Every finding on record at Kattleya Hospice & Palliative Care

Upon observation there was not evidence that during the Initial Assessment visit, in advance of furnishing care, the Hospice had provided the patient and/or family with verbal (meaning spoken) and written notice of the Patient's Rights and Responsibilities: Patient #1: SOC was 12/17/2023. During surveyor-attended home visit on 03/05/24 it was identified that the patient's admission documents were still in the RN Case Manager's car, to include their written copy of the Patient's Rights and Responsibilities. Patient #3: SOC was 02/21/2024. During surveyor-attended home visit on 03/05/24 it was identified that the patient's admission documents were still in the RN Case Manager's car, to include their written copy of the Patient's Rights and Responsibilities.

Upon patient record review, 1 of 14 (Patient #5) did not contain evidence that the patient had chosen a health care provider, specifically an Attending Physician: Patient #5: The section of the 07/18/23 Hospice Benefit Election Statement, for the patient to designate their choice of Attending, if any, had been left blank.

Upon patient record review, 3 of 14 (Patients #2, 3, and 5) did not contain evidence of a current/comprehensive Medication Profile, as follows: Patient #2: This patient is on Oxygen 2 lpm p.r.n. SOB via NC. This was not included on the Medication Profile. Patient #3: This patient is on Oxygen 2 lpm p.r.n. SOB via NC. This was not included on the Medication Profile. Patient #5: The nursing entry on the IDG Meeting note dated 02/28/24 included, "No BM 3-4 days. Caregiver inserted a Dulcolax Suppository." This medication was not included on the Medication Profile.

Upon patient record review, 1 of 14 (Patient #13) did not contain evidence that the SOC comprehensive assessment had included a Bereavement Risk 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 #13: SOC was 07/22/22. The Bereavement Risk Assessment component, of the initial Comprehensive Assessment was not conducted/dated until 09/15/23.

Upon patient record review, 6 of 14 (Patient #1, 2, 3, 4, 7, and 8) did not contain evidence that these Plan(s) of Care included all services necessary for the palliation and management of the terminal illness and related conditions, including the following: A detailed statement of both the scope and frequency of all services necessary to meet the specific patient and family needs: Patient #1: The IDG POC dated 02/28/24 included, "Volunteer as needed to run errands...."; without a baseline visit frequency for Volunteer services. Patient #2: The IDG POC dated 02/28/24 included, "Volunteer as needed to run errands...."; without a baseline visit frequency for Volunteer services. Patient #3: The IDG POC dated 02/28/24 included, "Spiritual Care one time, then p.r.n.; without a baseline visit frequency for such SC services. Patient #4: The IDG POC dated 02/28/24 included, "Volunteer as needed"; without a baseline visit frequency for Volunteer services. Patient #7: The IDG POC dated 02/28/24 included, "Volunteer as needed"; without a baseline visit frequency for Volunteer services. Patient #8: The IDG POC ending upon the 12/17/23 discharge, included, "Volunteer as needed"; without a baseline visit frequency for Volunteer services.

Upon patient record review, 3 of 14 (Patient #1, 3, 7) did not contain evidence that the Plan of Care included all services necessary for the palliation and management of the terminal illness and related conditions; specifically medications and treatments: Patient #1: This patient is on Oxygen 2 lpm p.r.n. via NC. This was not on the POC. Patient #3: This patient is on Oxygen 2 lpm p.r.n. SOB via NC. This was not included on the POC. Patient #7: A verbal order was obtained on 01/25/24 for, "Cleanse L foot with warm soap/water, pat dry, apply triple ATB Ointment to first and second L toes, QD till healed." It is not clear as to 'who' is responsible for this dressing change in the absence of the Hospice nurse. The order is incomplete. Another verbal order was obtained on 02/07/24 for, "Wash L foot with warm/soapy water, pat dry, apply Calmoseptine to open L heel wound daily and as needed, without an indication for such 'as needed' wound care; nor who will be responsible for this dressing change in the absence of the Hospice nurse.

Upon patient record review, 2 of 14 (Patients #1 and 2) did not contain evidence that the Plan of Care included all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs: Patient #1: During Surveyor-attended home visit on 03/05/24, the following DME was observed in the home: Wheel chair and nebulizer. These were not included on the POC. Patient #2: During Surveyor-attended home visit on 03/05/24, the following DME was observed in the home: 1) Wheel chair; 2) Cane; 3) Walker; and 4) Shower Chair. These DME were not included on the POC.

Upon patient record review, 2 of 14 (Patients #2 and 6) did not contain evidence that a revised Plan of Care included information from the patient's updated comprehensive assessment(s): Patient #2: The IDG POC dated 02/28/24 continued to have old SOC (11/28/23) orders on it, as follows, "MSW and SC to conduct their initial 5-day Comprehensive Assessments." Patient #6: SOC was 08/22/23. The IDG POC dated 02/28/24 continued to have an outdated order for, "MSW and SC Initial Assessment within 5-days of admission." A verbal order had been obtained on 02/0824 to update these visit frequencies to 1x per month.

Upon patient record review, 2 of 14 (Patients #7 and 8) did not contain evidence that the IDG had ensured that care and services were provided in accordance with the Plan of Care: Patient #7: A verbal order was obtained on 02/07/24 for, "Wash L foot with warm/soapy water, pat dry, apply Calmoseptine to open L heel wound daily and as needed." On the 02/10/24 SN visit the nurse documented, "left heel wound care performed as "Cleansed with Normal Saline, applied Calmoseptine, and then covered with gauze." Patient #8: The Hospice nurse made weekly visits on 10/10, 10/17, 10/24, 10/31, and 11/08/23. The IDG Meetings dated 11/08/23, 11/22/23, and 12/06/23 all continued to order nursing at a visit frequency of 1x per week. There were not nursing visits documented for the weeks beginning 11/12/23, 11/19/23, and 11/26/23. The next weekly nursing visit was made 12/06/23. Then there was no nursing visit made/documented the week of 12/10-12/16/23. There was no documented evidence of the Hospice nurse having attempted to contact the patient during that week to schedule the ordered visit. The next nursing documentation was dated 12/17/23; reflecting a phone call from the patient's family/caregivers that he had fallen, injured L hip, and entered the hospital with resultant surgery.

Upon personnel record review, 1 of 10 (Personnel #7) did not contain evidence that her Aide Skills Competency Assessment had included all CMS-required subject matter. An RN conducted an Aide Skills Competency Assessment on 05/15/23. However, the following skill competence was not evaluated for: The physical, emotional, and developmental needs of, and ways to work with, the populations served by the Hospice, including the need for respect for the patient, his or her privacy and his or her property.

Upon patient record review, 1 of 14 (Patient #10) did not contain evidence that the Medical Director, or Physician Designee, had provided 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 #10: The 01/07/23 initial SOC CTI had not been dated by the signing Physician until 01/09/23. Their was an electronic date entry of 01/07/23 into the form, indicating that a verbal authorization had been obtained within the first 2 days of such cert period. However, there was no RN dated signature associated with that entry to confirm it occurred.

Upon patient record review, 2 of 14 (Patients #8 and 9) did not contain evidence that before the re-certification period for each patient, the Medical Director or Physician Designee had reviewed these patients' clinical information and provided written documentation that it was anticipated that these patients' life expectancy was 6 months or less: Patient #8: The CTI associated with the re-certification period of 11/08/23-01/06/24, had not been dated by the signing Physician until 11/16/23. Neither was their documentation of an RN having obtained a verbal authorization within the first 2 days of such cert period. Patient #9: The CTI associated with the re-certification period of 07/06-09/03/23, had not been dated by the signing Physician. Neither was their documentation of an RN having obtained a verbal authorization within the first 2 days of such cert period. In addition, the CTI re-certification form for period of 07/06-09/03/23, did not include a Physician established 'narrative.

Upon patient record review, 14 of 14 (Patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, and 14) did not contain evidence that each patient record contained: A signed Election Statement in accordance with 418.24. The Election Statement text included, "I understand that I have the right to request at any time, in writing, the "Patient Notification of Hospice Non-covered Items, Services, and Drugs that the Hospice ..... " The remainder of this sentence/entry is missing the following text, "... has determined to be unrelated to your terminal illness and related conditions, and that will not be covered by the Hospice." Also missing from the form is, "As a Medicare Hospice beneficiary, you have the right to contact the Beneficiary and Family-Centered Care Quality Organization (BFCC-QIO) to request Immediate Advocacy if you disagree with any of the Hospice's determinations. The BFCC-QIO that services your area is: _________, and their phone number is: _________. The information for the above lines had not been included on the form. Patient #5: The section of the Hospice Benefit Election Statement dated 07/18/23, for the patient to designate their choice of Attending, if any, had been left blank.

Upon patient record review, 5 of 14 (Patients #1, 5, 7, 10, and 12) did not contain 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: Patient #1: Multiple Aide home visit reports were not signed/dated by the Aide having provided the care/services. Patient #5: The Aide home visit reports dated January 15, 16, 17, 22, 24, 29, and 31, 2024; and all of the February 2024 home visits were not signed/dated by the Aide having provided the care/services. Patient #7: The nurse documents on the 01/27/24 home visit report that, "Dressing changed on his left heel"; without including the details of such dressing change provided. Patient #10: The Aide home visit reports dated July 3, 7, 15, 17, 20, 25, 27, 31, 2023 are not signed/dated by the Aide having provided the care/services. Patient #12: The nurse home visit reports dated September 15, 26, 27, 28, 29, and 30, 2023, and October 2, 2023 are not signed/dated by the nurse having provided the care/services.

Upon patient record review, 5 of 14 (Patients #8, 9, 10, 11, and12) did not contain evidence that the Discharge Summary included all CMS-required content, to include but not limited to the following: • The patient's current Plan of Care • The patient's latest Physician orders

Upon observation of the Hospice's Patient Admission Binder, and interview with the Administrator, there was not evidence that the Hospice had provided admitted patients/in-home caregivers with a written copy of the Hospice's policies and procedures on the management and disposal of controlled drugs.

Upon Inpatient contract review, 1 of 1 (Norwalk & Skilled Nursing & Wellness Center/GIP/RIP) did not contain content that required that a copy of the Discharge Summary shall be provided to the Hospice at the time of discharge from such inpatient facility.