Every finding on record at Life to Life Hospice Care, Inc.

Upon patient record review, 1 of 5 (Patient #1) 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 - SOC 11/27/23 - as of 12/06/23 no initial bereavement completed.

Upon patient record review, 1 of 5 (Patient #4) 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 #4 - SOC 09/07/23 - SC visit frequency 1 x month - as of 11/27/23 no intervention or goals related to SC services.

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

Upon patient record review, 3 of 5 (Patient #3, #4, #5) 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, #4, #5 There is no evidence of any problems, goals or interventions listed for the patients in the medical record.

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 Use of wheelchair, walker and shower chair mentioned during RN comprehensive visit on 10/28/23 but there are no order and not in the plan of care. Patient #2 Use of bed, walker Shower chair mentioned during RN comprehensive visit on 10/25/23 however, there is no evidence of orders and these are not listed on plan of care. Patient #3 Use of walker, bed, shower chair and commode mentioned during RN comprehensive visit on 10/19/23 however, there is no evidence of orders and these are not listed on plan of care. Patient #4 Use of bed, walker, shower chair and commode mentioned during RN comprehensive visit on 10/29/23however, there is no evidence of orders and these are not listed on plan of care. Patient #5 Use of cane, bed, walker mentioned during RN comprehensive visit on 10/24/23however, there is no evidence of orders and these are not listed on plan of care.

Upon client record review, 5 of 5 (Patient #1, #2, #3, #4, & #5) 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 #1, #2, #3, #4 & #5. There is no evidence in the medical record of any IDG meeting since 10/13/23.

Upon client record review, 2 of 5 (Patient #3, #5) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #3 RN frequency ordered every 14 days but medical record showed that last updated RN visit was completed on 10/19/23. Patient #5 RN frequency ordered every 14 days but medical record showed that last updated RN visit was completed on 10/24/23.

Upon patient record review 1 of 5 (Patient #5) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs. #5 HHA visit was recorded for 10/18, 10/25, 11/1, 11/8. The RN comprehensive visit of 10/24 did not contain completed HHA supervisory, and no other RN comprehensive visit recorded with HHA supervisory at the time of survey of 11/10.

Upon patient record review, 1 of 14 (Patient #11) did not have evidence that the hospice obtained the patient's or representative's signature confirming that they received a copy of the Patient's Rights and Responsibilities. Patient #11: Patient Comprehensive Assessment / SOC dated 2/3/23. All patient admission forms/consents have signature dates of 1/3/23, for patient and for staff. Staff reports that admission took place on 2/3/23 and the signature dates are error.

Upon patient record review, 1 of 14 (Patient #11) did not have evidence that the patient chooses a health care provider, including an attending physician Patient #11: Patient Comprehensive Assessment / SOC dated 2/3/23. All patient admission forms/consents have signature dates of 1/3/23, for patient and for staff. Staff reports that admission took place on 2/3/23 and the signature dates are error.

Upon patient record review, 1 of 14 (Patient #11) did not have evidence of the appropriate documentation for release of confidential information. Patient #11: Patient Comprehensive Assessment / SOC dated 2/3/23. All patient admission forms/consents have signature dates of 1/3/23, for patient and for staff. Staff reports that admission took place on 2/3/23 and the signature dates are error.

Upon patient record review, 1 of 14 (Patient #11) did not have evidence that the patient received information about the services covered under the hospice benefit. Patient #11: Patient Comprehensive Assessment / SOC dated 2/3/23. All patient admission forms/consents have signature dates of 1/3/23, for patient and for staff. Staff reports that admission took place on 2/3/23 and the signature dates are error.

Upon patient record review, 1 of 14 (Patient #11) did not have evidence that the patient received information about the scope of services that the hospice will provide and specific limitations on those services. Patient #11: Patient Comprehensive Assessment / SOC dated 2/3/23. All patient admission forms/consents have signature dates of 1/3/23, for patient and for staff. Staff reports that admission took place on 2/3/23 and the signature dates are error.

Upon patient record review, 1 of 14 (Patient #2) 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 #2: Initial comprehensive assessment states that Oxygen is in use and 2-5 l/min via NC, but not on Rx profile.

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

Upon patient record review, 6 of 14 (Patient #1, 2, 3, 4, 5, 6) 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, 3, 4, 5,6: The initial plan of care contains no problems, goals, interventions and no updates. Patient #2: The initial plan of care contains problems, but no related goals or interventions. Comprehensive assessment notes that patient is on Oxygen 2-5l NC prn. There is no related PGI.

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: Initial comprehensive assessment states that Oxygen is in use and 2-5 l/min via NC, but there is no physician order

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 equipment and supply needs. Patient #2: Initial comprehensive assessment states that Oxygen is in use and 2-5 l/min via NC, but there is no physician order for related equipment.

Upon client record review, 6 of 14 (Patient #1, 2, 3, 4, 5, 6) 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 #1, 2, 3, 4, 5, 6: No documented IDG for 9/1 and 9/15/23.

Upon patient record review, 1 of 14 (Patient #2) 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 #2: Comprehensive assessment notes that patient is on Oxygen 2-5l NC prn. There is no related PGI. There is no update to include in subsequent plans of care reviews, although patient continued to utilize Oxygen as documented in 9/12/23 SN visit note.

Upon client record review, 6 of 14 (Patient #1, 2, 3, 4, 5, 6) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1: Admitted 7/10/23 with LVN frequency of 1/wk and 1 PRN. There are no LVN visits documented for July or September. LVN visits documented for August 3, 8, 18 only. RN freq 1 RN every 14 days for SV visit and assessments. RN visits July 10, 18, 26; Aug 9, 23; Sept 6, 2023. There is no RN visit 8/27-9/2/23. Initial SC frequency of 1x within 5 days. SC ordered 1 visit within 5 days. SC visits made 7/11 and 8/8/23. Patient #2: Adm 7/17/23. LVN frequency of 1/wk and 1 PRN. LVN visits Aug 5, 12, 19, 26. There are no July or Sept LVN visits. RN freq 1 RN every 14 days for SV visit and assessments. There is no RN visit week of July 23-29th or Sept 3-9th. SC ordered 1 visit within 5 days. The SC saw patient 7/18 and 8/15/23. The RN initial comprehensive assessment documents patient on Oxygen 2-5 liters NC prn. 9/12/23 Note RN includes that patient using Oxygen still. References that patient has concentrator. There is no order for Oxygen or concentrator included in POC. Patient #3: Adm 7/24/23 LVN frequency of 1/wk and 1 PRN. LVN visits Aug 13, 27. RN freq 1 RN every 14 days for SV visit and assessments. RN visits July 24; Aug 8, 22; Sept 5, 19. No RN visit 7/31-8/5/23 or 9/10-9/16/23. SC frequency to visit within 5 days. SC visited patient 7/18 and 8/15/23. Patient #4: Adm 7/26/23 LVN frequency of 1/wk and 1 PRN. LVN visits Aug 16, 30. RN frequency 1 RN every 14 days for SV visit and assessments RN visits July 26; Aug 9, 23; Sept 6. No RN visit week of 7/30-8/5/23. Patient #5: Adm 8/4/23. LVN frequency of 1/wk and 1 PRN. LVN Aug 6, 21; RN frequency 1 RN every 14 days for SV visit and assessments RN visits Aug 14, 18, 25; Sept 8, 18. LVN did not see patient weekly. RN saw patient more than q14 days. There was no RN visit week of 8/27-9/2/23. Patient #6: Adm 8/16/23. LVN frequency of 1/wk and 1 PRN. LVN Aug 21 and Sept 4. RN 1 RN every 14 days for SV visit and assessments RN Aug 16, 29 and Sept 12. LVN did not see patient weekly.

Condition of Participation: Hospice Aide and Homemaker Services. L607

Upon personnel record review, 1 of 12 (Personnel #5) 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.) ·Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff. ·Reading and recording temperature, pulse, and respiration ·Safe transfer techniques and ambulation. ·Normal range of motion and positioning ·Appropriate and safe techniques in personal hygiene and grooming that include-- ·(A) Bed bath ·(B) Sponge, tub, and shower bath ·(C) Shampoo, sink, tub, and bed ·(D) Nail and skin care ·(E) Oral hygiene ·(F) Toileting and elimination The other subject areas in this section may be evaluated through written examination, oral examination or after observation of a Hospice Aide with a patient. Personnel #5: The Aide competency form utilized by the agency, lists the above skills (A-F) with * as required skills. The skills are blank with no indication that they were demonstrated for competency. This is the only Aide on staff.

Upon patient record review, 1 of 14 (Patient #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 #10: SOC 8/28/23. The IDG POC includes frequency of Aide 1 per 2 wk. There is no documented Aide Care Plan Assignment completed by RN.

Upon patient record review 2 of 14 (Patient #10, 12) 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 • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #10: SOC 8/28/23. The IDG POC includes frequency of Aide 1 per 2 wk. There are no visit notes to reflect Aide services provided. Patient #12: SOC 2/7/23. Aide Assignment and orders Aide 2 per week. Only 3/8 and 3/26/23 visits documented.

Upon patient client record review, 8 of 14 (Patient #3, 5, 6, 7, 8, 10, 11, 12) 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: Name of hospice agency and effective date are left blank. Patient #5 Name of hospice agency is left blank. Patient #6: Effective date is blank on election. Patient #7: Effective date is blank on election. Patient #8: Name of hospice agency is left blank. Patient #10: Name of hospice agency is left blank. Patient #11: Effective date is blank. (Signed 1/3/23 with SOC date of 2/3/23). Checked acknowledgment that chose physician, but physician name is blank. Patient #12: Effective date is blank.

Upon patient client record review, 2 of 14 (Patient #11, 12) did not evidence that each patient record contains physician orders. Patients# 11, 12: Patients identified as live discharges on patient discharge list. There is no discharge order for either record.

Upon patient client record review, 5 of 14 (Patient #3, 4, 5, 6, 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. Patients #3, 4, 5, 6: There are IDG Meeting notes included in EMR that are dated prior to SOC. Patient #3 SOC 7/24/23, includes 7/21/23 IDG meeting note. Patient #4 SOC 7/26/23 includes 7/21/23 IDG meeting note. Patient #5 SOC 8/4/23 includes 7/21/23 IDG meeting note. Patient #6 SOC 8/16/23 includes meeting note 7/21/23 and 8/4/23. Patient #14: Patient admitted 1/23/23. Died 1/29/23. There are no actual visit notes after SOC. Discharge summary includes documentation that "SN orderly assisted family with medication disposal consistent with Bliss Hospice policy." The note/summary is not signed/authenticated with signature. No evidence who made entry.

Upon client record review, 2 of 14 (Patient #11, 12) 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 Patient #11, 12: Patients identified as live discharges on patient roster. However, there is no evidence of discharge summary. There is no evidence of discharge planning and therefore, no evidence that the summary was provided to physician.

Upon client record review, 1 of 14 (Patient #11) did not have evidence that the written policies and procedures for managing controlled drugs was provided and discussed. Patient #11: Patient Comprehensive Assessment / SOC dated 2/3/23. All patient admission forms/consents have signature dates of 1/3/23, for patient and for staff. Staff reports that admission took place on 2/3/23 and the signature dates are error.