Every finding on record at Kaplan Hospice, 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 is no evidence of an agreement with another agency/hospice to receive patients in the event the hospice cannot provide care to their patients during and emergency.

Upon observation, there was no evidence the Emergency Plan communication plan includes all of the following: Names and contact information for the following: • Hospice employees • Entities providing services under arrangement • Patients' physicians • Other hospices (Corrected on site by compiling a list of contacts and contact information.)

Upon observation, there was no evidence that during the initial assessment visit in advance of furnishing care, the hospice provided the patient and/or family with verbal (meaning spoken) and written notice of the Patient's Rights and Responsibilities in a language and manner that the patient understands. Patient #1: Upon observation of the medical record, the patient printed her initials (PD) on the admission paperwork. The initial nursing assessment and the Certification of Terminal Illness identified her primary diagnosis as Alzheimer's disease with a score of FAST 7A indicating severe dementia and inability to make decisions.

Upon patient record review, 1 of 14 (Patient #1) did not have evidence that the hospice informed and provided written information to the patient concerning its policies on advance directives, including a description of applicable state law. Patient #1: Upon observation of the medical record, the patient printed her initials (PD) on the admission paperwork. The initial nursing assessment and the Certification of Terminal Illness identified her primary diagnosis as Alzheimer's disease with a score of FAST 7A indicating severe dementia and inability to make decisions.

Upon patient record review, 1 of 14 (Patient #1) did not have evidence that the hospice obtained the patient's or representative's signature confirming that they received a copy of the Patient's Rights and Responsibilities. Patient #1: Upon observation of the medical record, the patient printed her initials (PD) on the admission paperwork. The initial nursing assessment and the Certification of Terminal Illness identified her primary diagnosis as Alzheimer's disease with a score of FAST 7A indicating severe dementia and inability to make decisions.

Upon patient record review, 1 of 14 (Patient #1) did not have evidence that if a state court has not adjudged a patient incompetent, any legal representative designated by the patient in accordance with state law may exercise the patient's rights to the extent allowed by state law. Patient #1: Upon observation of the medical record, the patient printed her initials (PD) on the admission paperwork. The initial nursing assessment and the Certification of Terminal Illness identified her primary diagnosis as Alzheimer's disease with a score of FAST 7A indicating severe dementia and inability to make decisions.

Upon client record review, 1 of 14 (Patient #1) did not have evidence that the plan of care included IDG's documentation of the patient's or families level of understanding, involvement and agreement with the plan of care. Patient #1: Upon observation of the medical record, the patient printed her initials (PD) on the admission paperwork. The initial nursing assessment and the Certification of Terminal Illness identified her primary diagnosis as Alzheimer's disease with a score of FAST 7A indicating severe dementia and inability to make decisions.

Upon patient record review, 1 of 14 (Patient #1) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient #1: Upon observation of the medical record, the patient printed her initials (PD) on the admission paperwork. The initial nursing assessment and the Certification of Terminal Illness identified her primary diagnosis as Alzheimer's disease with a score of FAST 7A indicating severe dementia and inability to make decisions.

Upon patient record review, 1 of 14 (Patient #1) did not have evidence of the appropriate documentation for release of confidential information. Patient #1: Upon observation of the medical record, the patient printed her initials (PD) on the admission paperwork. The initial nursing assessment and the Certification of Terminal Illness identified her primary diagnosis as Alzheimer's disease with a score of FAST 7A indicating severe dementia and inability to make decisions.

Upon patient record review, 1 of 14 (Patient #1) did not have evidence that the patient received information about the services covered under the hospice benefit. Patient #1: Upon observation of the medical record, the patient printed her initials (PD) on the admission paperwork. The initial nursing assessment and the Certification of Terminal Illness identified her primary diagnosis as Alzheimer's disease with a score of FAST 7A indicating severe dementia.

Upon patient record review, 1 of 14 (Patient #1) did not have evidence that the patient received information about the scope of services that the hospice will provide and specific limitations on those services. Patient #1: Upon observation of the medical record, the patient printed her initials (PD) on the admission paperwork. The initial nursing assessment and the Certification of Terminal Illness identified her primary diagnosis as Alzheimer's disease with a score of FAST 7A indicating severe dementia and inability to make decisions.

Upon patient record review, 1 of 14 (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: Upon observation of home visit, the patient was taking Vascepa one gram daily. This medication was not on the hospice medication list. Additionally, the patient had stopped taking Gabapentin 300 mg TID, a week ago. (corrected on site with a new order for Vascepa and an order to discontinue Gabapentin)

Upon patient record review, 1 of 14 (Patient #1) 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 #1: Upon record review the patient was admitted on 6/4/25 and the Bereavement Assessment was completed 6/17/25

Upon patient record review, 1 of 14 (Patient #3) 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 #3: Upon observation of home visit, the patient was taking Vascepa one gram daily. There was not an order for this medication. Additionally, the patient had stopped taking Gabapentin 300 mg TID, a week ago and there was no order to discontinue the medication. Correct

Upon patient client record review, 1 of 14 (Patient #1) 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 #1: Upon observation of the medical record, the patient printed her initials (PD) on the admission paperwork. The initial nursing assessment and the Certification of Terminal Illness identified her primary diagnosis as Alzheimer's disease with a score of FAST 7A indicating severe dementia and inability to make decisions (an election addendum was not requested).

Upon patient client record review, 9 of 14 (Patient #1,2,3,4,6,7,8,9,10) 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 #1,2,3,4,6,7,8,9,10: Upon record review the hospice staff signature on the election statement was not clear, complete and authenticated.

Upon observation, there was no evidence a copy is provided of the hospice written policies and procedures on the management and disposal of controlled drugs to the patient or patient representative and family. Patient #1: Upon observation there is no evidence the hospice discussed the policies and procedures for managing the safe use and disposal of controlled drugs with the patient or representative. There is no signature on the management and disposal of controlled drugs form. The Patient acknowledgement form does not include medication disposal and the patient's PCG did not know the proper disposal of medications. When the patient was asked about training, she said maybe I forgot. The primary caregiver did not know the proper disposal of medications.

Upon observation, there was no evidence the hospice discussed the policies and procedures for managing the safe use and disposal of controlled drugs with the patient or representative and the family in a language and manner that they understand to ensure that these parties are educated regarding the safe use and disposal of controlled drugs. Patient #1: Upon observation there is no evidence the hospice discussed the policies and procedures for managing the safe use and disposal of controlled drugs with the patient or representative. There is no signature on the management and disposal of controlled drugs form. The Patient acknowledgement form does not include medication disposal and the patient's PCG did not know the proper disposal of medications. When the patient was asked about training, she said maybe I forgot. The primary caregiver did not know the proper disposal of medications.

Upon client record review, 1 of 14 (Patient #1) did not have evidence that the written policies and procedures for managing controlled drugs was provided and discussed. Patient #1: Upon observation there is no evidence the patient did not receive information on policies and procedures for managing the safe use and disposal of controlled drugs with the patient or representative. There is no signature on the management and disposal of controlled drugs form. The Patient acknowledgement form does not include medication disposal.

Upon patient record review, 1 of 5 (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 equipment and supply needs. Patient #2: This patient had a bed rails 3/4 length and bedside table. These were not included on Plan of Care.

Upon observation, there was no evidence that the DMEPOS provider is accredited. The DMEPOS accreditation was effective 4-25-19 to 4-25-22.