Every finding on record at Kah Development 8, LLC

Upon patient record review 2 of 19 records (Patient #4,#11) 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 #4: The patient was admitted on 7/10/23. The record indicated that the spiritual assessment was completed on 7/17/23 which is greater than the 5 day requirement. Patient #11: The patient was admitted on 3/31/23. The record indicated that the spiritual assessment was conducted on 4/11/23.

Upon patient record review 1 of 19 records (Patient #14) did not have evidence in the patient record that the comprehensive assessment identifies the 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 #14: There was not evidence of a spiritual assessment.

Upon patient record review, 1 of 19 records (Patient #12) 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 #12: The medication profile contained duplicates of Senna 8.6, 1 tab po 2x/day, and Glycerine supp, 1 daily prn if Senna is ineffective. Corrected on site

Upon patient record review, 1 of 19 records (Patient #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 #11: The patient was admitted on 3/31/23. The record indicated that the bereavement assessment was conducted on 4/7/23.

Upon patient record review, 1 of 19 records (Patient #8) did not have evidence in the patient record that the hospice has developed an individualized written plan of care that reflects 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 #8: The record indicated a hospice diagnosis of hypertensive heart disease and chronic kidney disease without failure, with stage 1-4 unspecified kidney disease. There was not evidence of an individualized written plan of care that reflected patient/family goals and interventions based on the patient's cardiac problems identified in the initial, comprehensive, and updated comprehensive assessments.

Upon patient record review, 2 of 19 records (Patient #6,#14) did not have evidence the plan of care included all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #6: The record indicated that the patient had a Pleurix drain in her left upper back, placed 5/8/23. The record indicated the last order, dated 5/30/23 was for the Skilled Nurse to drain the Pleurix weekly. There was not evidence of how much to drain, the maximum amount to drain, or under what conditions to drain or hold the treatment. Corrected on site. Patient #14: The record indicated an order dated 7/17/23 to 'Place Foley Cath.' There was not evidence of a size of the catheter, the balloon, irrigation or change schedule. Corrected on site.

Upon client record review, 3 of 19 records (Patient #1,#7,#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 visit frequency for the skilled nurse was 2x/week. For the weeks of 7/2/23-7/8/23 and 8/13/23-8/19/23, the record indicated only 1 visit each of these weeks with no evidence of missed visit documentation. Corrected on site. Patient #7: The visit frequency for the Spiritual Care Counselor was 1x/month. The record indicated 2 routine visits were conducted for the month of August (8/8/23 and 8/14/23). Corrected on site. Patient #12: The skilled nurse visit frequency was 3x/week. For the weeks of 7/23/23-7/29/23 and 8/13/23-8/19/23, the record indicated only 2 visits each of these weeks. Corrected on site.

Upon patient record review, 1 of 19 records (Patient #14) did not have evidence that the IDG shares information on a on-going basis with non-hospice healthcare providers furnishing services unrelated to the terminal illness and related conditions. Patient #14: The record indicated a referral/consult to a physician for possible surgery to a wound on the patient's back, dated 6/29/23, and again for pain management to remove a 'pain pump' (which is actually a neuro stimulator that was breaking through the skin), dated 7/5/23. There was not evidence of documentation from the physician of the visits or the consult or the procedure that was performed.

Upon patient record review, 1 of 19 records (Patient #17) did not have evidence that 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 Patient #17: The plan of care indicated that the 2 week card was to be sent by 4/23/23. The record indicated that it was sent on 6/21/23. The 1 month letter by 5/9/23 and the record indicated that it was not sent until 6/29/23 and the 3 month letter was to be sent by 7/8/23 and was not sent until 7/20/23.

Upon personnel record review, 1 of 14 records (Personnel #12) 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 #12: An initial competency was conducted on 12/13/21. The validation method for all tasks was not documented as to how the validation was performed (Verbal or return demonstration during direct patient care). In addition, the annual competency dated 12/29/22 did not include initials in the provided area for the supervisor to document, that these tasks were validated or evidence that any of the above listed tasks were observed while providing direct care.

Upon patient record review, 1 of 19 records (Patient #7) did not have evidence in the patient record that hospice aide assignments and duties that: • There is evidence in the patient record that the plan of care specifically 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 #7: The aide plan of care indicated to shower every visit. Provide a bed bath every visit if the patient is too fatigued to shower. Also to change linens every visit prn at wife's request. Corrected on site.

Upon patient record review 4 of 19 records (Patient #8,#11,#12,#13) did not have evidence of documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care Patient #8: The aide visit frequency beginning 6/4/23 was 3x/week. For the weeks of 6/4/23-6/10/23, 6/11/23-6/17/23, and 7/23/23-7/29/23 the record indicated only 2 visits each of these weeks with no evidence of missed visit documentation. Patient #11: The aide visit frequency was 2x/week. For the week of 7/23/23-7/29/23, the record indicated only one visit on 7/25/23. Corrected on site. Patient #12: The aide visit frequency was 3x/week. For the week of 7/16/23-7/22/23, the record indicated only 2 visits, on 7/17/23 and 7/19/23. Corrected on site. Patient #13: The aide visit frequency was 3x/week. From 7/2/23 to current, the record indicated only 2 visits each week. Corrected on site.

Upon patient record review 1 of 19 records (Patient #12) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs. Patient #12: The record indicated an aide supervisory visit was conducted on 8/8/23. There was not evidence of another aide supervisory visit until 8/23/23.

Upon patient record review, 1 of 19 records (Patient #12) 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 #12: The ICD-10 indicated that the patient had a hospice diagnosis of cerebral atherosclerosis. The initial certification of terminal illness indicated that the terminal diagnosis was vascular dementia.

Upon patient record review, 1 of 19 records (Patient #8) 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. The narrative must reflect the patient's individual clinical circumstances and cannot contain check boxes or standard language used for all patients. The physician must synthesize the patient's comprehensive medical information in order to compose this brief clinical justification narrative. Patient #8: The patient was admitted on 5/31/23. On 6/20/23, the hospice diagnosis was changed to hypertensive heart disease and chronic kidney disease without failure, with stage 1-4 unspecified kidney disease. The re-certification narrative, dated 8/16/23, indicated that the diagnosis was Alzheimer's Disease

Upon patient client record review, 1 of 19 records (Patient #8) 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 #8: The record contained a missed visit note that was entered on 6/21/23 by the RN but was for a missed visit for the aide. There was not evidence of the day that the visit was missed, and the aide had completed all visits for the week of 6/18/23-6/24/23.

Upon client record review, 1 of 19 records (Patient #15) did not have evidence that the hospice forwarded a summary and a copy of the patient record, if requested, to a facility when transferring the patient to that facility. Patient #15: The patient chose to transfer to another hospice. There was not evidence that a ŸCopy of the interdisciplinary care plan, Ÿ Ÿ Ÿ Copy of signed consents for care, Copy of the certification of terminal illness, The hospice discharge summary, or Clinical record, (if requested) was forwarded to the receiving hospice.

Upon client record review, 1 of 19 records (Patient #2) 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 #2: The visit frequency for the spiritual care counselor was 1x/month. The record indicated 2 routine visits for the month of August (8/3/23 and 8/14/23). Corrected on site.