Every finding on record at K and S Hospice Inc.

Upon patient record review, 1 of 5 (Patient #3) 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 #3, Oxygen @2lPM via NC as needed or cont for breath/comfort was documented under treatment. No evidence of Oxygen @2lPM via NC as needed or cont for breath/comfort documented on medication profile.

Upon patient client record review, 3 of 5 (Patient #2,4,5) 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, No evidence of signature on IDG note for RN, SC on 3/30/24. No evidence of signature on IDG note for RN, SC, MSW on 4/9/24. No evidence of signature on IDG note for MD, RN, SC, MSW on 4/23/24. Patient #4, No evidence of signature on IDG note for SC on 4/20/24. No evidence of signature on IDG note for MD, RN, SC, MSW on 4/23/24. Patient #5, No evidence of signature on IDG note for MD, RN, SC, MSW on 4/23/24.

Upon patient record review, 7 of 14 (Patient #2, 3, 5, 6, 8, 9, 11) 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 #2: Initial POC ordered BC to complete Initial Bereavement assessment within 5 days of admission. Assessment completed late on 2/23. Patient #3: Initial POC ordered BC to complete Initial Bereavement assessment within 5 days of admission. Assessment completed late on 2/28. Patient #5: Initial POC ordered BC to complete Initial Bereavement assessment within 5 days of admission. Assessment completed late on 2/22. Patient #6: Initial POC ordered BC to complete Initial Bereavement assessment within 5 days of admission. Assessment completed late on 2/28. Patient #8: Initial POC ordered BC to complete Initial Bereavement assessment within 5 days of admission. Assessment completed late on 2/27. Patient #9: Initial POC ordered BC to complete Initial Bereavement assessment within 5 days of admission. Assessment completed late on 10/30. Patient #11: Initial POC ordered BC to complete Initial Bereavement assessment within 5 days of admission. Assessment completed late on 12/20.

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

Upon patient record review, 4 of 14 (Patient #3, 6, 10, 11) 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 #3: Patient POC lists Code Status as "Undecided" rather than Full Code or DNR. It is unclear what the code status is. Patient #6: Patient POC lists Code Status as "DNR with POLST in place/Full Code with POLST in Place" It is unclear what the code status is. Patient #10: Patient POC lists Code Status as "Undecided" and "DNR with POLST in place". It is unclear what the code status is. Patient #11: Patient POC lists Code Status as "DNR with POLST in place/Full Code with POLST in Place" It is unclear what the code status is.

Upon patient record review, 1 of 14 (Patient #2) 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 #2: Documentation indicates that patient has a foley catheter. POC has order "Foley catheter attached to urinary drainage bag for end of life comfort. May change as needed for leakage or dislodgement" Order doesn't specify size of catheter or specific frequency to change catheter.

Upon patient record review, 3 of 14 (Patient #1, 3, 6) 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 #1: Patient receiving wound care and suctioning. No supplies for either listed on the POC Patient #3: Documentation indicates that patient has foley catheter. No foley catheter supplies listed on the POC. Patient #6: Patient has foley catheter and tube feeding. No foley catheter or tube feeding supplies listed on the POC.

Upon patient record review, 4 of 14 (Patient #2, 4, 5, 10) 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 Patient #2: IDG dated 2/28 not signed by MSW or SC. No documentation on IDG Discussion/Update by MSW or SC to update the POC. No evidence to support MSW and SC participated in the IDG meeting. IDG dated 3/13 not signed by MD, MSW or SC. No documentation on IDG Discussion/Update by MSW or SC to update the POC. No evidence to support MD, MSW or SC participated in the IDG meeting. Patient #4: IDG dated 1/24, 1/31, 2/14, 2/28 not signed by RN. No documentation on IDG Discussion/Update by RN to update the POC. No evidence to support the RN participated in the IDG meeting. Patient #5: IDG dated 2/28 not signed MSW. No documentation on IDG Discussion/Update by MSW to update the POC. No evidence to support MSW participated in the IDG meeting. Patient #10: ID dated 2/28 not signed by RN. No documentation on IDG Discussion/Update by RN to update the POC. No evidence to support RN participated in the IDG meeting. care.

Upon client record review, 4 of 14 (Patient #3, 5, 11, 12) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #3: POC dated 2/6 ordered SN 1xwk. 2 SN visits documented the week of 2/25 on 2/28 and 3/1. No documentation to support either visit was a PRN or orders to change SN frequency. Patient #5: POC ordered SC 1xmonth. No evidence to support a visit was made in the month of January. Patient #11: POC ordered SN 1xwk. 2 routine scheduled SN visits noted the wk of 1/14 on 1/16 and 1/19. No evidence to support a change in frequency. 2 PRN SN visits made on 1/20 and 1/21. POC ordered 1 prn visit. No evidence to support an order for the additional PRN visit. Patient #12: POC ordered SN daily x 7 days. 2 visits made on 2/19 and 2/20. No evidence to support an order for PRN visits. No evidence to support a visit on 2/21.

Upon patient record review 2 of 14 (Patient #11, #12) 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 #11: POC ordered aide 2xwk. 3 visits noted the wk of 2/4, 4 visits the wk of 2/11 and 2/18. No evidence to support an order for a change in frequency. Patient #12: POC ordered aide 2xwk. No evidence of any aide visits the wk of 1/14 or documentation to support services were discontinued or missed visits.

Upon patient client record review, 2 of 14 (Patient #2, 3) did not have evidence that each patient record contains Physician certification and recertification of terminal illness. Patient #2: Physician Certification for Hospice Benefit electronically signed by hospice medical director Rajiv Bhuva instead of attending physician Tejal Ghadiali. Patient #3: Physician Certification for Hospice Benefit electronically signed by hospice medical director Rajiv Bhuva instead of attending physician Maneesh Penkar.