Every finding on record at Life Tree Hospice, Inc

It is required that each patient’s individualized written plan of care reflects patient and family goals, and identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review, document review and interview. 12 of 12 (100%) clinical records reviewed revealed the patient's individual written plan of care (POC) lacked goals and interventions based on problems identified in the initial and updated comprehensive assessments. Document 1: Policy #9-017, "The Plan of Care (Dated: 11/2020)," stated in part, "Policy: The plan of care will be based on the initial, comprehensive and ongoing comprehensive assessments performed by members of the interdisciplinary group . . . This plan will focus on identified problems, goals, and interventions." Clinical Record 8: The patient elected the hospice benefit on 2/23/23. The patient had the Social Work Initial assessment and the Chaplain initial assessment then refused further visits for both roles. The POC dated 6/2/23 lacked goals and intervention for psychosocial and spiritual. Clinical Record 9: The patient elected the hospice benefit on 2/23/23. The fall risk on the initial certificate of terminal illness (CTI) was, "10". The record lacked a goal and interventions for fall risk. Clinical Record 10: The patient elected the hospice benefit on 2/17/23. The initial nursing assessment reported that the patient had history of shortness of breath (SOB). The POC dated 2/23/23 included a goal for respiratory. The record lacked interventions for respiratory. The narrative documented education to the patient regarding energy conservation techniques for the patient to utilize to reduce SOB. Clinical Record 1: The patient elected the hospice benefit on 4/8/22. The initial nursing assessment dated 4/8/22 reported the patient was using oxygen. The plan of care dated 6/30/23 lacked a goal and interventions for oxygen. Clinical Record 4: The patient elected the hospice benefit on 8/18/22. The initial CTI dated 8/18/22 stated the patient was started on oxygen therapy. The plan of care dated 8/18/22 lacked a goal and intervention for oxygen. Clinical Record 5: The patient elected the hospice benefit on 9/3/22. The initial CTI dated 9/3/22 stated the patient had bladder incontinence. The POC dated 5/19/23 lacked a goal and interventions for bladder incontinence. Clinical Record 6: The patient elected the hospice benefit on 6/18/22. The initial nursing assessment dated 6/18/22 stated that the patient was demonstrating non-verbal signs of pain such as tensing up, moaning and groaning mildly and guarding. The POC dated 4/25/23 had a goal for pain but lacked interventions. Clinical Record 7: The patient elected the hospice benefit on 5/7/22. The initial nursing assessment dated 6/18/22 stated that patient had a history of arthritic pain in her joints and especially her lower back. The POC dated 4/25/23 had a goal for pain but lacked interventions to meet the goal. Clinical Record 11: The patient elected the hospice benefit on 8/2/22. The initial CTI dated 8/2/22 stated the patient has moderate shortness of breath at rest. The POC dated 2/10/23 had a goal for respiratory but lacked interventions. Clinical Record 12: The patient elected the hospice benefit on 6/15/23. The initial CTI dated 6/15/23 stated the patient of incontinent of bowel and bladder incontinence. The POC dated 6/30/23 had a goal for bladder incontinence but lacked interventions, and also lacked a goal and interventions for bowel incontinence. Clinical Record 13: The patient elected the hospice benefit on 3/4/23. The initial CTI dated 3/4/23 had a diagnosis of Atherosclerotic Heart Disease of native coronary artery without Angina Pectoris. The POC dated 4/7/23 had a goal for the cardiovascular diagnosis but lacked interventions. Clinical Record 14: The patient elected the hospice benefit on 2/6/23. The initial CTI dated 2/6/23 had a diagnosis of Atherosclerotic Heart Disease of native coronary artery without Angina Pectoris. The POC dated 3/10/23 had two goals for the cardiovascular diagnosis but lacked interventions. Upon interview on 7/13/23, the Administrator/Director of Patient Care Services and the Administrator Designee reviewed and agreed patients' POCs lacked goals and/or interventions.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: Physician orders. This standard was not met as evidenced by clinical record review, document review and interview. 2 of 14 (14%) clinical records reviewed revealed the agency did not ensure a physician order was written for care and treatment provided to the hospice patient. Document 7: Policy #2-002, "Verification of Physician Orders (Dated: 11/2020)," stated in part, "Policy: Orders will be obtained from a licensed physician (or other authorized independent practitioner) for care and services to be provided to hospice patients." Clinical Record 1: The patient elected the hospice benefit on 4/8/22. The initial nursing assessment dated 4/8/22 stated the patient was on oxygen at 2-5 LPM via nasal cannula, as needed. The record lacked a physician order for the oxygen. Clinical Record 4: The patient elected the hospice benefit on 8/18/22. The plan of care dated 8/18/22 stated the Care Level was Continuous Care (CC). The record lacked a physician order for the CC level of care. Upon interview on 7/13/23, the Administrator/Director of Patient Care Services and the Administrator Designee reviewed and agreed the record lacked physician orders for the care and treatment provided to the hospice patients.

It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid certified facility, the hospice forwards to the receiving facility a copy of the hospice discharge summary described in HCDT 40.I, and the patient’s record, if requested. This standard was not met as evidenced by clinical record review, document review and interview. 2 of 2 (100%) clinical records reviewed for patients that revoked the hospice benefit and were transferred to a facility (Hospital) revealed the records lacked evidence that the hospice forwarded a copy of the hospice discharge summary to the receiving facility. Document 5: Policy #1-022, "Transfer Information (Dated: 11/2020)," stated in part, "Procedure: 4. Completed discharge summaries will be given to a clinical records clerk who will send a copy to the receiving organization within 72 hours of transfer and file the original in the clinical record." Clinical Record 13: The patient elected the hospice benefit on 3/4/23. The family revoked hospice services on 4/10/23. The record lacked evidence that the discharge summary was forwarded to the receiving hospital. Clinical Record 14: The patient elected the hospice benefit on 2/6/23. The family revoked hospice services on 3/24/23. The record lacked evidence that the discharge summary was forwarded to the receiving hospital. Upon interview on 7/13/23, the Administrator/Director of Patient Care Services and the Administrator Designee both reviewed and agreed the agency did not ensure the patients discharge summary was forwarded to the receiving hospital.

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary, and the patient's record, if requested. This standard was not met as evidenced by clinical record review, document review and interview. 7 of 7 (100%) clinical records reviewed where the patient/family revoked hospice services revealed the hospice did not ensure a copy of the discharge summary was forwarded to the patient's attending physician. Document 6: Agency Revocation of Hospice Benefit Policy: Policy #1-024, "Revocation of Hospice Benefit (Dated: 11/2020)," stated in part, "Procedure: 3. The Case Manager will notify the attending physician and interdisciplinary group about the revocation and reason. A discharge summary will be sent to the attending physician." Clinical Record 5: The patient elected the hospice benefit on 9/3/22. The family revoked hospice services on 6/1/23. The record lacked evidence that the discharge summary was forwarded to the patient attending physician. Clinical Record 6: The patient elected the hospice benefit on 6/18/22. The family revoked hospice services on 4/28/23. The record lacked evidence that the discharge summary was forwarded to the patient attending physician. Clinical Record 7: The patient elected the hospice benefit on 5/7/22. The family revoked hospice services on 4/28/23. The record lacked evidence that the discharge summary was forwarded to the patient attending physician. Clinical Record 11: The patient elected the hospice benefit on 8/2/22. The family revoked hospice services on 2/12/23. The record lacked evidence that the discharge summary was forwarded to the patient attending physician. Clinical Record 12: The patient elected the hospice benefit on 6/15/23. The family revoked hospice services on 7/2/23. The record lacked evidence that the discharge summary was forwarded to the patient attending physician. Clinical Record 13: The patient elected the hospice benefit on 3/4/23. The family revoked hospice services on 4/10/23. The record lacked evidence that the discharge summary was forwarded to the patient attending physician. Clinical Record 14: The patient elected the hospice benefit on 2/6/23. The family revoked hospice services on 3/24/23. The record lacked evidence that the discharge summary was forwarded to the patient attending physician. Upon interview on 7/13/23, the Administrator/Director of Patient Care Services and the Administrator Designee both reviewed and agreed the agency did not ensure that a copy of the discharge summary was forwarded to the patients attending physician when a patient/family revokes hospice services.

Upon patient record review, 15 of 15 (Patients #1,#2,#3,#4,#5,#6,#7,#8,#9,#10,#11,#12,#13,#14,#15) 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. Patients 1,2,3,4,5,6,7,8,9,10,11,12,13,14,15: There was no evidence the patients received written information regarding agency policies on advance directives including description of the state law.

Upon patient record review, 1 of 15 (Patient #10) 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 10: Information regarding Patient's Rights and Responsibilities was received 5/26/22 after start of care 5/25/22.

Upon patient record review, 5 of 15 (Patients #4,#5,#6,#7,#8) did not have evidence that the patient chooses a health care provider, including an attending physician. Patients 4,5,6,7,8: The medical records contained election forms with original entry of attending physician chose scribbled out and the name of the medical director written next to it. Original entry was illegible and there was no signature or date to clarify the patient/representatives were responsible for the modifications.

Upon patient record review, 1 of 15 (Patient #10) did not have evidence that the patient received information about the services covered under the hospice benefit. Patient 10: Information regarding hospice services was received 5/26/22 after start of care 5/25/22.

Upon patient record review, 1 of 15 (Patient #10) 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 10: Information regarding the scope of services hospice will provide was received 5/26/22 after start of care 5/25/22.

Upon patient record review 1 of 15 (Patient #1) 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: The medical record contained an initial spiritual assessment completed 7/28/22 with start of care 6/18/22. After discussion with agency leadership, the chaplain stated that original assessment was completed 6/21/22 and entered documentation.

Upon patient record review 1 of 15 (Patient #5) 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 5: There was no evidence of an initial spiritual assessment. After discussion with agency leadership, the chaplain stated that original assessment was completed 3/7/23 and entered documentation.

Upon patient record review, 6 of 15 (Patients #1,#5,#9,#10,#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. 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: The plan of care identified patient use of oxygen. There was no evidence of oxygen included on the medication profile. The medication profile contained Voltaren gel with no defined route, dose, frequency, or instructions for administration and z-pac dated 3/28/23 with no end date still listed as current medication on med profile. Patient 5,9,10,12,14: The medical record contained nursing documentation upon admission identifying patient use of oxygen. There was no evidence of oxygen included on the medication profile.

Upon patient record review, 6 of 15 (Patients #1,#2,#4,#6,#7,#8) 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: The medical record contained an initial bereavement assessment completed 7/28/22 with start of care 6/18/22. After discussion with agency leadership, the chaplain stated that original assessment was completed 6/21/22 and entered documentation. Patient 2: The medical record contained an initial spiritual assessment completed 3/29/23 with start of care 9/3/22. After discussion with agency leadership, the chaplain stated that original assessment was completed 9/6/22 and entered documentation. Patient 4: The medical record contained an initial spiritual assessment completed 4/20/23 with start of care 3/5/23. After discussion with agency leadership, the chaplain stated that original assessment was completed 3/7/23 and entered documentation. Patient 6,7,8: There was no evidence of a bereavement assessment.

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

Upon patient record review, 5 of 15 (Patients #4,#5,#6,#7,#8) 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 4: There was no evidence of nursing visits the weeks of 4/2/23, 4/9/23, and 4/16/23. When addressed with agency leadership, nurse entered visits for 4/2/23, 4/9/23, and 4/16/23. Patient 5: There was no evidence of nursing visits the weeks of 4/9/23, and 4/16/23. When addressed with agency leadership, nurse entered visits for 4/9/23, and 4/16/23. Patient 6: There was no evidence of nursing visits the weeks of 4/2/23, 4/9/23, and 4/16/23. When addressed with agency leadership, nurse entered visits for 4/2/23, 4/9/23, and 4/16/23. Patient 7: There was no evidence of nursing visits the weeks of 3/26/23, 4/2/23, 4/9/23. When addressed with agency leadership, nurse entered visits for 3/26/23, 4/2/23, 4/9/23. Patient 8: There was no evidence of nursing visits the weeks of 3/26/23, 4/2/23, 4/9/23, and 4/16/23. When addressed with agency leadership, nurse entered visits for 3/26/23, 4/2/23, 4/9/23, and 4/16/23.

Upon patient record review, 8 of 16 (Patients #1,#2,#3,#6,#9,#10,#12,#14) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient 1: Upon observation during home visit, the patient was witnessed needing assist of one from sit to stand and refusal of using walker. There was no evidence of problems, goals, and interventions related to fall risk and safety included on the plan of care. Patient 2: The medical record contained nursing documentation 4/15/23 identifying patient need for fall prevention. There was no evidence of problems, goals, and interventions related to fall risk and safety included on the plan of care. Patient 3,12,14: The medical record contained nursing documentation upon admission identifying patient problem of dyspnea. There was no evidence of problems, goals, and interventions related to respiratory dysfunction included on the plan of care. Patient 6: The medical record contained documentation identifying patient primary hospice diagnosis of hypertensive heart disease with heart failure. There was no evidence of problems, goals, and interventions related to cardiac dysfunction. Patient 9,10: The medical record contained nursing documentation upon admission identifying patient was high risk for skin impairment. There was no evidence of problems, goals, and interventions related to risk for skin impairment included on the plan of care.

Upon patient record review, 6 of 15 (Patients #1,#3,#5,#10,#12,#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. Patient 1,3,5,12,15: The medical records contained ordered frequencies for social work and spiritual care for one time then as needed. Patient 10: The medical record contained ordered frequencies for social work and spiritual care one time as needed.

Upon patient record review, 6 of 15 (Patients #1,#5,#9,#10,#12,#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 medical record contains nursing documentation 4/8/23 identifying patient use of oxygen. There was no evidence of an order for oxygen dose, frequency, and delivery method. Patient 5,9,10,12,14: The medical records contain nursing documentation upon admission identifying patient use of oxygen. There was no evidence of an order for oxygen dose, frequency, and delivery method.

Upon patient record review, 11 of 15 (Patients #1,#2,#5,#6,#7,#8,#9,#10,#11,#12,#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 equipment and supply needs. Patient 1: The medical record contains nursing documentation 4/8/23 identifying patient use of wheelchair and nebulizer. There was no evidence of the wheelchair and nebulizer included as DME on the plan of care. Patient 2: The medical record contains nursing documentation 4/15/23 identifying patient use of a walker. There was no evidence of the walker included as DME on the plan of care. Patient 5: The medical record contains nursing documentation upon admission identifying patient use of oxygen. There was no evidence of the oxygen concentrator included as DME on the plan of care. Patient 6,7,8: The medical records contain nursing documentation upon admission identifying patient use of a walker and shower chair. There was no evidence of the walker and chair included as DME on the plan of care. Patient 9: The medical record contains nursing documentation upon admission identifying patient use of oxygen and a hospital bed. There was no evidence of the oxygen concentrator and bed included as DME on the plan of care. Patient 10: The medical record contains nursing documentation upon admission identifying patient use of an oxygen concentrator, hospital bed, air mattress, and nebulizer. There was no evidence of the oxygen, bed, mattress, and nebulizer included as DME on the plan of care. Patient 11: The medical record contains nursing documentation upon admission identifying patient use of a walker. There was no evidence of the walker included as DME on the plan of care. Patient 12,14: The medical records contain nursing documentation upon admission identifying patient use of an oxygen concentrator. There was no evidence of the oxygen included as DME on the plan of care.

Upon client record review, 12 of 15 (Patients #1,#2,#3,#4,#5,#6,#7,#8,#11,#13,#14,#15) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 1: The medical record contained an order for social work visits one time then as needed. There was evidence of visits completed 9/15/22, 12/1/22, and 2/10/23 with no order. Patient 2: The medical record contained an order for a social work visit one time within 5 days. There was evidence of a visit completed 12/1/22 with no order. Patient 3: The medical record contained an order for social work visits one time then as needed. There was evidence of visits completed 8/3/22, 11/1/22, 1/1/23, and 3/2/23 with no order. The record also contained an order for nurse frequency of once weekly. There was no evidence of a visit the week of 4/9/23. Patient 4,6: The medical records contained orders for nurse frequency of once weekly. There was no evidence of visits the weeks of 4/2/23, 4/9/23, and 4/16/23. After discussion with agency leadership, the entered documentation for 4/2/23, 4/9/23, and 4/16/23. Patient 5: The medical record contained an order for nurse frequency of once weekly. There was no evidence of visits the weeks of 4/9/23, and 4/16/23. After discussion with agency leadership, the entered documentation for 4/9/23 and 4/16/23. Patient 7: The medical record contained an order for nurse frequency of once weekly. There was no evidence of visits the weeks of 3/26/23, 4/2/23, and 4/9/23. After discussion with agency leadership, the entered documentation for 3/26/23, 4/2/23, and 4/9/23. Patient 8: The medical record contained an order for nurse frequency of once weekly. There was no evidence of visits the weeks of 3/26/23, 4/2/23, 4/9/23, and 4/16/23. Corrected on site with late nurse documentation. Patient 11: The medical record contained an order for nurse frequency of once every 14 days. There was evidence of visits completed 10/14/22, 10/31/22, 11/7/22, 11/14/22, 11/21/22, 11/28/22, and 12/5/22. Patient 13: The medical record contained order for nurse frequency once weekly and RN visit once every 14 days. There was no evidence of the LVN visits the weeks of 1/22/23 and 2/5/23. Patient 14: The medical record contained documented visits by the RN 11/25/22, 12/9/22, 12/23/22, 1/6/23, 1/20/23, and LVN visits 11/24/22, 12/7/22, 12/14/22, 12/21/22, 12/28/22, 1/4/23, 1//9/23, 1/16/23, 1/23/23, and 1/30/23. There was no evidence of an order for nurse frequencies. Patient 15: The medical record contained orders for social work and spiritual care frequencies of once then as needed. There was evidence of a social work visit completed 9/13/22 and spiritual care visit 9/20/22.

Condition of Participation: Quality Assessment and Performance Improvement.

Upon observation, there was no evidence the board of directors/governing body approves the frequency and detail of the data collection.

Upon observation, there was no evidence a written plan of correction is developed in response to any QAPI activity that does not meet an acceptable threshold. No evidence of any QAPI projects.

Upon observation, there was no evidence the hospice documents what QAPI projects are being conducted, the reasons for conducting these projects, and the measurable progress achieved on these projects.

Upon observation, there was no evidence of involvement of the governing body and organizational leaders in the Quality Assessment/Performance Improvement (QAPI) program.

Upon observation, there was no evidence the hospice's governing body is responsible for ensuring that the hospice-wide Quality Assessment and Performance Improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness.

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 home visit observation, the LVN conducted a blood glucose check without using gloves while handling used monitoring strip. The LVN was also only witnessed washing hands at the beginning of the visit. Hands were not washed or sanitized after obtaining vital signs, washing equipment, or obtaining blood glucose.

Upon patient record review, 1 of 15 (Patient 13) did not have evidence that the hospice provided spiritual counseling in accordance to the patient desires. Patient 13: The medical record contains chaplain documentation after initial visit identifying follow up spiritual visits will be part of the plan of care. There was no evidence of any additional visits made by the chaplain.

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

Condition of Participation: Organization and Administration of Services.

Upon observation, there was no evidence BOD/governing body minutes reflect the involvement in the hospice's management and administration of its resources to provide hospice services to patients and families. No evidence of governing body involvement in oversight of the hospice agency.

Upon observation, there was no evidence the hospice is directed by a Board of Directors/governing body which assumes full legal authority and responsibility for the operation of the hospice.

Upon personnel record review, 1 of 13 (Personnel #10) did not have evidence the contract employee had received orientation on the hospice philosophy.

Upon patient record review, 5 of 15 (Patients #1,#2,#3,#13,#14) 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 1: The CTI for benefit period starting 12/15/22 stated the face to face was completed 2/8/23. There was no evidence of face to face completed for the benefit periods starting 12/15/22 and 4/14/22. Face to faces were also completed by a contracted nurse practitioner who was not an employee of the hospice. Patient 2: There was no evidence of a face to face completed for the benefit period starting 3/2/23. Face to faces were also completed by a contracted nurse practitioner who was not an employee of the hospice. Patient 3: The CTI for benefit period 3 starting 11/3/22 stated the face to face was completed 12/30/22. The CTI for benefit period starting 1/2/23 stated the face to face was completed 2/23/23. There was no evidence of a face to face completed for the benefit period starting 11/2/22. Face to faces were also completed by a contracted nurse practitioner who was not an employee of the hospice. Patient 13: The CTI for benefit period 3 starting 1/29/23 stated the face to face was completed 2/1/23. Documented face to face occurred 1/15/23. Face to faces were also completed by a contracted nurse practitioner who was not an employee of the hospice. Patient 14: Face to face completed 11/10/22 was by a contracted nurse practitioner who was not an employee of the hospice.

Upon patient client record review, 13 of 15 (Patients #1,#2,#3,#4,#5,#6,#7,#8,#10,#11,#12,#13,#14) 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 Patients 1,2,3,4,5,6,7,8,11,12,13,14: The medical record contained election forms identifying patient/representative elected to receive the Notice of Hospice Non-covered Items. There was no evidence the patient received the form. Patient 10: The medical record contained election forms identifying patient/representative elected to receive the Notice of Hospice Non-covered Items. There was no evidence the patient received the form. The medical record contained signed receipt of patient rights and election statement 5/26/22, after start of care 5/25/22.

Upon client record review, 5 of 15 (Patients #11,#12,#13,#14,#15) 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.

Upon client record review, 5 of 15 (Patients #11,#12,#13,#14,#15) did not have evidence that the discharge summary includes all required information.

Upon personnel record review, 1 of 13 (Personnel #9) did not have evidence of criminal background checks being obtained in accordance with state requirements. In the absence of state requirements, criminal background checks are obtained within three months of the date of employment for all states that the individual has lived or worked in the past 3 years.

Upon observation, there was no evidence there is a CLIA certificate for the hospice performing waived testing. During home visit, LVN was witnessed performing a blood glucose test with monitor brought in nursing bag.