Every finding on record at Light Beam Hospice Inc

Condition of Participation: Emergency Preparedness

Upon observation, there was no evidence the Emergency Preparedness plan: • Is based on and includes a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach • Includes strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care The hazardous vulnerability assessment is for Certified Hospice Care Inc. There is not evidence of a hazardous vulnerability risk assessment for Light Beam Hospice for 2022, 2023, or 2024.

Upon observation, there was no evidence the The Emergency Preparedness plan addresses patient population, including, but not limited to: • The type of services the hospice has • The ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans The emergency plan command structure that has a plan for continuity of operations is for Spring Meadow Hospice, no evidence of one for Light Beam Hospice for 2022, 2023, or 2024.

Upon observation, there was no evidence the Emergency Preparedness plan includes a process for cooperation and collaboration with local, tribal, regional, state, and federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation for 2022, 2023, or 2024.

Upon observation, there was no evidence the agency has conducted exercises to test the emergency plan every two years. No evidence of testing of the emergency preparedness plan for 2022, 2023, or 2024. There is a drill documented on 8/22/24 however it does not state what the drill was for or the details of the events, and it is not documented as a community event.

Upon patient record review, 1 of 14 (Patient #14) 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 14 is alert and oriented, admitted on 8/4/24 and signed his own revocation on 10/1/24. The patient's wife signed admission paperwork, election of benefits, and there is no evidence that the patient was involved in the discussion or signing of admission paperwork during the admission process.

Upon patient record review, 1 of 14 (Patient #14) 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 14 is alert and oriented, admitted on 8/4/24 and signed his own revocation on 10/1/24. The patient's wife signed admission paperwork, election of benefits, and there is no evidence that the patient was involved in the discussion or signing of admission paperwork during the admission process.

Upon patient record review, 3 of 14 (Patient #11, 13, 14) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient 11 no evidence the patient chose an attending physician. Patient 13 the attending choice does not include the name of the primary physician to serve as an attending. Patient 14 is alert and oriented, admitted on 8/4/24 and signed his own revocation on 10/1/24. The patient's wife signed admission paperwork, election of benefits, and there is no evidence that the patient was involved in the discussion or signing of admission paperwork during the admission process.

Upon patient record review, 1 of 14 (Patient #14) did not have evidence of the appropriate documentation for release of confidential information. Patient 14 is alert and oriented, admitted on 8/4/24 and signed his own revocation on 10/1/24. The patient's wife signed admission paperwork, election of benefits, and there is no evidence that the patient was involved in the discussion or signing of admission paperwork during the admission process.

Upon patient record review, 1 of 14 (Patient #14) did not have evidence that the patient received information about the services covered under the hospice benefit. Patient 14 alert and oriented and his wife signed the election without any documentation why or that the patient was involved in the admission process.

Upon patient record review, 1 of 14 (Patient #14) 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 14 is alert and oriented, admitted on 8/4/24 and signed his own revocation on 10/1/24. The patient's wife signed admission paperwork, election of benefits, and there is no evidence that the patient was involved in the discussion or signing of admission paperwork during the admission process.

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

Upon patient record review 1 of 14 (Patient #5) did not have evidence that the hospice Registered Nurse must complete an initial assessment within 48 hours after the election of hospice care in accordance with §418.24 Patient 5 election of benefit start of care effective 8/12/24, initial nursing assessment completed on 8/15/24.

Upon patient record review 1 of 14 (Patient #5) 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 5 election of benefit start of care date effective 8/12/24, initial spiritual and psychosocial assessments completed on 8/19/24.

Upon patient record review 7 of 14 (Patient #1, 2, 3, 8, 9, 12, 14) 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 1 initial SW visit note on 8/2/24 the assessment portion of the note is blank, it includes a general narrative yet no initial psychosocial assessment is documented. Patient 2 declined SC on 7/16/24, no evidence of an initial spiritual assessment. Patient 3 declined SC on 7/5/24, no evidence of an initial spiritual assessment. Patient 8 declined SC on 4/6/24, no evidence of an initial spiritual assessment. Patient 9 declined SC on 7/2/24, no evidence of an initial spiritual assessment. Patient 12 no evidence of an initial spiritual assessment. Patient 14 initial SW visit note on 8/7/24 the assessment portion of the note is blank, it includes a general narrative yet no initial psychosocial assessment is documented.

Upon patient record review, 14 of 14 (Patient #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12 ,13, 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, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12 ,13, 14 initial plan of care includes orders for comfort kit as per instructions, no evidence of the specific medications that are included in the comfort kit (Morphine, Ativan, Levsin, Zofran, and Bisacodyl) on the medication profile. Patient 1 treatment order for oxygen on 9/5/24 effective 7/30/24 for oxygen 2-3LPM NC, no evidence of oxygen on medication profile. Patient 2 RN visit 9/26/24 documents oxygen 2-5LPM NC, no evidence of oxygen on the medication profile. Patient 3 Lidoderm patch is on the medication profile and does not include the location to apply. Patient 4 Oxygen ordered as a treatment, no evidence of oxygen on the medication profile. Patient 5 medication profile included Tylenol 325mg 1 Q6h prn, Tylenol 325mg 2 Q6h prn, Tylenol 500mg 2 Q6h prn, no evidence of a max allowable dose. initial nursing visit documents oxygen in use, no evidence of oxygen on the medication profile. Patient 7 nursing visit 9/18/24 documents Colace in use, no evidence of Colace on the medication profile. Patient 8 DME order for oxygen, no evidence of oxygen on the medication profile. Patient 10 initial nursing visit documents oxygen, no evidence of oxygen on the medication profile.

Upon patient record review, 3 of 14 (Patient #5, 12, 14) 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 5 election of benefit start of care effective 8/12/24, initial bereavement risk assessment completed on 8/19/24. Patient 12 election of benefit began 6/10/24, initial bereavement risk assessment was completed at the time of the death on 6/17/24 after the death. Patient 14 no evidence of an initial bereavement risk assessment.

Upon patient record review, 2 of 14 (Patient #1, 2) did not have evidence in the patient record that as part of the patient-specific comprehensive assessment the hospice may determine the need for a referral and/or further evaluation by other appropriate health professionals. Patient 1 and 2 initial social work assessment documents referrals made, no documentation of who the referrals were made to or any follow up on the referrals. Patient 4 initial nursing assessment documented the need for a volunteer, no evidence of a referral or follow up on the need.

Upon patient record review, 9 of 14 (Patient #1, 2, 3, 4, 5, 6, 7, 8, 14) 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 no evidence of a comprehensive assessment update since 8/14/24. Patient 2 no evidence of a comprehensive assessment update from 7/12/24-8/14/24, 8/28/24-9/19/24 and 9/19/24 to current. Patient 3 no evidence of a comprehensive assessment update from 7/10/24-9/20/24 and 9/20/24 to current. Patient 4 no evidence of a comprehensive assessment update since admission on 8/21/24. Patient 5 no evidence of a comprehensive assessment update since 8/22/24. Patient 6 no evidence of a comprehensive assessment update from 8/3/24 to 9/11/24. Patient 7 no evidence of a comprehensive assessment update since 6/20/24. Patient 8 comprehensive assessment updated on 9/6/24 and then again on 10/1. Patient 14 admitted 8/4/24 and revocated on 10/1/24, no evidence of a comprehensive assessment update after admission.

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

Upon patient record review, 3 of 14 (Patient #1, 8, 10) 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 1 admitted 7/30/24 with wound. No evidence of an assessment of the wound by the RN after admission. Patient 8 RN visit 9/6/24 documents wound is healed, no assessment. LVN visits on 9/7, 9/14, 9/22 document sacral wound care provided. RN visit on 9/17 does not assess the wound, and RN visit on 10/1 documents unable to assess calf and sacral wounds. Patient 10 no evidence of wound assessment by the RN after admission on 7/15/24, patient expired 8/19/24.

Upon patient record review, 7 of 14 (Patient #2, 3, 5, 7, 8, 9, 10) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient 2, 3 oxygen ordered on initial POC as treatment, no evidence of a respiratory care plan to include oxygen and oxygen safety. Patient 5 No evidence of a care plan to address oxygen safety, high risk for skin impairment, decreased intake, of needing assistance with ADLs. Patient 7 on Aspirin, no evidence of bleeding precautions. In addition, initial plan of care does not include a care plan to address pain or anxiety. Patient is ordered Norco, Tramadol, Tylenol and has documented anxiety throughout the nursing visits. Patient 8 initial POC includes Oxygen DME, no evidence of a respiratory care plan to include oxygen and oxygen safety. In addition, ordered Xanax for anxiety, no evidence of a care plan for anxiety. Patient 9 initial nursing assessment documents high risk for falls, no evidence of fall precautions on the care plan. Nursing visit 6/28/24 documents wound care to right toe and right shoulder and a PICC line, no evidence of a care plan for the PICC or the wounds. Patient 10 taking Levetiracetam for seizures, no evidence of seizure precautions on the care plan.

Upon patient record review, 5 of 14 (Patient #4, 5, 6, 7, 8) 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 4 initial order for RN Q14 days and prn, no quantity for the prn. Patient 5 initial orders include SN once/twice per week, the visit frequency is unclear. Patient 6 order on 8/18/24 for RN 1x week and prn, no quantity for the prn. Patient 7 order 8/6/24 for RN 1 every other week and prn, no quantity for the prn. Patient 8 order on 7/2/24 for RN 1w and prn, no quantity for prn.

Upon patient record review, 14 of 14 (Patient #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12 ,13, 14) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12 ,13, 14 initial plan of care includes orders for comfort kit as per instructions, no evidence orders for the specific medications that are included in the comfort kit (Morphine, Ativan, Levsin, Zofran, and Bisacodyl). Patient 2 RN visit 9/26/24 documents oxygen 2-5LPM NC, treatment order for oxygen is 2-3LPM, no evidence of an order for 2-5LPM. Patient 3 Lidoderm patch is ordered and does not include the location to apply. Suction is in the patient's home during the surveyor visit, no evidence of an order to suction the patient. Patient 5 orders for Tylenol 325mg 1 Q6h prn, Tylenol 325mg 2 Q6h prn, Tylenol 500mg 2 Q6h prn, no evidence of a max allowable dose. Initial nursing visit documents oxygen in use, no evidence of an order for oxygen. Patient 7 nursing visit 9/18/24 documents Colace in use, no evidence of an order for Colace. Patient 8 DME order for oxygen, no evidence of an order for oxygen. Patient 9 nursing visit 6/28/24 documents PICC line left arm 5fr, no evidence of an order for the care or flushing of the PICC. Patient 10 initial nursing visit documents oxygen, no evidence of an order for oxygen.

Upon patient record review, 10 of 14 (Patient #1, 2, 3, 4, 5, 6, 7, 8, 9, 10) 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 initial nursing visit documents bed, mattress, OBT, wheelchair, oxygen concentrator and oxygen tank, no evidence of an order for the DME. Patient 2 initial nursing visit documents walker, cane, shower chair, no evidence of an order for the DME. Oxygen ordered as a treatment, no evidence of an order for the DME for oxygen. Patient 3 RN visit 7/3/24 documents the use of a walker, no evidence of an order for the DME. During surveyor visit the patient has suction and an oxygen tank in the home, no evidence of a DME order for these. Patient 4 oxygen is ordered as a treatment 2LPM NC, no evidence of an order for the DME. Patient 5 initial nursing visit documents oxygen, nebulizer, bed and walker, no evidence of an order for the DME. Patient 6 initial nursing visit documents walker and shower chair, no evidence of an order for the DME. Patient 7 initial nursing visit documents bed, egg crate, wheelchair, shower chair and hoyer lift, no evidence of an order for the DME. Patient 8 initial nursing visit documents oxygen e-tank, no evidence of an order for the DME. Patient 9 initial nursing visit documents walker and cane, no evidence of an order for the DME. Patient 10 initial nursing visit documents wheelchair, oxygen concentrator and oxygen e-tank, no evidence of an order for the DME.

Upon client record review, 8 of 14 (Patient #1, 2, 3, 4, 5, 6, 7, 8) 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, 2, 3, 4, 5, 6, 7, 8 no evidence of an IDG/POC update since 9/19/24. Patient 6 no evidence of an IDG/POC update from 6/14/24-7/11/24. Patient 8 no evidence of an IDG/POC update from 4/3/24-5/3/24 and 6/14/24-7/25/24.

Upon patient record review, 10 of 14 (Patient #1, 2, 3, 4, 5, 6, 7, 8, 9, 10) 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 1 on 8/21/24 stool sent to lab for C-Diff testing, 8/23/24 Imodium ordered, 9/3/24 Restora ordered for constipation, no evidence of a care plan to include diarrhea or constipation. Initial care plan problems all controlled by 8/7/24, no evidence of any updates or progress toward goals after 8/7/24. Patient 2, 3 no evidence of updates or progress toward goals since initial POC. Patient 4 no evidence of updates or progress toward goals since 9/20/24. On 9/19/24 Zofran added for N/V, no evidence of a care plan for N/V. Patient 5 no evidence of updates or progress toward goals since 8/20/24. Patient 6 all care plans opened 5/20/24 no evidence of any changes or updates since 5/20/24. Patient 7 no evidence of updates or progress toward goals since 5/8/24. Nursing visit 9/18/24 documents Colace in use, no evidence of a care plan for constipation. Patient 8 no evidence of updates or progress toward goals since 6/14/24. Patient 9 no evidence of updates or progress toward goals since 6/28/24. Patient 10 no evidence of updates or progress toward goals since 7/15/24.

Upon client record review, 10 of 14 (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 RN ordered 1 per 2 weeks and SN ordered 2 per week. RN visit and LVN visits completed on 8/7/24 no evidence of the third visit that was due this week. RN visit 8/14/24, no evidence of a second nursing visit that was due this week. Nursing visits on 9/19/24 and 9/26/24 document oxygen saturations dropping into the 60's. There is an order to report oxygen saturation less than 90 to the physician, no evidence this was reported to the physician. Patient 2 order for RN eval and then Q14 days. RN visits completed 8/9/24, 8/14, 8/21, 8/28, 9/5, 9/12, 9/19, 9/26. Patient 3 initial POC ordered Bereavement initial and monthly. Initial bereavement assessment completed 7/5/24, no evidence of bereavement visits in August or September, Chaplain did visit on September 9/30. RN ordered initial and then Q14 days. RN visits completed 9/4/24, 9/20/24, and no evidence of a RN visit after 9/20/24. Patient 4 initial POC ordered RN Q14days. RN visits completed on 8/21/24, 9/6, 9/20 and no RN visits after 9/20. Patient 5 initial POC ordered RN Q14 days. RN visits completed 9/19/24 and the next one on 10/3/24. Patient 6 initial POC and 8/18/24 order RN 1x week, order on 5/20 for SN 1x week. RN visits completed on 8/3, 8/28, 9/11, and 9/26. Patient 7 initial POC and 9/19/24 POC ordered RN 1 per week and SN 1 per week. No evidence of RN visit the weeks of 8/18/24, 9/1, 9/15, or 9/22. Patient 8 order on 7/2/24 for RN 1x week and SN 1x week. No evidence of RN visit the week of 9/8/24 or the week of 9/22. LPN visits on 9/7/24, 9/14/24 and 9/22/24 documented wound care to sacral wound, no evidence of an order for the wound care. Order on 5/31/24 to discontinue wound care to coccyx. Patient 9 RN visit 6/28/24 documented wound care to right great toe and right shoulder, no evidence of an order for wound care. RN visits ordered SN 1w and RN q14 days. RN visits completed on 6/28/24, 7/6, 7/12. Patient 10 SC visit completed on 8/19/24, no evidence of an order for this visit.

Upon patient record review 1 of 14 (Patient #1) did not have evidence that the IDG ensures that the care and services provided are based on all assessments of the patient and family needs. Patient 1 initial RN assessment documented referral made to PT. No evidence of a referral to PT or follow up.

Condition of Participation: Quality Assessment and Performance Improvement.

Upon observation, there was no evidence the program shows measurable improvement in indicators related to improved palliative outcomes and hospice services for 2022, 2023, or 2024.

Upon observation, there was no evidence the program must use quality indicator data, including patient care, and other relevant data, in the design of the program. The agency had audited 3 patient records total, however this data was not incorporated into the design of the program and no patient audits prior to July 2023.

Upon observation, there was no evidence the QAPI program uses quality indicator data, including patient care and other relevant data in the design of its program. The hospice must use the data collected to: • Monitor the effectiveness and safety of services and quality of care • Identify opportunities and priorities for improvement

Upon observation, there was no evidence the board of directors/governing body approves the frequency and detail of the data collection. No evidence of this for 2022, 2023, or 2024.

Upon observation, there was no evidence QAPI activities focus on high risk, high volume, or problem prone areas. No evidence of QAPI activities for 2022 or 2023. In 2024 the agency has demographic data only, no evidence of using the data for any projects or improvements.

Upon observation, there was no evidence Quality Assessment and Performance Improvement activities focus on high risk, high volume or problem-prone areas by understanding how they affect palliative outcomes, patient safety and quality of care for 2022, 2023, or 2024.

Upon observation, there was no evidence the number and scope of distinct QAPI projects conducted annually is based on the needs of the hospice's population and internal organizational needs and must reflect the scope, complexity, and past performance of the hospice's services and operations. No evidence of QAPI projects for 2022, 2023, or 2024.

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. No evidence of QAPI projects for 2022, 2023, or 2024.

Upon observation, there was no evidence of involvement of the governing body and organizational leaders in the Quality Assessment/Performance Improvement (QAPI) program. QAPI program was not defined, implemented, maintained or evaluated for 2022, 2023, or 2024.

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. No evidence of this for 2022, 2023, or 2024.

Upon observation, there was no evidence licensed professionals participate in the hospice's QAPI program. No evidence of QAPI meetings or evidence of disciplines involved with QAPI for 2022, 2023, or 2024.

Upon personnel record review, 1 of 16 (Personnel #8) did not have evidence that the hospice routinely provide substantially all core services directly by hospice personnel (The hospice issues a W-2 form for the employee). These services include: • Medical social services Personnel 8 the MSW is a 1099/W-9 contracted staff member and is not a direct employee.

Upon patient record review, 1 of 14 (Patient #11) did not have evidence the hospice offers bereavement counseling that includes: • Making bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. Bereavement counseling also extends to residents of a SNF/NF or ICF/IID when appropriate and identified in the bereavement plan of care • Ensuring that bereavement services reflect the needs of the bereaved • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery Patient 11 the 1 month and 3 month letters were sent on 10/7/24, patient expired 4/5/24.

Condition of Participation: Hospice Aide and Homemaker Services. L607

Upon personnel record review, 2 of 16 (Personnel #6, 7) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient. Personnel 6 range of motion was not completed as part of the initial competency, this was blank and there is evidence that the aide completed this task with patient 2 and patient 1 verbalizes that aide performing range of motion with her on her visits. Personnel 7 initial competency states all tasks were verified by observation, no evidence of how the observation was completed, and no evidence it was completed with a patient or pseudo patient. No evidence of credentials for the personnel that completed the competency.

Upon patient record review, 5 of 14 (Patient #2, 3, 5, 7, 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 2 aide care plan did not include bleeding or oxygen precautions. Aide care plan included assist with oral medications as per RN instructions, encourage fluids as tolerated if not contraindicated, mouth special care as specified in RN instructions, equipment as specified in RN instructions, and provide companionship as per RN instructions: no evidence of specific instructions for any of these. Change linen does not have a frequency. Patient 3 aide care plan did not include bleeding or oxygen precautions. Aide care plan included encourage fluids as tolerated if not contraindicated, skin special care as specified in RN instructions, and equipment as specified in RN instructions: no evidence of specific instructions for any of these. Change linen does not have a frequency. Patient 5 aide care plan did not include aspiration, bleeding or oxygen precautions. Change linen did not have a frequency. Patient 7 Aide care plan included assist with oral medications as per RN instructions, encourage fluids as tolerated if not contraindicated, skin and mouth special care as specified in RN instructions: no evidence of specific instructions for any of these. Record BM, change linen and turn and reposition does not have a frequency. Diet is listed as tolerated, and does not include pureed diet, also includes feeding assistance. Vital signs are listed and do not include parameters or a frequency. Patient 10 no evidence of aspiration or seizure precautions. Change linen and turn and reposition do not have a frequency.

Upon patient record review 4 of 14 (Patients 2, 5, 6, 10) 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 aide ordered 3x week starting 7/21/24, aide visits 9/3, 9/7, 9/10, 9/14, 9/17, 9/21, 9/24, no evidence of visits 3x week or refusal of visits. There was documentation passive and active range of motion provided with dates throughout August and September. No evidence of an order for the aide or a care plan for the aide to provide this service, Patient 5 aides ordered 2x week, no evidence of visits after 9/19/24. Patient 6 aide completed a visit on 6/4/24, no evidence of an order for this visit. Patient 10 aide visit on 8/7/24 states give patient shower, and bed bath is on the aide care plan.

Upon patient record review 3 of 14 (Patient #2, 3, 6) 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 2 no evidence of aide supervision from 8/21/24-9/12/24. Patient 3 no evidence of aide supervision from 7/10/24-8/7/24 and 9/4/24-9/20/24. Patient 6 aide visit on 6/4/24, no evidence of aide supervision.

Conditions of Participation - Volunteers. L641

Upon observation, there was no evidence the hospice documents and demonstrates viable and ongoing efforts to recruit volunteers for 2022, 2023, or 2024.

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 There is no documentation of cost saving for the volunteers for 2022, 2023, or 2024.

Upon observation, there was no evidence the annual report documents the use of volunteers providing day to day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract personnel. No documentation of volunteer utilization for 2022, 2023 and only one month is documented for 2024.

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 for 2022, 2023, or 2024.

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. There was no evidence of the following in the governing body meeting minutes: • Decision making • Appointing a qualified administrator • Arranging for professional advice • Adopting and periodically reviewing written bylaws or equivalent • Establishing or approving written policies and procedures governing operations • Human resource management • Quality Assessment/ Performance Improvement • Community needs planning, if applicable • Oversight of the management and fiscal affairs of the hospice • Annual review of the policies and procedures There is no evidence the Board of Directors/governing body or administrator assume responsibility for oversight of hospice operations as evidenced by: -No patient files available prior to July 2023 -Not ensuring staff are properly trained and competency performed for services performed for patients -No QAPI program oversight -No EPP oversight -No job description signed by administrator and alternate administrator did not have appropriate education and experience requirements, signed job description, or evidence of orientation to job role. -No governing body meeting minutes prior to July 2023. The agency had 3 governing body meeting minutes (after July 2023) that were all very brief and did not include the above bullet points -Not ensuring core services, such as medical social services, are provided by employee(s)

Upon personnel record review, 2 of 16 (Personnel #9, 12) did not have evidence that a skills competency assessment, specific to each discipline had been conducted for all personnel including volunteers initially during orientation. Personnel 9 initial competency page one is completed and page 2 and 3 are blank, no evidence of a competency for the following sections for the chaplain: conducts spiritual assessment, communication skills, reporting/documenting skills, death process, liaisons with community spiritual care providers, funeral/memorial services, or education/consultation/support to hospice personnel on spiritual care. No evidence of credentials for the personnel that completed the chaplain competency. Personnel 12 no evidence of an initial competency.

Upon patient record review, 1 of 14 (Patient #5) 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 5 election of benefit effective date is 8/12/24, no evidence of a certification until 8/15/24.

Upon patient record review, 4 of 14 (Patient #3, 6, 7, 8) 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 for the second BP effective 10/1/24 there is no evidence of a verbal or signed certification. Patient 6 CTI for the second BP effective 8/18/24 there is no evidence of a verbal or signed certification. Patient 7 CTI for the second BP effective 8/6/24 there is no evidence of a verbal or signed certification. Patient 8 CTI for the third BP effective 9/30/24 there is no evidence of a verbal or signed certification.

Condition of Participation: Clinical Records.

Upon patient client record review, 4 of 14 (Patient #5, 11, 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 Patient 5 has 2 election of benefit documents both signed on 8/12/24, one does not have an effective date and the other the effective date is blank. Patient 11 election of benefit the effective date is blank and the choice for attending is blank. Patient 13 election of benefit does not include the BFCC-QIO or contact for the BFCC-QIO. The attending physician choices are 1- my primary with my current physician 2- NS Hospice Inc Medical Director with Light Beam Hospice on the header. The attending choice does not include the name of the primary physician to serve as an attending. Patient 14 alert and oriented and his wife signed the election without any documentation why or that the patient was involved in the admission process.

Upon patient client record review, 2 of 14 (Patient #1, 9) did not have evidence that each patient record contains responses to medications, symptom management, treatments, and services. Patient 1 nursing visit on 8/7/24 documents Foley changed and does not document how the patient tolerated the Foley change. Patient 9 nursing visit on 7/6/24 documents wound care provided and PICC line dressing change and does not document how the patient tolerated the wound care or PICC dressing change.

Upon patient client record review, 3 of 14 (Patient #2, 3, 5) did not have evidence that each patient record contains Physician certification and recertification of terminal illness. Patient 2 and 3 election of benefit elected Dr DV as the attending, no evidence of a CTI from Dr DV. Patient 5 election of benefit elected Dr A as the attending, no evidence of a CTI from Dr A.

Upon patient client record review, 2 of 14 (Patient #1, 10) 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 RN visit on 9/26/24 documents aide supervision, the patient does not have any aide services. Nursing visits on 9/20/24, 9/24, 9/27 document wound care per orders, no evidence of the detail of the care provided. Patient 10 nursing visit on 8/10/24 documents wound care per orders and does not include the detail of the care provided.

Upon observation, there is not evidence that all patient records are retained for a minimum of six years from the date of the most recent discharge or the death of the patient, unless state law stipulates a longer period of time. No evidence of any patient records prior to July 2023.

Upon client record review, 1 of 14 (Patient #13) did not have evidence that if a patient revokes the election of hospice care or is discharged from hospice in accordance with §418.26, the hospice must forward to the patient's attending physician: • A copy of the hospice discharge summary • The patient's clinical record, if requested

Upon client record review, 2 of 14 (Patient #9, 13) did not have evidence that the discharge summary includes all required information Patient 9 the discharge summary did not include the current plan of care, the latest physician orders, or a summary of the patients care under hospice. Patient 13 the discharge summary did not include the current plan of care, or the latest physician orders.

Upon client record review, 3 of 14 (Patient #4, 5, 14) did not have evidence that the written policies and procedures for managing controlled drugs was provided and discussed. Patient 4, 5 no evidence that the written policies and procedures for managing controlled drugs was provided and discussed. Patient 14 alert and oriented and his wife signed the election without any documentation why or that the patient was involved in the admission process. No evidence the patient was provided with the procedures for managing controlled drugs.

Upon client record review, 5 of 14 (Patient #2,4,5,8,10) did not have evidence that the patient/family receive instruction in the safe use of durable medical equipment and supplies. The hospice may use persons under contract to ensure patient/family are educated. The patient and family can demonstrate the appropriate use of durable medical equipment to the satisfaction of the hospice staff. Patient 2, 4, 8, 10 no evidence of teaching provided on oxygen. Patient 5 No evidence of education on the DME in the home including oxygen, walker, bed, and nebulizer.

Upon inpatient contract review, 1 of 3 (Astoria Nursing & Rehab) did not have evidence that the inpatient facility has identified an individual within the facility who is responsible for the implementation of the provisions of the agreement.