Every finding on record at Kindred Heart Hospice, Inc.

Upon personnel record review, 12 of 14 (Personnel #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12) did not have evidence Emergency Preparedness training including: • Demonstrate staff knowledge of emergency procedures

Upon patient record review, 1 of 14 (Patient #13) did not have evidence in the patient record that the comprehensive assessment takes into consideration the imminence of death.

Upon patient record review, 2 of 14 (Patient #6, 9) 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 #6 - Medication profile did not contain Lantus 100u/ml 30 units at bedtime. Patient #9 - Medication profile did not contain Ativan 2mg/ml 0.25 ml every 6 hours as needed sublingual and Morphine 20mg/ml 0.25mg every 4 hours as needed - no modifier for as needed.

Upon patient record review, 6 of 14 (Patient #5, 6, 7, 9, 13 14) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual's attending physician, if any) • Changes that have taken place since the initial assessment • Information on the patient's progress toward desired outcomes • Reassessment of the patient's response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days Patient #5 - RN completed assessment on 01/13/24 then again 02/10/24 - greater than 15 days. Patient #6 - RN completed assessment on 01/27/24 then again 02/22/24 - greater than 15 days. Patient #7 - RN completed assessment on 12/23/24 then again 01/14/24 - greater than 15 days. Patient #9 - RN completed assessment on 01/16/24 then again 02/25/24 - greater than 15 days. Patient 13 - RN completed assessment on 01/25/24 then again 02/27/24 - greater than 15 days. Patient #14 - RN completed assessment on 01/25/24 then again 02/07/24 - greater than 15 days.

Upon patient record review, 2 of 14 (Patient #6, 9) 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 #6 - POC dated 01/02/24 did not contain Lantus 100u/ml 30 units at bedtime. Patient #9 - POC dated 12/04/23 did not contain Ativan 2mg/ml 0.25 ml every 6 hours as needed sublingual and Morphine 20mg/ml 0.25mg every 4 hours as needed - no modifier for as needed.

Upon patient record review, 1 of 14 (Patient #7) 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 #7 - POC dated 12/20/24 did not include walker, wrist and ankle braces or seat cushion.

Upon client record review, 3 of 14 (Patient #7, 9, 13) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #7 - POC dated 12/20/23 SN visit frequency 1 x week - 2 visits made week 2, 4, 7. Patient #9 - POC dated 12/04/23 SN visit frequency 1 x week - 2 visits made week 3, 6. Patient #13 - POC dated 01/25/24 SN visit frequency 1 x week - 2 visits made week 5, 6.

Upon personnel record review, 1 of 14 (Personnel #9) did not have evidence in the personnel file that the following initial 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.) ·Appropriate and safe techniques in personal hygiene and grooming that include-- ·(A) Bed bath ·(B) Sponge, tub ·(C) Shampoo, sink, tub, and bed

Upon patient client record review, 4 of 14 (Patient #5, 11, 13, 14) 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 #5 - LVN visits made on 01/06/24, 01/19/24, 01/27/24 or 02/10/24 did not contain the employees credentials. Patient #11 - LVN visits made on 02/28/24 did not contain the employees credentials. Patient #13 - MSW visit made on 01/26/24 and LVN visits made 02/05/24 did not contain the employees credentials. Patient #14 - RN visit made on 01/25/ and LVN visits made on 02/01/24, 02/08/24 or 02/15/24 did not contain the employees credentials.