Every finding on record at Joy Hospice Care Inc.

Upon observation, there was no evidence of contracts/agreements with other facilities/agencies/hospices to receive patients in the event the hospice cannot provide care to their patients during an emergency. There was no evidence of contracts/agreements with other facilities/agencies/hospice to receive patients in event of emergency.

Condition of Participation: Medical Director.

Upon patient record review, 4 of 14 (Patient #3, 4, 7, 9) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient #3, 4, 7, 9: There is no evidence patient offered opportunity to choose or decline to choose physician. No physician name written in and no space to decline to choose.

Upon patient record review, 1 of 14 (Patient #14) 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 #14: SC/BC documented in initial bereavement assessment "Patient has no family." Documentation is inadequate to determine if there are friends/caregivers who might grieve patient prognosis/loss and or there was no documented bereavement assessment data for patient with no support system.

Upon patient record review, 1 of 14 (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: Admitted with ileostomy. Plan of Care includes supplies of ostomy barrier, ring, bag, stoma skin barrier and bag belt. 11/04/24 note includes reference to ileostomy and assessment and instructions on ileostomy care, but there are no related problems, goals or related orders/interventions identified in Plan of Care.

Upon patient record review, 3 of 14 (Patient #1,3,10) 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 #1,3,10: MSW as needed and recert. SC as needed and recert. A discipline's ordered visit frequency cannot include a PRN visit frequency, without a baseline frequency to support it.

Upon patient record review, 1 of 14 (Patient #1) 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: 9/5/24 order for Oxygen 5L. The order does not specify continuous or prn. SN note same date includes Oxygen 2-5lpm prn.

Upon patient record review, 7 of 14 (Patient #1,2,3,5,6,13,14) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient #1: No RN signed in for IDG, although notation for meetings. No MSW signature for 11/6 Patient #2: No MSW 10/23 OR 11/6. No RN 11/23. Patient #3: No MSW 11/6. Patient #5: Only MD signature 9/11, 10/9, 10/23, 11/6/24 Patient #6: Only MD signature 9/26, 10/9/, 10/23, 11/6/24. Patient 13, 14: MSW not signed in for IDG meetings but there is notation (Patient13: 10/27, 11/1, 11/15, 11/17/24) (Patient 14: 2/19, 2/28, 2/29/24).

Upon client record review, 3 of 14 (Patient #1, 3, 5) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1: MSW frequency of as needed and recert. The patient was seen 9/6 and 10/5/24. Recert periods 9/5-11/3 and 11/4-1/02/24. Patient #3: MSW and SC frequency as needed and recert. Visits by MSW 9/17 and 10/7 and SC 9/10 and 10/30. Recert period 9/6-11/4/24 and 11/5-1/3/25. Patient #5: MSW and SC ordered within 5 days of admission. RN documented patient consented to MSW, SC and LVN; however, there was no documented MSW or SC visit and no notation of decline.

Upon observation, there was no evidence the organization develops, implements, and maintains an effective, on-going, organization wide Quality Assessment and Performance Improvement (QAPI) program. There is no evidence of ongoing monitoring since March 31, 2024.

Upon observation, there was no evidence the program shows measurable improvement in indicators related to improved palliative outcomes and hospice services. Most recent QAPI information gathered ended March 31, 2024. Unable to confirm improvement.

Upon observation, there was no evidence the board of directors/governing body approves the frequency and detail of the data collection.

Upon observation, there was no evidence a written plan of correction is developed in response to any QAPI activity that does not meet an acceptable threshold. Most recent QAPI information gathered ended March 31, 2024. Unable to confirm improvement.

Upon observation, there was no evidence of involvement of the governing body and organizational leaders in the Quality Assessment/Performance Improvement (QAPI) program. There was no available governing body minutes to demonstrate governing body's involvement in QAPI program. The only governing body minutes provided to surveyor were 2021/2022 under prior ownership.

Upon observation, there was no evidence the hospice's governing body is responsible for ensuring that the hospice-wide Quality Assessment and Performance Improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness

Upon personnel record review, 1 of 14 (Personnel # 6) did not have evidence that the hospice routinely provide substantially all core services directly by hospice personnel (The hospice issues a W-2 form for the employee). These services include: • Physician services (may contract for physician services) • Nursing • Medical social services • Counseling Personnel #6 MSW core service has W9 on personnel file.

Upon observation, there was no evidence the hospice ensures that non-core services are provided to hospice patients and their families according to applicable laws and regulations. Non-core services include Physical Therapy, Occupational Therapy and Speech-Language Pathology. The agency reports that they do not have OT and ST services.

Condition of Participation: Hospice Aide and Homemaker Services. L607

Upon personnel record review, 1 of 14 (Personnel #572) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) ·Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff. ·Reading and recording temperature, pulse, and respiration ·Safe transfer techniques and ambulation. ·Normal range of motion and positioning ·Appropriate and safe techniques in personal hygiene and grooming that include-- ·(A) Bed bath ·(B) Sponge, tub, and shower bath ·(C) Shampoo, sink, tub, and bed ·(D) Nail and skin care ·(E) Oral hygiene ·(F) Toileting and elimination The other subject areas in this section may be evaluated through written examination, oral examination or after observation of a Hospice Aide with a patient. Personnel #5: Hospice Aide assignment for Patient #2 include colostomy care and empty colostomy bag. There is no documented evidence of competency in assigned tasks.

Upon patient record review, 6 of 14 (Patient #1,2,3,7,10,11) 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 #1: 9/5/24 POC and continued currently, there is an ordered frequency for hospice aide 2/wk but there is no hospice aide assignment sheet Patient #2: 9/29/24 hospice aide assignment sheet includes colostomy - empty bag every visit as needed and colostomy care every visit as needed. The colostomy care cannot be as needed as the aide is unable to determine need. Patient #3: Initially 3x/wk, but order for 2x 11/8/24. No update to hospice aide assignment. Patient #7: 9/28/24 hospice aide assignment sheet has no tasks checked/assigned and no RN signature or typed name... only task is if patient is experiencing pain/change in condition, notify RN. Does not specify frequency of HA visits either. Patient #10: Hospice aide assignment does not include frequency of visits Patient #11: Hospice aide frequency per Plan of Care is 3x/wk. 9/2/24 IDG narrative says patient declined, but no update to hospice aide frequency listed in POC. Hospice aide assignment sheet blank.

Upon patient record review 4 of 14 (Patient #1, 2, 7, 11) 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: There is an ordered frequency for aide 2/wk but there is no hospice aide assignment sheet or visits documented. Patient #2: HA documented performed colostomy care 10/26 and 10/29/24 Patient #7: Hospice aide visit notes reflect multiple tasks checked, although not assigned by RN. Patient #11: Hospice aide frequency per Plan of Care is 3x/wk. 9/2/24 SOC IDG narrative says patient declined, but Hospice aide frequency documented as 3/wk with in IDG POC. No update to frequency listed. Hospice Aide assignment sheet blank. Hospice aide visit notes (Sept 3, 5, 7, 9, 14, 26, 30, 2024) created/entered by CEO/Owner name and assigned to Hospice Aide. These notes had time in and out entered, but no tasks checked and no hospice aide signature. One visit (Sept 12, 2024) entered by hospice aide with tasks completed, although no tasks assigned by RN.

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. There is no evidence of annual report available to surveyor

Upon observation, there was no evidence BOD/governing body minutes reflect the involvement in the hospice's management and administration of its resources to provide hospice services to patients and families. There were no governing body minutes provided to surveyor other than 2021/2022 under prior ownership.

Upon observation, there was no evidence the hospice is directed by a Board of Directors/governing body which assumes full legal authority and responsibility for the operation of the hospice. Upon arrival to agency and throughout Day 1, the agency was unclear who was the Administrator and the current authority of agency in absence of Administrator/DPCS. Various employees identified as both administrator and alternate and there were no signed job descriptions or orientation for employees definitively identified by agency in these roles. In addition, no evidence of governing body involvement with agency since 2022 therefore, no documented evidence of governing body's appointment of individual as administrator. In addition, agency is not providing core services of medical social services by an employee but rather contract, the agency is unable to provide therapy for OT/SLP for patients as there is no contract or employees in these roles. There is no evidence of human resource management as evidenced by the lack of signed job descriptions, orientation, criminal background checks, I-9 completion, and lack of competencies. There is no oversight of management and fiscal affairs of the hospice as there was no evidence of a budget, billing activities, and improper completion of CTI's per Medicare rules and regulations. Building marquis does not list agency under suite 202 but rather lists a different agency and the entry door to the agency does not contain permanent signage for the agency name rather a laminated sign taped on door below permanent suite number. In addition, the door has an ACHC accreditation sign although the agency has not been accredited by ACHC.

Upon observation, there was no evidence the hospice is primarily engaged in providing the following care and services: • Nursing services • Medical social services • Physician services • Counseling services, including spiritual counseling, dietary counseling and bereavement counseling • Hospice aide, volunteer, homemaker services • Physical therapy, occupational therapy, speech-language pathology services • Short-term inpatient care • Medical supplies (including drugs and biologicals) and medical appliance There were no signatures on short term inpatient contract presented to surveyor Day 1 of survey. On Day 2 a signed contract was presented to surveyor.

Upon personnel record review, 3 of 14 (Personnel #1,2,14 ) did not have evidence that the hospice employees have received orientation on their specific job requirements. Personnel #1, 2 no evidence of orientation to stated roles and no signed job descriptions to confirm. Personnel #14 no evidence of orientation to stated roles and has only job description for Administrator, but Day 2, surveyor was informed he is not actually Administrator, but administrative support staff - title/responsibilities not specified.

Upon personnel record review, 1 of 14 (Personnel #7 ) 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 #7: There is no documented competency for Bereavement Coordinator

Upon patient record review, 8 of 14 (Patient #1, 2, 5, 8, 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 Patient #1,2: CTI narrative by MD simply includes the certification statement: I certify that .... has a life expectancy of six months or less if the terminal illness runs its normal course. Patient #5: CTI narrative for SOC Benefit Period #1 does not includes patient name, dob, age, soc date and diagnoses and cert statement. There is no specific clinical data included. Patient #8 CTI narrative by MD simply includes the certification statement: I certify that ...has a life expectancy of six months or less if the terminal illness runs its normal course. There is no clinical information specific to patient. Patient #10: CTI narrative by MD simply includes the certification statement: I certify that ...has a life expectancy of six months or less if the terminal illness runs its normal course. There is no clinical information specific to patient. Patient #11: 10/3/24 CTI narrative includes name, dob, age, soc date, diagnoses related/unrelated and certification statement only. It does not include specific clinical information. Patient #12: 9/2/24 CTI narrative by MD simply includes the certification statement: I certify that ...has a life expectancy of six months or less if the terminal illness runs its normal course. There is no clinical information specific to patient. Patient #13: 10/27/23 CTI narrative by MD simply includes the certification statement: I certify that ...has a life expectancy of six months or less if the terminal illness runs its normal course. There is no clinical information specific to patient. cert statement only.

Upon patient record review, 6 of 14 (Patient #1, 3, 4, 7, 9, 14) did not have evidence that before the recertification period for each patient, the medical director or physician designee must review the patient's clinical information and provide written documentation that it is anticipated that the patient's life expectancy is 6 months or less. Patient #1: CTI narrative for 15th benefit period: includes name, DOB, age, SOC and diagnosis and certification statement only.. I certify that ... has a life expectancy of six months or less if the terminal illness runs its normal course. There is no specific clinical information to support recertification. Patient #3: CTI narrative for 8th benefit period: includes name, DOB, age, SOC and diagnosis and certification statement only. I certify that ... has a life expectancy of six months or less if the terminal illness runs its normal course. There is no specific clinical information to support recertification. CTI narrative for SOC Benefit Period #9 beginning 9/6/24 includes clinical data, but it is signed 9/23/24 with no verbal certification documented with 48 hours. Patient #4: CTI narrative for SOC Benefit Period #4 beginning 9/6/24 includes clinical data but it is signed 9/23/24 with no verbal certification documented within 48 hours. CTI narrative for 5th benefit period: includes name, DOB, age, SOC and diagnosis and certification statement only.. I certify that ... has a life expectancy of six months or less if the terminal illness runs its normal course. There is no specific clinical information to support recertification. Patient #7: CTI narrative for SOC benefit #7 includes name, dob, age, soc date, diagnoses related/unrelated and certification statement only. It does not include specific clinical information. Patient #9: Patient admitted 1/28/24 in 3rd Benefit Period, as a transfer in from prior hospice. Inquired about copies from prior hospice, but not available per staff. There is no CTI by prior hospice or receiving hospice. CTI narrative for Benefit periods 4, 5, 6 simply contain certification statement only.. I certify that ... has a life expectancy of six months or less if the terminal illness runs its normal course. There is no specific clinical information to support recertification. CTI for 7th benefit period: includes name, DOB, age, SOC and diagnosis and certification statement only.. I certify that ... has a life expectancy of six months or less if the terminal illness runs its normal course. There is no specific clinical information to support recertification. Patient #14: 2/18/24 CTI narrative by MD simply includes the certification statement: I certify that ...has a life expectancy of six months or less if the terminal illness runs its normal course. There is no clinical information specific to patient. The patient was admitted in 13th benefit period beginning 2/18/24. The CTI was electronically signed 4/22/24, with no documented verbal certification of terminal illness received within 48 hours.

Condition of Participation: Clinical Records.

Upon patient client record review, 5 of 14 (Patient #2, 3, 4, 7, 9) 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 #2: Notice of Non-Covered Items, Services requested and is blank. Rx profile shows non-covered medications to include HCTZ, Losartan, MVI, insulin pen. Patient #3, 4, 7, 9: There is no evidence patient offered opportunity to choose or decline to choose physician. No physician name written in and no space to decline to choose.

Upon patient client record review, 2 of 14 (Patient #1,2) 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: Comprehensive nursing assessment begins with ... 91 year old male ... for the 1st benefit period from 9/5/24 to 11/03/24. However the face sheet identifies 11/4/24 to be the 15th benefit period. 11/2/24 visit note by RN is incomplete in that care provided is blank and there is no narrative. Patient #2: IDG summary begins with reviewed plan of care of 67 year old patient under routine level of care with the primary diagnosis of 50 year old male to Joy Hospice care with .....

Upon observation, there was no evidence that when the hospice provides durable medical equipment under contract, then the DMEPOS provider is accredited by a CMS approved accreditation organization. Be Rite DME provider ACHC accreditation expired 8/7/24 with no updated credential.

Upon observation, there was no evidence of a contract to provide inpatient care for respite purposes in a Medicare or Medicaid certified nursing facility, if applicable. There were no signatures on Respite contract presented Day 1 of survey. On Day 2 a signed contract was presented to surveyor.

Upon observation, there was no evidence the total number of inpatient days used by Medicare beneficiaries who elected hospice coverage in a 12-month period in a particular hospice may not exceed 20 percent of the total number of hospice days consumed in total by this group of beneficiaries. Most recent CAP report was not available to surveyor.

Condition of Participation: Personnel Qualifications.

Upon personnel record review, 1 of 14 (Personnel # 13) 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. Personnel #13: No evidence of SLP HR file as agency states they do not provide.

Upon personnel record review, 1 of 14 (Personnel #12) did not have evidence all Occupational Therapy Services are provided by a qualified licensed Occupational Therapist (OT) in accordance with the state's Occupational Therapy Practice Act and the hospice's policies and procedures and/or job descriptions. Personnel #13: No evidence of OT HR file as agency states they do no provide.

Upon personnel record review, 1 of 14 (Personnel #12 ) did not have evidence all Physical Therapy Services are provided by a qualified licensed Physical Therapist (PT) in accordance with the state's Physical Therapy Practice Act and the hospice's policies and procedures and/or job descriptions. Personnel #12: License on file expired 7/31/24.

Upon personnel record review, 7 of 14 (Personnel #4,6,10,11,12,13,14: ) 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 #4,6,10,11,12,13,14: There is no evidence of criminal background checks.

Upon personnel record review, 6 of 14 (Personnel #1, 2, 3, 5, 7, 8 ) did not have evidence of criminal background checks being obtained in accordance with state requirements. In the absence of state requirements, criminal background checks are obtained within three months of the date of employment for all states that the individual has lived or worked in the past 3 years. Personnel #1, 2, 3, 5, 7, 8: Background checks are public record searches. They are not inclusive of criminal background, but primarily history of residences and financial history.

Upon observation, there was no evidence the organizational chart matches the hospice's information submitted to CMS and/or State licensing agencies for ownership and management personnel. The agency provided on Day 1 of survey and old organization chart from 2022 prior to new ownership. A current organization chart was not provided until Day 3 of survey.