Every finding on record at Lenity Hospice LLC

Upon personnel record review, 2 of 15 (Personnel #4, 12 ) 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 Personnel #4, 12: Upon review, there is no evidence of Emergency Preparedness training.

Upon patient record review, 4 of 14 (Patient #2, 3, 6, 8) 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: Patient admitted with existing pacemaker per CTI and diagnosis of existing pacemaker, but no related problems, goals, interventions. Patient #3: Patient admitted with diagnosis of epilepsy. History of hospitalization for altered mental status and seizures. (per CTI), but no related problems, goals, interventions. Neuro problem listed, but does not address seizures. Patient has diagnosis of existing pacemaker, but no related problems, goals, interventions. Patient #6: Patient has Eliquis prescribed with no related problems, goals, interventions for bleeding precautions Patient #8: Patient admitted with diagnosis of epilepsy and Keppra prescribed 11/3/25. The F2F 3/20/26 NP documents patient has 1-2 seizures per week. There were no related problems, goals, interventions related to seizure precautions until 3/27/26. Patient on Oxygen 3 LPM continuous with dyspnea and flow rate addressed, but no problems, goals, interventions specific to related to oxygen safety precautions.

Upon patient record review, 1 of 14 (Patient #2) 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 #2: Wound care orders for skin tear 1/26/26: left arm, cleanse wound with dermal wound cleanser or NS. Pat dry. Apply Medi-honey and cover with a non-adherent dressing. Wrap with Kerlix. Secure with Coban. There is no frequency for wound care.

Upon patient record review, 1 of 14 (Patient #3) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient #3: 1/30/26 prn visit related to cough, secretions. Keflex ordered. No update to problems, goals, interventions at that time related to respiratory/infection.

Upon client record review, 4 of 14 (Patient #1, 3, 4, 9) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1: Volunteer 2/month per initial and ongoing POC. No documented visits. Vol frequency remains the same 2/month and 1 /prn 4/1/26 IDG. Patient #3: 12/12/25 order for 16fr 8 cc balloon.... may change every 4 weeks and prn... and irrigate... 12/28/25 visit related to discomfort. Catheter changed. SN documented inserted 16 Fr 10 cc. No evidence order updated from 8 to 10 cc balloon at that time. Patient #4: 3/20/26 order to insert 16 Fr/5cc catheter.... may change every 4 weeks... No documented evidence catheter was inserted. GU consult suggests existing 18fr. No balloon size specified and no documentation of last change. Interview with staff confirm catheter was existing upon admission and not inserted 3/20/26. Patient #9: SC 1/month. No visit Jan 2026. No communication note of decline.

Upon record review, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient #3: Upon clinical record review, the SN documented on the 12/27/25 SN visit, patient c/o discomfort related to catheter. RN noted catheter dislodged, the RN advanced existing catheter and documented patient subsequently felt better. There was no specific documentation regarding procedure/technique of catheter advancement.

Upon patient record review, 2 of 14 (Patient #13, 14) 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 Patients #13, 14: There is no documented evidence of post death bereavement assessment and update. Subsequently, no update to plan of care/bereavement care plan. Bereavement services were provided in form of mailings, but no documented evidence individualized to meet the needs of bereaved.

Upon personnel record review, 1 of 15 (Personnel #8) did not have evidence in the personnel file that the following 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.) ·(A) Bed bath ·(B) Sponge, tub, and shower bath ·(C) Shampoo, sink, tub, and bed; Personnel #8: Upon personnel review, there is no documented evidence of competency for sponge, tub bath, only shower and bed bath. The shampoo is listed only as general and does not specify competency for all types of sink, tub and bed.

Upon patient record review, 5 of 14 (Patient #2, 3, 4, 6, 8) 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 #2: The 3/5/26 Hospice Aide assignment/care plan includes Oxygen flow rate prescribed, but does not include related safety precautions. Patient #3: Patient has Epilepsy diagnosis with no seizure precautions included in hospice aide care plan. Patient has Oxygen prescribed with no flow rate or related safety precautions include in hospice aide care plan.. Patient #4: Patient has oxygen 2 LPM continuously per order and per RN assessment. The 3/20/26 Hospice aide care plan includes flow rate as prn and no Oxygen related safety precautions. Patient has Foley catheter, but the hospice aide care plan has no reference to alert hospice aide and/or no reference to catheter care. Patient #6: Patient has Eliquis prescribed with no bleeding precautions included in the hospice aide care plan. Patient #8: Patient has Epilepsy diagnosis with Keppra prescribed with no seizure precautions in hospice aide care plan. Oxygen flow rates says 3lpm prn, but order is for continuous.

Upon observation, there was no evidence the annual report documents the use of volunteers providing day to day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract personnel. Upon observation of volunteer activity tracking, volunteer activity for most recent 12 month period was less than 5%.

Upon personnel record review, 2 of 15 (Personnel #4, 12) did not have evidence the hospice employees and contract employees have received orientation on the hospice philosophy. Personnel #4, 12: Upon personnel review, there was no documented evidence of orientation to hospice philosophy.

Upon patient client record review, 1 of 14 (Patient #3) 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 #3: 12/12/25 order for 16fr 8 cc balloon.... may change every 4 weeks and prn... and irrigate... 12/28/25 visit related to discomfort. Catheter changed. Documentation does not specify amount deflated from balloon when removed. On 2/18/26, 3/2/26, and 3/23/26, the SN visit note states catheter changed today related to discomfort. No specifics of procedure for removal or insertion of new catheter. Does not specify balloon deflation with removal and/or catheter/balloon size inserted to demonstrate compliance.

Upon client record review, 1 of 14 (Patient #11) did not have evidence that the discharge summary includes all required information. Patient #11: The discharge summary is not comprehensive in that it does not address current treatment orders and problems over hospice admission to assist in continuity. It does not address the stage 3 sacral wound.

Upon personnel record review, 3 of 15 (Personnel #13,14,15) did not have evidence the hospice obtained a criminal background check on all contracted individuals who have direct patient care and access to patient records. Personnel #13, 14, 15: Upon personnel review, there was no evidence of criminal background checks available prior to end of survey.

Upon patient record review, 1 of 14 (Patient #13) did not have evidence that the hospice informed and provided written information to the patient concerning its policies on advance directives, including a description of applicable state law. Patient 13: The medical record contained an election form signed by a patient representative states that the representative is the POA. There was no legal document in the medical record to show proof of authority.

Upon patient record review, 2 of 14 (Patients #2,#12) did not have evidence that if a state court has not adjudged a patient incompetent, any legal representative designated by the patient in accordance with state law may exercise the patient's rights to the extent allowed by state law. Patient 2: The medical record contained an election form and consents signed by the patient's ex-wife. There was no legal document in the medical record to show proof of authority and no evidence the patient was able to defer to this decision maker. Patient 12: The medical record contained an election form signed by a patient representative that is undefined to show any legal authority. There were no legal documents or explanation of authority per state delineation of authority documented in the medical record and no evidence the patient was able to defer to this decision maker.

Upon patient record review, 1 of 14 (Patient #12) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient 12: The medical record contained an election form with a blank section for the patient/representative to elect or decline choosing an attending physician.

Upon patient record review, 5 of 14 (Patients #2,#4,#9,#12,#14) 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. Patient 2: The medical record contained nursing documentation identifying patient allergy to Bactrim. There was no evidence of the allergy included on the medication profile. Patient 4: The medication profile contained duplicative listings of docusate and morphine. Patient 9: The medical record contained nursing documentation identifying patient use of oxygen. There was no evidence of the oxygen included on the medication profile. Patient 12: The medical record contained nursing documentation identifying patient use of oxygen. There was no evidence of the oxygen included on the medication profile. Patient 14: The medical record contained nursing documentation identifying patient use of oxygen. There was no evidence of the oxygen included on the medication profile.

Upon patient record review, 3 of 14 (Patients #1,#2,#11) did not have evidence in the patient record that the comprehensive assessment includes a bereavement 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 1: There was no evidence of a bereavement assessment completed. Patient 2: The initial bereavement assessment was completed 2/27/23. Patient admitted 2/21/23. Patient 11: The initial bereavement assessment was completed 1/12/23. Patient admitted 1/5/23.

Upon patient record review, 5 of 14 (Patients #6,#7,#10,#12,#13) 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 Patients 6,7,10,12,13: There was no evidence of IDG updates including response to care and progress toward goals documented in the medical charts. The agency stated documentation had been on paper during use of their old EMR and were unable to locate and provide the documentation during the survey.

Condition of Participation: Interdisciplinary Group, Care Planning, and Coordination of Services. L536

Upon patient record review, 9 of 14 (Patients #1,#2,#3,#4,#6,#9,#10,#12,#13) 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 medical record contained nursing documentation identifying patient issues with skin impairment, primary hospice diagnosis of malnutrition, and need for spiritual care services. There was no evidence of problems, goals, and interventions related to skin impairment, nutritional deficit, and spiritual care included in the plan of care. Corrected on site. Patient 2: The medical record contained an order for spiritual care visits once monthly. There was no evidence of problems, goals, and interventions related to spiritual care included in the plan of care. Corrected on site. Patient 3: The medical record contained an order for spiritual care and social work visits once monthly. There was no evidence of problems, goals, and interventions related to spiritual care and social work included in the plan of care. Corrected on site. Patient 4: The medical record contained documentation identifying patient receives spiritual care and is on services with primary diagnosis of respiratory failure. There was no evidence of problems, goals, and interventions related to respiratory dysfunction and spiritual care included in the plan of care. Corrected on site. Patient 6: The medical record contained nursing documentation 8/4/22 identifying patient issue with dyspnea. There was no evidence of problems, goals, and interventions related to respiratory dysfunction included in the plan of care. Patient 9: The medical record contained nursing documentation upon admission identifying patient issue with dyspnea. There was no evidence of problems, goals, and interventions related to respiratory dysfunction included in the plan of care. Patient 10: The medical record contained an order for spiritual care and social work visits once monthly. There was no evidence of problems, goals, and interventions related to spiritual care and social work included in the plan of care. Patient 12: The medical record contained nursing documentation upon admission identifying patient use of indwelling catheter and ostomy, and orders for spiritual care and social work frequencies. There was no evidence of problems, goals, and interventions related to genitourinary and gastrointestinal dysfunction, or spiritual care and social work included in the plan of care. Patient 13: The medical record contained nursing documentation upon admission identifying patient primary diagnosis of senile degeneration of the brain. There was no evidence of problems, goals, and interventions related to neurological dysfunction included in the plan of care.

Upon patient record review, 1 of 14 (Patients #7) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient 7: The medical record contained a frequency order for Social Work PRN only. There was no evidence of an order for frequency to anticipate needs.

Upon patient record review, 5 of 14 (Patients #1,#9,#12,#13,#14) 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: The order for thickener to fluids 4/11/23 did not include instructions for appropriate consistency. Corrected on site. Patient 9: The medical record contained nursing documentation upon admission identifying patient use of oxygen, catheter, tube feedings, and wounds. There was no evidence of orders for oxygen, catheter maintenance, tube feedings, and wound care. Patient 12: The medical record contained nursing documentation upon admission identifying patient use of a catheter and oxygen. There was no evidence of orders for catheter maintenance and oxygen. Patient 13: The medical record contained nursing documentation upon admission identifying patient use of an indwelling catheter. There was no evidence of an order for catheter maintenance. Patient 14: The medical record contained nursing documentation upon admission identifying patient use of oxygen. There was no evidence of an order for oxygen.

Upon patient record review, 6 of 14 (Patients #1,#2,#3,#4,#9,#12) 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: The medical record contained nursing documentation upon admission identifying patient use of a wheelchair. There was no evidence of the wheelchair included as DME in the plan of care. Corrected on site. Patient 2: The medical record contained nursing documentation identifying patient use of wheelchair, commode, and mechanical lift. There was no evidence of the wheelchair, commode, and lift included as DME in the plan of care. Corrected on site. Patient 3: The medical record contained nursing documentation 4/6/23 identifying patient use of shower chair and commode. There was no evidence of the chair and commode included as DME in the plan of care. Corrected on site. Patient 4: The medical record contained nursing documentation upon admission identifying patient use of a hospital bed, over the bed table, shower chair, and mechanical lift. There was no evidence of the bed, table, chair, and lift included as DME in the plan of care. Corrected on site. Patient 9: The medical record contained nursing documentation upon admission identifying patient use of a hospital bed, over the bed table, oxygen, tube feedings, and catheter supplies. There was no evidence of the bed, table, oxygen, tube feedings, and catheter DME and supplies included in the plan of care. Patient 12: The medical record contained nursing documentation upon admission identifying patient use of a catheter, ostomy supplies, shower bench, bed alarm, lift, commode, bed, table, nebulizer, oxygen, mattress, and wheelchair. There was no evidence of the catheter and ostomy supplies, bench, alarm, lift, commode, bed, table, nebulizer, oxygen concentrator, mattress, and wheelchair included as DME in the plan of care.

Upon client record review, 5 of 14 (Patients #6,#7,#10,#12,#13) did not have evidence that the IDG in collaboration with the attending physician reviewed, revised and documents the individualized plan as frequently as the patient's condition requires but no less frequently then every 15 calendar days. Patients 6,7,10,12,13: There was no evidence of IDG updates including plan of care updates documented in the medical charts. The agency stated documentation had been on paper during use of their old EMR and were unable to locate and provide the documentation during the survey.

Upon client record review, 4 of 14 (Patients #3,#7,#9,#12) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 3: The medical record contained ordered social work and spiritual care frequencies of once monthly. There was no evidence of March visits completed for either discipline. Patient 7: The medical record contained ordered spiritual care frequency of one to two times monthly. There was no evidence of a visit completed July 2022. Patient 9: There was no evidence of orders for discipline frequencies. Initial visits were completed by the social worker and chaplain, and regularly scheduled visits were completed by nursing. Patient 12: The medical record contained ordered nursing frequency of twice weekly. There was no evidence of second visits completed each week throughout the hospice stay.

Upon observation, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. During observation of the home visit, the LVN placed cleansed vital sign equipment to dry where previously dirty equipment was placed, allowing for contamination prior to putting away in clean area of bag.

Condition of Participation: Hospice Aide and Homemaker Services. L607

Upon patient record review, 4 of 14 (Patients #1,#2,#3,#4) 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. Patients 1,2,3,4: The aide care plan contained the task for the aide to obtain vital signs without parameters of when to report findings to the RN.

Upon patient record review 4 of 14 (Patients #2,#6,#7,#9) 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 2: The medical record contained an ordered aide frequency of once weekly. There was no evidence of a visit completed the week of 3/5/23. Patient 6: The medical record contained evidence of aide visits completed twice weekly. There was no evidence of an order for aide frequency. Patient 7: The medical record contained an ordered aide frequency 8/16/22 for visits once weekly. There was no evidence of aide visits completed from 8/16/22 through time of discharge. Patient 9: There was no evidence of orders for discipline frequencies. Regularly scheduled visits were completed by aide services.

Upon patient record review 1 of 14 (Patient #4) did not have evidence in the patient record that the hospice aides report: • Changes in the patient's medical, nursing, rehabilitative, and social needs to a registered nurse, as the changes relate to the plan of care and quality assessment and improvement activities • Hospice aides must also complete appropriate records in compliance with the hospice's policies and procedures Patient 4: The medical record contained aide documentation identifying patient had temperature of 101.8 on 4/5/23. There was no evidence of the change of condition reported to the RN.

Upon observation, there was no evidence the hospice documents and demonstrates viable and ongoing efforts to recruit and retain volunteers.

Upon observation, there was no evidence the hospice documented the cost savings achieved through the use of volunteers. Documentation must include the following: • The identification of each position that is occupied by a volunteer • The work time spent by volunteers occupying those positions • Estimates of the dollar costs that the hospice would have incurred if paid employees occupied the positions identified in paragraph (d)(1) of CFR 418.78 for the amount of time specified in paragraph (d)(2) of CFR 418.78

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: There was no evidence of a face to face completed for the 60 day benefit period starting 10/25/22, this information was not included in the review of information for the certification of terminal illness.

Upon patient client record review, 5 of 14 (Patients #2,#3,#4,#6,#12) did not have evidence that each patient record contains signed election statement in accordance with 418.24. Patient 2,3,4: The election form contained a section for the patient/representative to declare election or declination for receipt of Notice of Hospice Non-Covered Items. The section was empty and not completed upon admission. Patient 6: The election form identified the patient/representative elected to receive the Notice of Hospice Non-covered Items. There was no evidence the patient received the form. Patient 12: The election form contained a section for the patient/representative to declare election or declination for receipt of Notice of Hospice Non-Covered Items, a section to elect or decline an attending physician, and a section to define relationship of the patient representative. All mentioned sections were empty and not completed upon admission.

Upon client record review, 3 of 14 (Patients #11,#12,#13) did not have evidence that if a patient revokes the election of hospice care or is discharged from hospice in accordance with §418.26, the hospice must forward to the patient's attending physician: • A copy of the hospice discharge summary • The patient's clinical record, if requested Patients 11,12,13: There was no evidence of discharge summaries being forwarded to the patients' physicians following revocations.

Upon client record review, 8 of 14 (Patients #6,#7,#8,#9,#10,#12,#13,#14) did not have evidence that the discharge summary includes all required information. Patients 6,7,8,9,10,12,13,14: There was no evidence of discharge summaries included in the medical records. Agency confirmed this was not completed in their old EMR.

Upon observation, there was no evidence a copy is provided of the hospice written policies and procedures on the management and disposal of controlled drugs to the patient or patient representative and family.

Upon client record review, 14 of 14 (Patients #1,#2,#3,#4,#5,#6,#7,#8,#9,#10,#11,#12,#13,#14) did not have evidence that the written policies and procedures for managing controlled drugs was provided and discussed. Patients 1,2,3,4,5,6,7,8,9,10,11,12,13,14: There was no evidence in the patients' records that the written policies and procedures for managing controlled drugs was provided.