Every finding on record at Legend Hospice Inc.

Upon patient record review, 5 of 19 (Patient #1,#5,#10,#16,#19) 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 • Drug therapy currently associated with laboratory monitoring Patient #1: Patient indicated she is taking Pepto-Bismol, Arnica, Magnesium rub, Vitamin C and Guaifenesin, which are not on the medication profile. Patient #5: On admission, the plan of care indicated an oxygen concentrator was available for PRN use, but there was no oxygen on the medication profile. Patient #10: On admission, the plan of care indicated the patient was using Oxygen at 2L via NC. This was not on the medication profile. Patient #16:The plan of care on 06-05-24 indicated the patient had an oxygen concentrator. Oxygen was not listed on the medication profile. Patient #19: O2, Morphine and Lorazepam were ordered on admission, but there was no evidence they were listed on the medication profile.

Upon patient record review, 2 of 19 (Patient #2, #14) 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 #2: The plan of care dated 06-05-24 has no evidence that interventions are specified for patients. For interventions, assess grade of edema, encourage elevation of edematous area and instruct in diet and fluids and assist with transfers, there is no indication of the edematous area, the type of assist the patient requires or the specific diet to be educated. Patient #14: The plan of care dated 06-27-24 is without evidence of an individualized plan for the following interventions: use of restraints- no indication of the type of restraint; assist with transfers- no indication of the assistance required; instruct in diet and fluids with no indication of the specific diet or fluids required.

Upon patient record review, 3 of 19(Patient #1,3,8) 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: Patient indicated she is taking Pepto-Bismol, Arnica, Magnesium rub, Vitamin C and Guaifenesin, which are not on the plan of care. Patient #3: The RN note dated 6-21-24 and 6-27-24 indicated the patient was using 3 L O2 per NC. The order indicated the patient was using 5-10 LPM of O2. Patient #8: On 06-10-24, the RN indicated the patient was using 6 LPM of O2, the order indicated the patient was using O2 at 2LPM.

Upon patient record review, 1 of 19 (Patient #2) did not have evidence in the patient record that hospice aide assignments and duties are: • 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 #2: On 6-17-24 the RN documented that she asked the aide to apply anti-fungal cream daily to patient's arm crease. However, this was not documented on the aide plan of care and the aide was visiting 3 x week. Additionally, the aide care plan dated 6-13-24 indicated the aide was to provide a complete bed bath 3 x week and a partial bed bath 2 x week. The aide's frequency was 3 x week.

Upon patient record review 5 of 19 (Patient #3,#4,#8,#12,#17) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care Patient #3: Aide visits were ordered 2 x week. on the week of 06-09-24 to 06-15-24, there was evidence of only visit by the aide on 06-14-24. Patient #4: Aide visits were ordered 3 x week. On he weeks of 05-26-24 to 06-01-24 and 06-02-24 to 06-08-24, only 1 visit per week by the CNA was evidenced on 05-27-24 and 06-07-24. Patient #8: On 06-13-24, the RN indicated the CNA would begin visiting the patient on 06-16-24 with a frequency of 5 x week. The aide began visiting on 06-19-24 and for the week of 06-16-24 to 06-22-24, only 3 visits were evidenced by the CNA on 06-19, 06-20 and 06-21-24. Patient #12: Aide visits were ordered 5 x week. During the week of 06-16-24 to 06-22-24, there were only 4 visits evidenced on 06-18, 19, 20, and 21. Patient #17: On 12-28-24 the CNA completed a visited, acknowledged, but did not complete tasks assigned: Precautions; aspiration, skin, standard and falls; shower, shampoo, and change linens, report refusal of tasks and services to RNCM and document "here " if refused. The aide did not document communication or the reason incomplete. Additionally, on 12-27-23, the aide did not complete precautions for skin, aspiration, standard and falls, and on 01-03-24 the aide did not complete apply barrier cream.

Upon patient record review, 1 of 19 (Patient #17) did not have evidence that the hospice assumes responsibility for professional management of the resident's hospice services in accordance with the hospice plan of care. The hospice is responsible for providing all hospice services including: • Ongoing assessment, care planning, monitoring, coordination and provision of care by the Hospice IDG • Consultation about the patient's care with facility staff • Coordination by the hospice RN for the implementation of the plan of care for the patient • Provision, in a timely manner, of all supplies, medications, and DME needed for the palliation and management of the terminal illness and related conditions • Financial management responsibility for all medical supplies, appliances, medications and biologicals related to the terminal illness and related conditions Patient #17: On admission 12-27-23, there was not evidence of documentation of wound care or measurements of wounds that were requiring daily dressing changes by the facility nurse.

Upon patient record review, 1 of 11 (Patient #3) did not contain evidence that the patient had been provided the right to choose their health care provider, specifically an Attending Physician. The section of the Election of Hospice Benefit statement, intended for the entry of the patient's choice of Attending Physician, if any, had been left blank. There was no additional evidence of the patient's choice of physician.

Upon patient record review, 1 of 11 (Patient #5) did not contain evidence that a Registered Nurse was designated to ensure continuous assessment of the patient and family's needs. On 02/16/22 the RN documented, "Patient reports a fall on 02/11/22. At today's visit there is bruising up her right extremity, shoulder to elbow. Patient does not believe anything is broken." On the next subsequent SN visit 02/22/22 there was no documented evidence that the nurse had followed up on this area of concern.

Upon patient record review, 2 of 11 (Patient #3 and 4) 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 #3: During surveyor-attended home visit on 03/08/22, upon interview of the Aide, the Aide reported an area of skin integrity concern. The patient's left medial heel revealed a linear skin crevice approximately 2-3" long that was reddened, and slightly swollen. The Aide reported that the ALF nursing staff provides wound care/applied something to this site after the Aide completes the patient's bathing. Upon record review, there was no mention of such area of skin concern, nor any details of ordered wound interventions. Patient #4: The RN Initial Assessment reflected that the patient had a right wrist brace. The POC did not include a reference to this brace, nor who/how/frequency it was to be removed/re-applied, and monitored for areas of skin concern.

Upon patient record review, 2 of 11 (Patients #3 and 6) 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 all Equipment and Supply needs: Patient #3: During the Surveyor-attended home visit on 03/08/2022, a walker was noted in this patient's room. This was not included on the POC. Patient #6: The record reflected that this patient had a DME of cane. This was not included on the IDG POC dated 02/23/22.

Upon patient record review, 5 of 9 applicable (Patient #3, 4, 6, 7, 8) did not contain evidence that an RN had established a written Hospice Aide Plan of Care/Assignment that detailed the care/services to be provided, their specific frequency, and included any other pertinent patient information: Patients #3, 4, 6, 7: These records reflected that these patients were a D.N.R. status. This pertinent information was not included on these Aide POCs. Patients #8: The clinical record reflected that this patient was a Full Code. This patient's Advance Directive status, or lack thereof, was not included on the Aide POC.

Upon patient record review, 3 of 9 applicable (Patients #3, 5, and 6) did not contain documented evidence that the Hospice Aide had provided care/services that were: • Ordered by the Interdisciplinary Group • Included in the Plan of Care Patient #3: The Aide POC dated 02/23/22 assigned: 1) Denture/Oral care; 2) Nail care; and 3) Shower each visit. There was no documented evidence that the Aide had provided these interventions at any of the 02/28, 03/03 or 03/03/22 visits. Patient #5: The Aide POC assigned: 1) Change linen M, W, F. This service was not provided on W/03/02 or F/03/04/22. 2) Bed Bath M, W, F. This service was not provided on W/03/02 or F/03/04/22. 3) Denture/Oral Care. This service was not provided on W/03/02 or F/03/04/22. 4) Shampoo M, W, F. This service was not provided on W/03/02 or F/03/04/22. 5) Nail care. This service was not provided on W/03/02 or F/03/04/22. Patient #6: There was an order for Aide services to be provided at a frequency of 2x per week on the SOC 02/01/22. On 02/02/22 another order was obtained for Aide services to be provided at a frequency of 3x per week. There were only two Aide visits made the week of 02/01-02/05/22. There were four Aide visits made the week of 02/06-02/12/22.

Upon patient record review, 1 of 11 (Patient #3) did not contain evidence that each patient record contained: A signed Election of Hospice Statement in accordance with 418.24. The section of the Election of Hospice Benefit, intended for the entry of the patient's choice of Attending Physician, if any, had been left blank.

Upon patient record review, 1 of 1 applicable (Patient #10) did not contain evidence that this patient's record contained an Attending Physician's Certification of the Terminal Illness (CTI), supporting their meeting of the Hospice criteria. Patient #10 had an Attending Physician identified in their Election of Hospice Benefit Statement. There was no evidence that a SOC CTI had been obtained from such Attending.

Upon patient record review, 6 of 11 (Patient #3, 4, 5, 6, 7, 8) did not contain evidence that all entries were legible, clear, complete, and appropriately authenticated and dated, in accordance with the organizations policies and procedures and currently accepted standards of practice: Patient #3 and 5: There were no credentials attached to the Aide (JD)'s signature, for any of her entries within these records. Patient #4: There were no credentials attached to the Aide (TB)'s signature, for any of her entries within the record. Patient #5: The clinical record reflected that this patient was a D.N.R. This Advance Directive status was not included on the 02/23/22 IDG POC update. Patients #6 and 7: There were no credentials attached to the Aide (LG)'s signature, for any of her entries within these records. Patient #8: The clinical record reflected that this patient was a Full Code. This patient's Advance Directive status, or lack thereof, was not included on the 02/23/22 IDG POC update.

Upon patient record review, 1 of 1 applicable (Patient #8) did not contain evidence that the Discharge Summary included all CMS-required content as follows: • A summary of the patient's stay, including treatments, symptoms and pain management • The patient's current Plan of Care • The patient's latest Physician orders

Upon inpatient contract review, 1 of 1 applicable (DHR) did not contain a provision that at the time of discharge of the Hospice patient, from inpatient services, that a copy of the Discharge Summary shall be provided to the Hospice.