Every finding on record at Life Touch Hospice

Upon patient record review 1 of 5 (Patient #4) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient 4: The spiritual assessment done by the RN in the medical record was incomplete and the only information given was that the patient did not have concerns and declined spiritual care.

Upon patient record review, 1 of 5 (Patient #3) 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 Patient 3: The medical record contained RN visits 5/5/25 and 5/22/25 exceeding a comprehensive assessment completed within 15 days.

Upon patient record review, 3 of 5 (Patients #2,#3,#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 2: The medical record contained nursing documentation upon admission identifying patient use of a shower chair. There was no order for the shower chair included in the plan of care. Corrected on site. Patient 3: The medical record contained nursing documentation upon admission identifying patient use of a walker and shower chair. There was no evidence of orders for the DME included in the plan of care. The plan of care contained orders for a nebulizer, wheelchair, hospital bed, commode, APP mattress, and suction machine without evidence of patient use. Agency confirmed these orders were in error. Corrected on site. Patient 5: The medical record contained nursing documentation upon admission identifying patient use of a cane and walker. There was no evidence of orders for the DME included in the plan of care. Corrected on site.

Upon client record review, 1 of 5 (Patient #4) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 4: The medical record contained an order for nursing visits twice monthly. There were scheduled nursing visits completed 5/5/25, 5/17/25, and 5/28/25.

Upon patient record review 1 of 5 (Patient #2) 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 one visit weekly. There were two aide visits completed the weeks of 5/18/25 and 5/25/25.

Condition of Participation: Initial and Comprehensive Assessment of the Patient.

Upon patient record review 0 of 5 contained evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Unable to abate due to no newly admitted patients since last survey.

Upon patient record review 0 of 5 contained evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Unable to abate due to no newly admitted patients since last survey.

Upon patient record review, 0 of 5 contained 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. Unable to abate due to no newly admitted patients since last survey.

Upon patient record review, 5 of 5 (Patient #1, 2, 3, 4, 5) 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 Patient #1: Visits made 3/23(LVN), 4/6 (LVN), 4/11 (RN), exceeding 15 days 3/23-4/11/25. Patient #2: RN visits documented 3/7/25, 3/17/25 and 4/4/25. There are no other nursing visits documented. 18 days between 3/17 and 4/4/25. Patient #3: RN visits 3/13 (only visit documented in March), 4/4 and 4/8 only, exceeding 15 days. Patient #4: No documented RN visits since 3/25/25, exceeding 15 days. . Patient #5: No documented RN visits since 3/26/25, exceeding 15 days.

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

Upon patient record review, 1 of 5 (Patient #3) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient #3: 4/4/25 SN visit patient c/o diarrhea x 2 weeks. Self medicated with Imodium. RN educated regarding dehydration and prevention and recommended 85 year old patient follow up with her primary MD. The patient had requested medical director as attending. Updated MD: yes per RN visit note, without details. 4/8/25 RN visit note does not reference follow up for symptoms.

Upon patient record review, 0 of 5 contained 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. Unable to abate due to no newly admitted patients since last survey.

Upon patient record review, 4 of 5 (Patient #1, 2, 3, 5) 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 #1: IDG Plan of Care frequency SC 1 as needed and recert. Patient #2 IDG POC frequency MSW one time then prn eval and recertification. Patient #3: IDG POC 3/6, 4/29: MSW 1x and then prn. LVN as needed. MD as needed and recert. Patient #5: IDG POC MD as needed and recert. MSW as needed and recert. SC as needed and recert.

Upon patient record review, 2 of 5 (Patient #2,5) 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 #2, 5: Order for Oxygen, but not included in DME/supplies for current POC

Upon patient record review, 1 of 5 (Patient #4) 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 #4: 3/25/25 visit patient complained of symptoms cough, cold, body aches. Received order for ZPAK and Tylenol. No updates to problems, goals and interventions.

Condition of Participation: Hospice Aide and Homemaker Services.

Upon patient record review, 3 of 5 (Patient #2, 3, 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 2- Patient has order for Oxygen and also history of seizures (as recently as January 25 per 3/25/25 IDG). Oxygen and seizure precautions are not specified most recent Hospice Aide assignment. 3, 5: Patient has order for Oxygen. No Oxygen / precautions on Hospice Aide assignment

Upon patient record review 3 of 5 (Patient #2, 3, 5) 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 #2: Hospice Aide frequency ordered and assigned is 2/week. Visits documented are 3/26, 3/31/25 and nothing more. Aide visit 3/31/25 she made narrative note that she changed patient linens and did light housekeeping and provided companionship. Changing linens is not assigned by RN. No evidence of communication to RN documented. Patient #3: Hospice Aide frequency is 2/week 4/11/25 assignment sheet. Visits documented are 3/ 27, 3/31 and no others. Patient #5: Hospice Aide frequency is 2x/wk. Last note is 3/31/25

Upon patient record review 3 of 5 (Patient #1, 2, 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. Patient #1: Visits made 3/23(LVN), 4/6 (LVN), 4/11 (RN), exceeding 15 days 3/23-4/11/25. Patient #2: There are no SV visits noted between 3/17 and 4/4/25. 18 days. Patient #5: Last documented SV note is 3/26/25, 20 days at time of survey.

Upon patient record review, 0 of 5 contained 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 Unable to abate due to no newly admitted patients since last survey.

Upon patient client record review, 3 of 5 (Patient #1, 4, 5) 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: 4/6/25 LVN note is incomplete with care provided section and visit checklist section totally blank. There is no narrative and there is no clinical signature/credential. Patient #4: IDG 3/26/25 RN notation states SN will continue to visit 1xweek and prn, but frequency IDG POC is RN 2 per month and 2 prn. CTI signed (and typed/electronic signature) Jose Velasquez, MD and Jose Fernando Velasquez, MD. Administrator reports they are the same person. Patient #5: 3/26/25 SN note is incomplete including no narrative and not authenticated with signature/credentials.

Upon patient record review, 1 of 15 (Patient #10) 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 10: Notice of election includes choices to indicate whether or not patient has advance directives. No choices made.

Upon patient record review, 5 of 15 (Patient #3,6,7,9,10) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient 3: There are multiple choices for attending physician. All choices are indicated. No attending physician information is documented. Patient 6,7,9,10: Attending physician was chosen (indicated that patient wanted an attending physician). No attending physician information was included on notice of election.

Upon patient record review, 1 of 15 (Patient #9) did not have evidence of the appropriate documentation for release of confidential information. Patient 9: Authorization/disclosure of health information form is blank except patient signature. Patient 10: Notice of election includes choices to indicate how they will allow private health information to be shared. No choices are made. Patient 11: Notice of election includes choices to indicate how they will allow private health information to be shared. No choices are made. Authorization/disclosure of health information form is not signed by patient. There is no documentation of relationship of signer.

Condition of Participation: Initial and Comprehensive Assessment of the Patient.

Upon patient record review 6 of 15 (Patient #1,2,3,8,12,13) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient 1: Patient admitted 1/27/25. Initial psychosocial assessment documented 2/6/25. Patient 2: Patient admitted 12/4/24. Initial psychosocial assessment documented 12/11/24. Initial spiritual assessment documented 2/3/25. Patient 3: Patient admitted 7/10/24. Initial psychosocial assessment documented 8/1/24. Patient 8: Patient admitted 10/24/24. Initial spiritual assessment documented 11/1/24. Patient 12: Patient admitted 4/20/24. Initial psychosocial assessment documented 4/27/24. Initial spiritual assessment documented 4/28/24. Patient 13: Patient admitted 9/9/24. Initial spiritual assessment documented 9/18/24.

Upon patient record review 7 of 15 (Patient #4,6,7,10,11,13,15) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient 4,11,15: There is no evidence of an initial psychosocial or spiritual assessment. Patient 6,7,10: There is no evidence of an initial spiritual assessment. Patient 13: There is no evidence of an initial psychosocial assessment.

Upon patient record review, 10 of 15 (Patient #1,2,3,5,6,7,8,9,10,11) 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: Medication list with order: metronidazole 0.75% topical. 1 topical daily for skin infection. There is no evidence of application site in the medication list. COS Medication list with no evidence of oxygen on medication profile, as this order appears only as DME on the plan of care. During home visit for this patient, there were 4 medications on the medication list that the patient is no longer taking, Iron, myrbetiq, mirtazipine, cream . Additionally, the patient and caregiver reported 5 medications that they are taking that are not on the medication list, Icy Hot rub, SalonPas patch, ibuprofen, vitamin D, calcium, preservision vitamins. They also reported taking a daily nutritional supplement. The RN was not observed to update the medication list during the home visit. Patient 2: Medication list : ipratropium bromide BP. 1 box 1 dose every 4 hours as needed for SOB/wheeze/COPD. There is no evidence of medication dose. Administration route for this medication is documented as unknown. COS Medication list with no evidence of oxygen, as this order appears only as a treatment on the plan of care. Patient 3: Medication list with no evidence of order for oxygen, as this order appears only as DME on the plan of care. Patient 5: Medication list with 4 orders that contain acetaminophen. There is no evidence of max dose warning in the medication list. COS Patient 6,7,8: Medication list with no evidence of oxygen, as this order appears only as a treatment on the plan of care. Patient 9: Medication list with no evidence of oxygen, as this order appears only as DME on the plan of care. Patient 10: Medication list with order: Bacitracin 2% 1 cream topical three times daily for 10 days. Order originated 9/10/24 and is still active. There is no evidence of application site. COS Medication list with no evidence of oxygen, as this order appears only as a treatment on the plan of care. Patient 11: Medication list with no evidence of oxygen, as this order appears only as a treatment on the plan of care. This order also appears as an “other” order.

Upon patient record review, 14 of 15 (Patient #1,2,3,4,5,6,7,8,9,10,11,12,13,15) 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: Patient admitted 1/27/25. Initial bereavement assessment documented 2/6/25. Patient 2: Patient admitted 12/4/24. Initial bereavement assessment documented 1/21/25 Patient 3: Patient admitted 7/10/24. Initial bereavement assessment documented 1/27/25 Patient 4,11,13,15: There is no evidence of an initial bereavement assessment in the medical record. Patient 5: Patient admitted 12/12/24. Initial bereavement assessment documented 2/6/25. Patient 6: Patient admitted 10/25/24. Initial bereavement assessment documented 1/21/25. Patient 7: Patient admitted 10/25/24. Initial bereavement assessment documented 1/21/25. Patient 8: Patient admitted 10/24/24. Initial bereavement assessment documented 1/22/25. This visit is documented as an unscheduled (PRN) visit. Patient 9: Patient admitted 9/14/24. Initial bereavement assessment documented 1/22/25. Patient 10: Patient admitted 9/10/24. Initial bereavement assessment documented 1/27/25. Patient 12: Patient admitted 4/20/24. Initial bereavement assessment documented 4/26/24.

Upon patient record review, 7 of 15 (Patient #2,4,5,7,8,9,10) 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 Patient 2: Documented RN visits: 12/4/24 (admission), 12/23, 1/6, 1/16, 1/23, 2/6, 2/20. 12/4-12/23 is 19 days Patient 4: Only Documented RN visit is 1/25/25 (admission). Patient 5: Documented RN visits: 12/12/24 (admission), 1/30, 2/17, 2/20, 2/27. 12/12 to 1/30 is 50 days. 1/30 to 2/17 is 18 days. Patient 7: Documented RN visits: 10/25/24 (admission), 10/30, 11/12, 12/15, 1/9, 1/22, 2/20, 2/21. 11/12 to 12/15 is 33 days. 12/15 to 1/9 is 25 days. 1/22 to 2/20 is 29 days. Patient 8: There is no evidence of documented RN visit since 2/15/25. Patient 9: Documented RN visits: 9/14/24 (admission), 9/20, 9/24, 10/8, 11/6, 11/30, 12/11, ¼, 1/10, 1/31, 2/4, 2/8. Unscheduled (PRN) visits documented: 11/16, 1/18, 2/22. 10/8 to 11/6 is 29 days. 11/6 to 11/30 is 24 days. 12/11 to 1/4/25 is 24 days. 1/10 to 1/31 is 21 days. Patient 10: Documented RN visits: 9/10/24 (admission), 9/20, 9/24, 10/2, 10/8, 10/15, 10/21, 11/6, 11/12, 12/15, 1/5, 1/15, 1/24, 2/5, 2/26. 10/21 to 11/6 is 16 days. 11/12 to 12/15 is 33 days. 12/15 to 1/5 is 21 days. 2/5 to 2/26 is 21 days.

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

Upon observation, there was no evidence the hospice has an interdisciplinary group (IDG) or groups composed of individuals who work together to meet the physical, medical, psychosocial, emotional, and spiritual needs of the hospice patients and families facing terminal illness and bereavement. Interdisciplinary group members must provide the care and services offered by the hospice, and the group, in its entirety, must supervise the care and services. Patient 1: IDG dated 2/12/25 and 2/26/25 has no evidence of MD signature. Patient 3: IDG dated 2/12,2/26: There is no evidence MD note or signature. Patient 4: IDG dated 2/12/25: No evidence of MD signature. 2/26 IDG: No MSW participation.

Upon patient record review, 5 of 15 (Patient #1,2,3,4,9) 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. All COS: Patient 1: There is no evidence of problems, goals, interventions for dyspnea, oxygen in the plan of care. Patient 2: There is no evidence of problems, goals, interventions for confusion, enteral feedings, NPO with pleasure food and drink per family request, dyspnea, oxygen in the plan of care. Patient has 12/4/24 order: crush meds and mix with applesauce which is incorrect as patient is NPO. Patient 3: There is no evidence of problems, goals, interventions for edema, oxygen in the plan of care. Patient 4: There is no evidence of problems, goals, interventions for dyspnea, seizure, anxiety, confusion in the plan of care. Patient 9: There is no evidence of problems, goals, interventions for pain in the plan of care.

Upon patient record review, 10 of 15 (Patient #1,2,3,5,6,10,11,12,14,15) 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. corrected on site Patient 1: Physician’s visit frequency order for MSW: initial, then PRN. There is no evidence of physician’s order for scheduled visits or quantifier for PRN visits in the plan of care. Physician’s visit frequency order for SC: recert, PRN. There is no evidence of quantifiers for this order in the plan of care. : Physician’s visit frequency order for LVN: PRN. There is no evidence of physician’s order for scheduled visits or quantifier for PRN visits in the plan of care. Patient 2: Physician’s SC and volunteer visit frequency order is PRN. There is no evidence of physician’s order for scheduled visits or quantifier for PRN visits in the plan of care. corrected on site Patient 3: Physician’s visit frequency order for MSW and for SC: initial, then PRN. There is no evidence of physician’s order for scheduled visits or quantifier for PRN visits in the plan of care. corrected on site Patient 5,6,15: Physician’s visit frequency order for MSW: initial, then PRN. There is no evidence of physician’s order for scheduled visits or quantifier for PRN visits in the plan of care. corrected on site for 5 and 6 only Patient 10: Physician’s visit frequency order for volunteer: twice a month as needed. There is no evidence of physician’s order for scheduled visits in the plan of care. Patient 11: Physician’s visit frequency order for MSW and for SC: initial, then PRN. There is no evidence of physician’s order for scheduled visits or quantifier for PRN visits in the plan of care. Patient 12: Physician’s visit frequency order for aide: twice weekly and 1-2 PRN. Patient 14: Physician’s visit frequency order for SC: initial, then PRN. There is no evidence of physician’s order for scheduled visits or quantifier for PRN visits in the plan of care.

Upon patient record review, 10 of 15 (Patient #1,2,3,5,6,7,8,9,10,11) 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: Plan of care with order: metronidazole 0.75% topical. 1 topical daily for skin infection. There is no evidence of medication dosage or application site in the plan of care. COS Plan of care with no evidence of order for oxygen, as this order appears only as DME on the plan of care. Patient 2: Plan of care with order: ipratropium bromide BP. 1 box 1 dose every 4 hours as needed for SOB/wheeze/COPD. There is no evidence of medication dose. Administration route for this medication is documented as unknown. COS Plan of care with no evidence of order for oxygen, as this order appears only as a treatment on the plan of care. Patient 3: Plan of care with no evidence of order for oxygen, as this order appears only as DME on the plan of care. Patient 5: Plan of care with 4 orders that contain acetaminophen. There is no evidence of max dose warning in the plan of care. COS Patient 6,7,8: Plan of care with no evidence of order for oxygen, as this order appears only as a treatment on the plan of care. Patient 9: Plan of care with no evidence of order for oxygen, as this order appears only as DME on the plan of care. Patient 10: Plan of care with order: Bacitracin 2% 1 cream topical three times daily for 10 days. Order originated 9/10/24 and is still active. There is no evidence of application site, or amount of application for each dose. COS Plan of care with no evidence of order for oxygen, as this order appears only as a treatment on the plan of care. Patient 11: Plan of care with no evidence of order for oxygen, as this order appears only as a treatment on the plan of care. This order also appears as an “other” order.

Upon patient record review, 2 of 15 (Patient #3,5) 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 3: No evidence of DME on plan of care: cane, walker, bed, overbed table, nebulizer, oxygen. Patient 5: No evidence of DME on plan of care: wheelchair, overbed table, nebulizer, oxygen, walker.

Upon client record review, 3 of 15 (Patient #1,2,3) 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. Patient 1: IDG dated 1/31/25, 2/12, and 2/26 has no evidence of SC signature or update to plan of care although actively involved visiting patient. Patient 2: IDG dated 12/5/24, 12/18,12/31,1/15,1/29 has no evidence of SC note or signature or update to plan of care although actively involved visiting patient.. Patient 3: IDG dated 2/12,2/26: There is no evidence of SC signature or update to plan of care although actively involved visiting patient.

Upon patient record review, 1 of 15 (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: IDG dated 11/6, 11/20, 12/4,12/18,12/31,1/15,1/29: SC note states: “pt would like to continue SC services.” There is no evidence of update to the SC plan of care

Upon client record review, 10 of 15 (Patient #1,2,3,4,5,6,7,8,9,10) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 1: Physician’s order for RN visits is twice monthly for supervisory visits. Documented RN visits outside of this order: 1/27/25 (admission), 2/7 (with supervision), 2/20, 2/24. No PRN documented. Physician’s order for LVN visits is PRN. Documented scheduled LVN visits: 2/1, 2/26 with no evidence these were PRN. Patient 2: Physician’s order for RN visits is twice monthly for supervisory visits. Physician’s order for LVN 4 times weekly and 2 PRN. There are also 2 orders for SN visits: twice monthly and 2PRN as well as 4 times monthly. All orders written 12/4/24. Documented RN visits: 12/4/24 (admission), 12/23/24, 1/6, 1/16, 1/23, 2/6, 2/20/25. Documented LVN visits: 12/4, 1/ 2, 2/28. LVN also made PRN visits: 12/5 and 1/31. During home visit for this patient, family reported that they are giving patient PO tea for comfort/ pleasure as per MD order. Surveyor observed RN providing education to family member that this cannot occur, as patient is to be NPO due to enteral feedings. Patient 3: Physician’s order for MSW visits is X1 for initial visit, then PRN. MSW visits documented outside of this order are recertification: 9/26, 12/23. Routine: 8/6, 9/4, 10/3, 1/7, 2/13. for SC visits is X1 for initial visit, then PRN. SC visits documented outside of this order are Recertification: 7/15/24, 8/7. Routine: 8/7, 9/3, 10/2, 11/7, 12/3/24, 1/ 4/25, 2/5. Patient 4: Physician’s order for SN visits is twice monthly and 2 PRN. Documented SN visits: 1/25 (admission) RN visit and 2/20/25 LVN visit. Patient 5: Physician’s order for RN visits is twice monthly and 2 PRN. Documented RN visits outside this order: No second December 2024 RN visit; 1/30, 2/17, 2/20, 2/27/25 No PRN documented. Physician’s order for MSW visits is X1 for initial visit, then PRN. Documented MSW visits outside of this order: 1/13, 2/12/25. Patient 6: Physician’s order for RN visits is twice monthly and 2 PRN, Documented RN visits outside this order: 1/9/25, 1/12, 1/22, 1/30, 2/27 no PRN documented. Physician’s order for MSW visits is X1 for initial visit, then PRN. Documented MSW visits outside this order: 11/26, 1/17/25, 1/23, 2/12. Patient 7: Physician’s order for SN visits is 1 every 2 weeks and 1 PRN. Documented SN visits outside this order: 11/12, 12/15. Physician’s order for MSW visits is once monthly and 1 PRN, written on admission (10/25/24). Documented MSW visits outside this order: 11/26/24, 1/17/25, 1/23/25. Patient 8: Physician’s order for SN visits is twice monthly and 2 PRN. Documented SN visits outside this order: No visit 10/25 - 12/1. Visit made 12/1, 12/11, 12/20, 12/26, 1/4/25, 1/9, 1/18, 1/24. Physician’s order for MSW visits is once monthly, on recertification, and 1 PRN. Most recent documented MSW visit 1/5/25. Patient 9: Physician’s order for SN visits is twice monthly and 1 PRN. Documented scheduled SN visits outside this order: 10/8, 12/11/24 (one visit in each of these months), 1/4/25, 1/10, 1/31. Physician’s order for MSW visits is once monthly, on recertification, and 1 PRN. No documented December MSW visit. Most recent documented MSW visit 1/5/25. Documented SC visits: 10/7/24, 11/1 (PRN), 12/1, 2/4/25. There is no evidence of physician’s visit frequency orders for SC in the medical record. Patient 10: Physician’s order for MSW visits is once monthly, on recertification, and 1 PRN. Documented MSW visits outside this order: 9/12/24, 9/18, 11/20, 11/26/24, 1/5/25, 1/9. Physician’s order for SN visits is once weekly and 2 PRN. Documented scheduled SN visits outside this order: 10/21 – 11/6/24; 11/12 -12/15/24; 12/15/24 – 1/5/25; 1/24 – 2/5; 2/5 – 2/26. 2/26/25 is the most recent documented SN visit.

Condition of Participation: Hospice Aide and Homemaker Services.

Upon patient record review, 7 of 15 (Patient #1,2,3,4,8,9,10) 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 1: Aide care plan tasks were assigned in paragraph form. RN assigned aide to “provide bath per patient need.” The aide was instructed to ensure patient wearing brace as prescribed, without further instruction such as site, on/off instructions, what signs/symptoms to report. Vital signs were to be taken, but there were no parameters given. No task was given a frequency and there was no specificity to any of the tasks that were assigned. One of the tasks was to assess patient’s skin. Patient 2: Aide care plan tasks were assigned in paragraph form. RN assigned aide to “provide bath per patient need.” Vital signs were to be taken, but there were no parameters given. No task was given a frequency and there was no specificity to any of the tasks that were assigned. One of the tasks was to assess patient’s skin. During home visit, RN told caregiver to ask aide to clip patient’s nails during next bath. Offered education that this will assist in less skin breakdown. Patient 3: No frequencies for tasks: change patient’s linen, record bowel movement, feed assist. Oxygen was noted in aide plan of care, but no flow rate was documented. Check vital signs (no frequency) task was assigned to aide. No parameters were given to aide in their plan of care. The instruction: “report abnormal vital signs” was given instead. Patient 4: Aide care plan tasks were assigned in paragraph form. RN assigned aide to “provide bath per patient need" and no note that patient is cognitively able to make decisions. No task was given a frequency and there was no specificity to any of the tasks that were assigned. One of the tasks was to assess patient’s skin. Patient 8: No frequency for task: change patient’s linen. Patient 9: No frequency for tasks: change patient’s linen, street clothes, dentures. Patient 10: No frequency for tasks: change linen. Check vital signs was assigned without frequency or parameters. Medication management was assigned without frequency or parameters as well. Information from administrator when asked: aides are not to check vital signs, assist with any medication tasks, clip any nails.

Upon patient record review 9 of 15 (Patient #1,2,3,4,7,8,9,10,11) 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. Patient 1: Physician’s order for aide visits is weekly. Aide supervisory visit documented 2/7 only. Patient 2: Physician’s order for aide visits is twice weekly. Aide supervisory visit documented 2/7 only. Patient 3: Physician’s order for aide visits is twice weekly. No evidence of aide supervisory visit documented 8/7/24 – 9/21; 9/21 – 10/10; 10/30 – 1/2/25; 1/ 2 – 2/7; 2/7 – 3/1. Patient 4: Physician’s order for aide visits is twice weekly. No evidence of aide supervisory visit documented in the medical record. Patient 7: Physician’s order for aide visits is twice weekly. No evidence of aide supervisory visit documented 10/25/24 – 11/12; 11/12 – 12/12; 12/27 – 1/22/25; 1/22 – 2/21. Patient 8: Physician’s order for aide visits is twice weekly. No evidence of aide supervisory visit documented 12/1/24 – 12/20; 1/18 – 2/15. 2/15 is the most recent documented aide supervisory visit. Patient 9: Physician’s order for aide visits is twice weekly. No evidence of aide supervisory visit documented 11/6/24 – 11/30; 12/11 – 1/4/25; 1/10 – 1/31. 2/8/25 is the most recent documented aide supervisory visit. Patient 10: Physician’s order for aide visits is weekly. No evidence of aide supervisory visit documented 10/21/24 – 11/6; 11/12 – 12/15; 12/15 – 1/5/25; 1/5 – 2/26. Patient 11: Physician’s order for aide visits is weekly. No evidence of aide supervisory visit documented after 12/5/24.

Condition of Participation: Medical Director.

Upon patient record review, 1 of 15 (Patient #11) 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 11: Initial CTI, dated 9/9/24, is not signed by the physician. There is no documentation of verbal order.

Upon patient record review, 3 of 15 (Patient #3,5,11) 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 3: CTI 6, dated 2/3/25, has no MD narrative, MD signature, and there is no documentation of verbal order. Patient 5: CTI 5, dated 2/10, is completely blank, has no MD signature, and there is no documentation of a verbal order. Patient 11: CTI 2, dated 11/6/24, is not signed, and there is no documentation of a verbal order.

Upon patient client record review, 9 of 15 (Patient #1,2,3,4,6,7,9,10,11) 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: Election for addendum for items, services, drugs not dated. No date of hospice election documented. Notice of election is not signed by patient; there is no documentation of relationship of signer. Patient 2: Notice of election is not signed by patient; there is no documentation of relationship of signer. Patient 3: Election for addendum for items, services, drugs: both choices (yes and no) are initialed and neither dated. Patient 4: Notice of election is blank except for signature of patient; election of addendum. At the election for addendum, both choices are initialed. Patient 6,7: Election for addendum for items, services, drugs: both choices (yes and no) are initialed and neither dated. No date of hospice election documented. Patient 9: Election for addendum for items, services, drugs: both choices (yes and no) are initialed. No date of hospice election documented. Notice of election is not signed by hospice staff. Patient 10: Election for addendum for items, services, drugs: both choices (yes and no) are initialed. No date of hospice election documented. Notice of election is not signed by hospice staff. Patient 11: Notice of election includes choices to indicate how they will allow private health information to be shared. No choices are made. No date of hospice election documented. Notice of election is not signed by patient; there is no documentation of relationship of signer.

Upon patient client record review, 6 of 15 (Patient #5,6,7,8,9,11) 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 5: LVN supervisory visit documented 2/17/25. There is no evidence of LVN visits documented in the medical record. Patient 6: There is no physician’s order for aide visits. There is a documented aide supervisory visit on 11/12/24. Patient 7: LVN supervisory visit documented 12/15/24. There is no evidence of LVN visits documented in the medical record until 2/20/25. Patient 8: LVN supervisory visit documented 1/9/25. There is no evidence of LVN visits documented in the medical record. Patient 9: LVN supervisory visit documented 10/8/24. There is no evidence of LVN visits documented in the medical record. Patient 11: LVN supervisory visit documented 11/21/24. There is no evidence of LVN visits documented in the medical record.

Upon patient record review, 2 of 15 (Patient #2,9) did not have evidence in the patient record that the interdisciplinary group, as part of the review of the plan of care, determines the ability of the patient and/or family to safely self-administer drugs and biologicals to the patient in his or her home. If the patient and/or family are not capable of safely administering drugs and biologicals in the home, the hospice must address this issue in the patient's plan of care. Patient 2: There is no documentation in assessment patient or caregiver can safely administer medications. Caregiver assessment section of initial comprehensive assessment is blank. Patient 9: There is no documentation in assessment patient or caregiver can safely administer medications. Caregiver assessment section of initial comprehensive assessment is blank.

Upon personnel record review, 1 of 1 applicable records (Personnel #5 ) did not have evidence in the personnel file that the competency assessment included appropriate and safe techniques in personal hygiene and grooming that included: ·(C) Shampoo, sink, tub, and bed Personnel Record #5: The form being utilized by agency does not differentiate types of shampoo competency, but simply "shampoo". There is no evidence that competency for sink, tub and bed shampoos were completed.

Upon patient record review, 5 of 5 (Patient #1, 2, 3, 4, 5) 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 Records #1-5: The majority of record entries are typed, but there are also manual strike-thru of words that are either to identify errors or updates to the record. The corrections are not made according to the agency's policy: Entries Into the Clinical Record, which requires single line strike thru, initials and dates for errors. Some entries have initials, but not all, and are not dated.