Every finding on record at Kush for Hospice and Palliative Care LLC

Upon patient client record review, 2 of 7 (Patient #1,7) 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: No evidence of the start of care date on the election statement or identification of the attending physician. Corrected during survey. Patient 7: No evidence of the start of care date on hospice election statement.

Condition of Participation: Emergency Preparedness

Upon observation, there was no evidence the Emergency Preparedness plan: • Is based on and includes a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach • Includes strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care Risk assessment performed by Admin. (only name on document) is basic, with extreme heat as only High risk issue identified, there are no specifics as to how to handle extreme heat emergencies within the plan, nor management of consequences of power failures, natural disasters, and other emergencies that would affect the hospices ability to provide care.

Upon observation, there was no evidence the Emergency Preparedness plan includes a process for cooperation and collaboration with local, tribal, regional, state, and federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation.

Upon observation, there was no evidence the hospice develops and maintains an emergency preparedness communication plan that complies with federal, state, and local laws and must be reviewed and updated every two years. There was no evidence of a communication plan.

Upon personnel record review, 8 of 11 (Personnel #1, #2, #3, #4, #5, #6, #7, #11 ) did not have evidence Emergency Preparedness training including: • Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles • Demonstrate staff knowledge of emergency procedures • Provide emergency preparedness training at least annually • Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others • Maintain documentation of all emergency preparedness training When asked to produce information included in Emergency preparedness training for orientation, unable to produce. "Have them read the Emergency Preparedness folder", safety manual provided does not include Emergency preparedness. There is a check mark on orientation of all employees as to Emergency preparedness training , no other documentation as to specific training.

Upon patient record review, 3 of 6 (Patient #1, #2, #6) 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 #1: SOC nurses admit note stated O2 2-4 L via NC PRN. There was no evidence of O2 on the medication profile. Patient #2: in home included medications: Levothyroxine 50mg daily and Polyethylene glycol daily (no route). There was no evidence of this on medication profile in record/office. Corrected on site. Patient 6: Med. profile on original SOC POC/IDG initial orders included an order for Polyethylene 17 Gm PO daily, there was no evidence of a diluent. An order for Albuterol 0.0083 3ml Inh. continuous.. Inhalation Albuterol meds are not routinely given continuously. Corrected on site.

Upon patient record review, 1 of 6 (Patient #1) 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 #1: The SOC Assessment dated 4/13/2023 included documentation of O2 2-4 L via nc PRN. There was no evidence of O2 problems, goals and interventions on the POC.

Upon patient record review, 3 of 6 (Patient #1, #2, #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 medications and treatments. Patient #1: SOC nurses admit note stated O2 2-4 L via NC PRN. There was no evidence of an O2 order. Patient #2: in home included medications: Levothyroxine 50mg daily and Polyethylene glycol daily (no route). There was no evidence of a physician order. Orders corrected on site. Patient #6: SOC POC/IDG initial orders included an order for Polyethylene 17 Gm PO daily, there was no evidence of a diluent. An order for Albuterol 0.0083 3ml Inh. continuous.. Inhalation Albuterol meds are not routinely given continuously. Corrected on site.

Condition of Participation: Hospice Aide and Homemaker Services. L607

Upon personnel record review, 1 of 11 (Personnel #5) did not have evidence that Hospice Aide Services are provided by a qualified individual in accordance with the appropriate state's regulations, the hospice's policies and procedures and/or job descriptions and the ACHC Glossary of Personnel Qualifications as defined by the Medicare Conditions of Participation. Personnel #5: Aide credentialing expired 7/7/2023. Per agency unable to verify via state site. Aide did provide patient care after 7/7/23.

Upon patient record review, 3 of 6 (Patient #3, #4, #5) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; 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 #3, #4: Pt has order for O2, there was no evidence of O2 precautions on the Aide POC/Assignment sheet. Patient #5: Pt identified as fall risk on SN SOC, has fall risk on POC. Pt. has O2 Order, there was no evidence of O2 precautions or fall precautions on the Aide POC/assignment sheet.

Upon patient record review, 1 of 6 (Patient #3) 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 #3: There was no evidence of appropriate authenticated and dated CTI. The Pt SOC dated 7/23/2023. The CTI stated for BP 7/20/2023-10/18/2023, and was signed dated 5/16/2023. Corrected on site.

Upon patient client record review, 1 of 6 (Patient #1) 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: There was no evidence of a complete document for nurses note dated 5/29/2023, page one with vitals, C/V, resp. missing from file.

Upon observation, there was no evidence the patient record, whether hard copy or in electronic form, is made readily available on request by an appropriate authority. Two of 5 records were available to this surveyor the first day of survey. The 2 records provided were missing nursing notes for over four weeks documentation. Per DON the records were locked in a file in the office, and only the owner/Adm. had the key, and he was out of town. Access to the files was made available on day two of survey.