Every finding on record at Legacy of Tender Care Hospice, Inc.

Upon patient record review, 5 of 14 (Patient #3,6,7,8,9) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient 3,6,7,8,9: Upon patient record review the Election statement section for "right to choose and attending physician" was left blank.

Upon patient record review, 2 of 14 (Patient #6,7) 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: Upon observation the medication record on 9/14/24 Cephalexin 500 mg X 5 days. The medication remained active on the medication list. Patient #7: Upon observation the patient has a treatment order for O2 2-5L via NC as needed for SOB. Oxygen is not on the medication record.

Upon patient record review, 1 of 14 (Patient #3) 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 #3: Upon observation the medication record indicates the patient is on Eliquis. The initial plan of care does not include bleeding precautions.

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 medications and treatments. Patient #7: Upon observation there is an order to evaluate and treatment Wound care on lower sacral area. There is not an order for wound care.

Upon patient record review, 1 of 14 (Patient #13) did not have evidence 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 #13: Upon record review the was not a bereavement plan of care.

Upon patient record review, 2 of 14 (Patient #6,10) 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 #6: Upon record review the patient initial plan of care contained seizure and aspiration precautions. The Aide Plan of care on admission did not contain seizure or aspiration precautions. Patient #10: Upon record review, the initial nursing assessment indicates "strict adherence to aspiration precautions. The aide plan of care does no indicate aspiration precautions when feeding snack.

Upon personnel record review, 1 of 12 (Personnel # 2) did not have evidence the alternate administrator's personnel record verifies that: • The employee has appropriate education and experience requirements • There is a signed job description for this role • The employee has been orientated to this role Personnel #2: Upon observation there was not a signed Alternate Administrator job description. There was a signed Administrator's job description. The agency provided a "correction" the Administrator's job description with the title at the top changed to Administrator Designee.

Upon patient record review, 1 of 14 (Patient #7) 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. Patient #7: Upon observation the physician narrative of the CTI for benefit period #7 states "Pt might be discharged soon due to prognosis being extended." There is no clinical information in the written documentation that it is anticipated the patient's life expectancy is 6 months or less.

Upon patient client record review, 3 of 14 (Patient #3,8,10) 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 #3,8: Upon review of the election statement, there is no indication if the patient elected or declined to receive the Patient notification of Hospice non-covered items, services and drugs. Patient #10: Upon review of the election statement, the effective date of election was blank.

Upon patient client record review, 5 of 14 (Patient #1,2,4,5,7) 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 1,2,4,5,7: Upon observation of the election statement, the signature of the hospice employee is not legible and credentials are not legible.

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. Upon request, it took the agency three hours to produce the patient medical records. Additionally, the hospice consents were on paper and it took and additional hour to produce the paper files.

Upon SNF/NF contract review, 1 of 3 (Astoria nursing) did not have evidence that specifies the provision of hospice services in the facility, including: A provision that the SNF/NF or ICF/IID immediately notifies the hospice if: • A significant change in a patient's physical, mental, social or emotional status occurs • Clinical complications appear that suggest a need to alter the plan of care • When a need to transfer a patient from the SNF/NF or ICF/MR arises, and the hospice makes arrangements for, and remains responsible for, any necessary continuous care or inpatient care necessary related to the terminal illness and related conditions • A patient dies

Upon SNF/NF contract review, 1 of 3 (Astoria nursing) did not have evidence of a provision stating that the hospice assumes responsibility for determining the appropriate course of hospice care, including the determination to change the level of services provided.

Upon SNF/NF contract review, 1 of 3 (Astoria nursing) did not have a provision stating that the hospice reports all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by anyone unrelated to the hospice to the SNF/NF administrator within 24 hours of the hospice becoming aware of the alleged violation.

Upon patient record review, 5 of 5 (Patient #1, 2, 3, 4, 5) 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 #1, 2, 3 and 4: The medical record indicated that the patient was on oxygen and was dependent on a cane and walker for safe ambulation. The DME was not listed on the plan of care. (Patient 1, 2 and 3 corrected on site). Patient #5: Medical record indicated that the patient had a wound which required dressing changes by the hospice. The necessary wound care supplies were not listed on the plan of care.