patient 3: There is evidence the SC visited the patient 1 time per month on 5/11/23,6/13/23,7/7/23,8/7/23. There is no evidence of an order for SC monthly visits. Corrected on site. Patient 5: The POC contains orders for SN 1x per week. The week of July 9-15 the nurse saw the patient as a routine visit 7/12/23 and 7/14/23 and the week of 7/23-7/29 the nurse made a routine visit on 7/24/23 and 7/26/23. The week of Aug 6-12 pt was seen by the nurse 8/10/23 and 8/11/23. There is no evidence of an order for these increased visits. Patient 6: The medical record contains evidence of SC visits being made 6/1/23,6/28/23,7/26/23 with no evidence of an order for SC. The POC contains orders for SN 1x week. The week of 7/30/23-8/5/23 the record contains routine visits made by the nurse on 7/31/23 and 8/3/23 and the week of 8/13/23-8/19/23 SN performed a routine visit 8/14/23 and 8/17/23. There is no evidence of these visits being PRN. Patient 7: The medical record contains evidence of SC visits made 6/12/23,7/13/23,8/9/23 with no evidence of an order for SC visits. Patient 8: The nurse documented on 8/3 "PRN visit for wound care, tolerated properly, on 8/5/23 "pressure sore tx provided" and 8/7/23 "treatments done as ordered". There is no evidence the nurse followed the POC for the wound care. Patient 10: The POC contains orders that the SC was declined. The medical record contains evidence of visits by the SC 6/14/23,7/14/23,8/11/23. Patient 12: The nurse documented on 5/10/22 "Pressure ulcer cleaned, dried and calmo applied by SN". There is no evidence the SN followed the POC orders.

Condition of Participation: Quality Assessment and Performance Improvement.

Upon observation, there was no evidence the QAPI program uses quality indicator data, including patient care and other relevant data in the design of its program. The hospice must use the data collected to: • Monitor the effectiveness and safety of services and quality of care • Identify opportunities and priorities for improvement The Hospice was unaware that they were able to pull reports from HospiceMD to monitor effectiveness and safety of services and quality of care and identify opportunities and priorities for improvement. They were not able to provide evidence of any current processes of monitoring for opportunities and priorities for improvement.

Upon observation, there was no evidence the board of directors/governing body approves the frequency and detail of the data collection. The agency was able to provide evidence of their board approving QAPI regarding Infection control related to PHE and personnel files. There was no evidence of a frequency or details of the data collection approved in the notes they have for 2/17/23 and 6/5/23.

Upon observation, there was no evidence QAPI activities focus on high risk,high volume, or problem prone areas. The agency did not provide evidence of QAPI of high risk, high volume or problem prone areas.

Upon observation, there was no evidence the number and scope of distinct QAPI projects conducted annually is based on the needs of the hospice's population and internal organizational needs and must reflect the scope, complexity, and past performance of the hospice's services and operations. The Hospice has just begun their QAPI program this year. They do not have any records from 2020,2021,2022 for QAPI.

Upon observation, there was no evidence of involvement of the governing body and organizational leaders in the Quality Assessment/Performance Improvement (QAPI) program. The agency was not able to provide evidence that the QAPI program is being evaluated by the governing body for ongoing quality improvement and patient safety.

Upon patient record review, 1 of 14 (Patient #3) did not have evidence that Social work services are based on the patient's psychosocial assessment and the patient/family's needs and acceptance of these services. Patient 3: Admitted 10/10/22. The RN comprehensive assessment indicated SW is needed, there is no evidence the MSW ever saw the patient. There is no evidence of pt refusal.

Upon patient record review, 2 of 14 (Patient 11,12) 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. Bereavement counseling also extends to residents of a SNF/NF or ICF/IID when appropriate and identified in the bereavement plan of care • 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 Patients 11 and 12: The medical record contains evidence that the 13 month mailing was not completed per the bereavement plan of care for either patient.

Upon patient record review 5 of 14 (Patient 1,2,5,6,12) did not have evidence documentation in the patient record that a hospice aide provides services that are: Patient 1: The POC contains orders for aide visits 3 times per week. The week of 8/13/23-8/19/23 the record contains evidence of only 2 visits made by the aide on 8/14/23 and 8/17/23. Patient 2: The POC contains orders for aide visits 2x per week. The week of 8/20/23-8/26/23 the aide saw pt 8/22/23 with no second visit that week. There was no missed visit documentation or evidence of client refusal. Patient 5: The POC contains an order for aide visits 1 time a week starting 5/21/23. The medical record contains evidence of aide visits being completed 5/24/23 and 5/25/23 that week. There is no evidence of any prn orders or orders for extra visits. Patient 6: The POC contains orders for aide 2x a week. The week of July 2-8, 2023 the aide saw pt once 7/8/23. The week of July 9-15, 2023 the aide visits once on 9/15/23. There are no visits made from July 16-29, 2023 with no missed visit documentation or refusal. The week of 8/13-19, 2023 the aide saw the pt once on 8/19/23 only. There was no missed visit documentation or refusal noted. Patient 12: The POC 4/29/23 contains an order for aides 2 times per week, there is evidence the patient was seen 1 time on 5/13/22. There were no visits made for the week of April 24-30, 2023 and May 1-7, 2023. There is no missed visit documentation or refusals for those weeks.

Upon observation, there was no evidence the hospice documents and demonstrates viable and ongoing efforts to recruit and retain volunteers. The agency has a pamphlet for recruiting volunteers but there is no evidence that they are demonstrating a viable and ongoing effort to recruit and retain volunteers. They just appointed a VC who is their MSW as well, this person has just started the VC role July 2023.

Upon patient client record review, 1 of 14 (Patient 1) did not have evidence that each patient record contains: Patient 1: The signed election statement indicates the patient does not wish to choose an attending physician. In the spot where the medical director's name is to be written, the nurse wrote the patient's name.

Upon patient client record review, 8 of 14 (Patient 1,2,3,5,6,7,8,9) 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: The nurse documented the following unapproved abbreviations on 7/1/23 "recertification for BP18, ES Alzheimer's, B&B, RP". The medical record contains nursing notes not appropriately signed and dated in accordance with the organizations policies and procedures and currently accepted standards of practice, on the following dates in 2023:7/19,7/20,7/26,8/2,8/3,8/8,8/9. Per agency policy 2-009.1 "All documentation must be turned in to office no greater than 5 days after visit." The medical record contains aide notes not appropriately signed and dated on the following dates in 2023: 7/18,7/24,7/25,8/1,8/3,8/10. Per agency policy 2-009.1 "All documentation must be turned in to office no greater than 5 days after visit." Patient 2: The nurse documented on 8/24/23 the following abbreviations: Cg, s/s, b/s. On 8/17 the nurse documented a+ox1, cx,b/b. There is no evidence these are approved abbreviations. The medical record contains visits that are not appropriately signed and dated in accordance with the organizations policies and procedures and currently accepted standards of practice on the following dates in 2023:7/18,7/24,7/25,8/1,/8/3,8/10. Per agency policy 2-009.1 "All documentation must be turned in to office no greater than 5 days after visit." Patient 3: The nurse documented on POC GT and on 8/3/23 the nurse documented HHN, there is no evidence these are approved abbreviations. Patient 5: The nurse documented on 8/15/23 the following abbreviations: wc, ssx. There is no evidence these are approved abbreviations. The nurse performed a visit on 8/23/23 that was not documented until 8/30/23 which is out of compliance of policy 2-009.1 "All documentation will be turned in to the office with in 5 days of visit". Patient 6: The nurse documented "ssx" on 8/14/23. There is no evidence this is an approved abbreviation. Patient 7: The SC comprehensive assessment from 5/17/23 and the MSW comprehensive assessment on 5/16/23 are not appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. The nurse documents on 8/16/23 "COC". There is no evidence this is an approved abbreviation. The record contains notes on the following dates in 2023: 7/19,7/26,7/27,8/2,8/9,8/11,8/16,8/23 that are not appropriately signed and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Per agency policy 2-009.1 "All documentation must be turned in to office no greater than 5 days after visit." Patient 8: The medical record contains a visit on 8/21/23 that is not appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Per agency policy 2-009.1 "All documentation must be turned in to office no greater than 5 days after visit." Patient 9: The nurse documented 8/24/23 "a+ox4, s/s,cx". There is no evidence these are approved abbreviations.

Upon observation there is not evidence that all patient records are retained for a minimum of six years from the date of the most recent discharge or the death of the patient, unless state law stipulates a longer period of time. The agency was unable to provide evidence of patient medical records from 2020-2021. They had a CHOW in 2021 and they do not have access to those patient's medical records.

Upon client record review, 1 of 14 (Patient 13) 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: Patient 13: The medical record did not contain evidence of the discharge summary being sent to the attending physician.

Upon client record review, 2 of 14 (Patient 13,14) did not have evidence that the discharge summary includes all required information. Patients 13 and 14: The discharge summary does not contain the following: A summary of the patient's stay, including treatments, symptoms and pain management, The patient's current plan of care, The patient's latest physician orders, Any other documentation that will assist in post-discharge continuity of care or that is requested by the attending physician or receiving facility.

Upon client record review, 1 of 14 (Patient 12) did not have evidence that the hospice plan of care identifies the care and services that are needed and specifically identify which provider (nursing facility or hospice) is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care. Patient 12: The POC 5/4/22 contains a wound care order to the coccyx but does not state who will be performing the wound care.