Every finding on record at Journey Hospice, LLC

Upon personnel record review, 2 of 15 (Personnel #12, 13 ) did not have evidence Emergency Preparedness training including: • Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles • Demonstrate staff knowledge of emergency procedures • Provide emergency preparedness training at least annually • Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others • Maintain documentation of all emergency preparedness training Personnel #12 and 13: PT and PTA did not have documented evidence that they received emergency preparedness training

Upon patient record review, 1 of 15 (Patient #2) 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: During patient visit, observed discussion between nurse and CG including review of recent pain regimen. Morphine Concentrate was recently started due to patient decline. The order was included in most recent IDG POC, but not yet transcribed to medication profile. (Morphine Sulfate Concentrate Oral Solution 20 mg/ml Dose: 0.25 ml every 1 hr prn pain, sob. CG is to administer 0.24-1 ml SL q 4 hr. prn.)

Upon contract review, 1 of 3 (Texas United Rehab contract) did not have evidence the agreement to furnish any services under arrangement included that the hospice must retain administrative and financial management, and oversight of staff and services for all arranged services, to ensure the provision of quality care. Arranged care/services are supported by written contract/agreement that requires all care/services are: • Authorized by the hospice • Delivered in accordance with the patient's plan of care Texas Rehab contract does not clearly specify that all services must be authorized by the hospice, furnished by qualified personnel and delivered in accordance with the patient's plan of care.

Upon personnel record review, 2 of 15 (Personnel #12, 13 ) did not have evidence the hospice employees and contract employees have received orientation on the hospice philosophy. Personnel #12, 13 did not have evidence received orientation on the hospice philosophy.

Upon personnel record review, 2 of 15 (Personnel #12, 13 ) did not have evidence that the hospice employees have received orientation on their specific job requirements. Personnel #12, 13: There is no evidence that contracted employees received orientation to specific job requirements.

Upon personnel record review, 3 of 15 (Personnel #10,12,13 ) did not have evidence that a skills competency assessment, specific to each discipline had been conducted for all personnel including volunteers initially during orientation. Personnel #10,12,13: Upon review, there is no documented evidence of competency for #10 volunteer. No patients have accepted services since hire and staff interview plan to observe/verify competencies during initial visit. Personnel 12, 13 PT, PTA have provided services, but competency skills checklist not available from contractor, by end of survey.

Upon patient client record review, 3 of 15 (Patient #5, 7, 14) 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 #5: In review of admission/consent forms, including election statement, noted that both Page 4 and Page 6 include effective date of hospice election. Page 4 identifies 01/09/24 as the effective date, whereas Page 6 identifies effective date as 01/29/24. All other dates are 01/29/24 and signature dates are 01/29/24. Patient #7: Noted that agency utilizes templates to prompt/facilitate clinician narrative in various formats. In reviewing record #7, noted that the template had not been individualized for specific patient. The narrative of 1/24/24 IDG Plan of Care Order reads "SNF facility care planning meeting (include day and time). NA. Identify attending physician and if they are involved in care: patient level of care: routine respite/GIP. Facility name_____________/ Dates of service __________ continuous care: reason________________ date started________date ended_________/ ..... " This patient did not reside in SNF, and therefore, this section of template should be removed. Patient #14: Patient admitted and passed away in SNF. DC Death note inadvertently documents patient status as expired at Assisted Living.

Upon personnel record review, 1 of 15 (Personnel #15 ) did not have evidence that all Speech Therapy Services are provided by a qualified licensed Speech-Language Pathologist (SLP) or Audiologist in accordance with the state's Speech-Language Pathology Practice Act and the hospice's policies and procedures and/or job descriptions. Upon personnel review, there is no SLP personnel file provided by contractor by end of survey. No SLP services have been ordered or provided.

Upon personnel record review, 2 of 15 (Personnel #14, 15 ) did not have evidence the hospice obtained a criminal background check on all contracted individuals who have direct patient care and access to patient records. Personnel #14, 15: There is no evidence of criminal background check. There have been no OT, ST services ordered/provided.