Every finding on record at Lighthouse Hospice LLC

Upon observation, there was no evidence the hospice has developed and maintained an emergency preparedness plan that must be reviewed, and updated at least every two years. The agency provided last revision dated 11/16/2020.

Upon observation, there was no evidence of contracts/agreements with other facilities/agencies/hospices to receive patients in the event the hospice cannot provide care to their patients during an emergency.

Upon observation, there was no evidence the Emergency Plan communication plan includes: • A method for sharing information and medical documentation for patients under the hospice's care, as necessary, with other health care providers to maintain the continuity of care • A means, in the event of an evacuation, to release patient information as permitted under 45 CFR 164.510(b)(1)(ii) • A means of providing information about the general condition and location of patients under the facility's care as permitted under 45 CFR 164.510(b)(4)

Upon patient record review, 2 of 14 (Patients #6,#8) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications. • Drug therapy currently associated with laboratory monitoring Patient 6: The medication profile contained diclofenac and lidocaine topicals with no area defined for administration. Corrected on site. Patient 8: The medication profile contained multiple pain medications including hydromorphone, morphine and oxycodone without instructions to differentiate appropriate indications for use. Corrected on site.

Upon patient record review, 1 of 14 (Patient #3) 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 3: The medical record contained an initial bereavement assessment 4/20/23 with a start of care 4/11/23.

Upon patient record review, 4 of 14 (Patients #6,#7,#8,#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. Patient 6: The medical record stated patient has comorbidities including coronary artery disease and atrial fibrillation. There was no evidence of problems, goals, and interventions related to cardiac dysfunction. Corrected on site. Patient 7: The medical record contained nursing documentation upon admission identifying patient risk for skin impairment. There was no evidence of problems, goals, and interventions related to risk for skin impairment included in the plan of care. Corrected on site. Patient 8: The medical record contained nursing documentation upon admission identifying patient had a chest port, nausea, and dyspnea. There was no evidence of problems, goals, and interventions related to the chest port, nausea, and dyspnea included in the plan of care. Corrected on site. Patient 9: The medical record contained nursing documentation upon admission identifying patient had a chest port. There was no evidence of problems, goals, and interventions related to the chest port included in the plan of care. Corrected on site.

Upon patient record review, 3 of 14 (Patients #6,#9,#10) 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 6: The medical record contained an order for social work frequency as needed. Corrected on site. Patient 9: The medical record contained an order for social work frequency as needed. Corrected on site. Patient 10: The medical record contained an order for social work frequency as needed. Corrected on site.

Upon patient record review, 2 of 14 (Patients #6,#8) 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 6: The medical record contained orders for diclofenac and lidocaine topical medications with no area defined for administration. Corrected on site. Patient 8: The medical record contained orders for multiple pain medications including hydromorphone, morphine, and oxycodone without instructions to differentiate appropriate use. Corrected on site.

Upon patient record review, 1 of 14 (Patient #8) 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 8: The medical record contained nursing documentation upon admission identifying patient use of a wheelchair. There was no evidence of the wheelchair included as DME in the plan of care. Corrected on site.

Upon client record review, 1 of 14 (Patient #1) 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 a social work visit 10/25/23. There was no evidence of an order for social work util 11/1/23.

Upon observation, there was no evidence the hospice investigates all adverse events, incidents, accidents, variances or unusual occurrences that involve patient care and develops a plan of correction to prevent the same or similar event from occurring again. Patient 10: The medical record contained nursing documentation identifying a patient fall 10/23/23. There was no evidence of an investigation and prevention of reoccurrence.

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 in governing body minutes of updates for QAPI.

Upon patient record review 1 of 14 (Patients #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 • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient 2: There was no evidence of an order for aide visits. The medical record contained aide visits completed twice weekly since admission.

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

Upon patient client record review, 1 of 14 (Patient #8) did not have evidence that each patient record contains: • Signed election statement in accordance with 418.24 Patient 8: The medical record contained an election statement identifying the patient elected to receive the Notification of Hospice Non-Covered Items upon admission 10/23/23. The patient did not receive the addendum until 10/30/23.

Upon inpatient contract review, 1 of 5 (Karcher Estates contract) 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.

Upon inpatient contract review, 2 of 5 (Saint Alphonsus and Karcher Estates contracts) did not have evidence that the hospice retains responsibility for ensuring that the training of personnel who will be providing the patient's care in the inpatient facility has been provided and that a description of the training and the names of those giving the training are documented.

Upon SNF/NF contract review, 1 of 5 (Karcher Estates contract) did not have evidence that specifies the provision of hospice services in the facility, including: A provision that the SNF/NF or ICF/IID immediately notifies the hospice if: • A significant change in a patient's physical, mental, social or emotional status occurs • Clinical complications appear that suggest a need to alter the plan of care • When a need to transfer a patient from the SNF/NF or ICF/MR arises, and the hospice makes arrangements for, and remains responsible for, any necessary continuous care or inpatient care necessary related to the terminal illness and related conditions • A patient dies

Upon SNF/NF contract review, 1 of 5 (Karcher Estates contract) did not have evidence of a provision stating that the hospice assumes responsibility for determining the appropriate course of hospice care, including the determination to change the level of services provided.

Upon SNF/NF contract review, 1 of 5 (Karcher Estates contract) did not have a provision stating that the hospice reports all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by anyone unrelated to the hospice to the SNF/NF administrator within 24 hours of the hospice becoming aware of the alleged violation.

Upon SNF/NF contract review, 1 of 5 (Karcher Estates contract) did not have a delineation of the responsibilities of the hospice and the SNF/NF to provide bereavement services to SNF/NF personnel.

Upon observation, there was no evidence the hospice has the appropriate licenses/permits required by state or local rules and regulations. During selection of home visits, it was observed that the agency had 7 of the 41 current patients located in the state of Oregon. Upon inquiry, the agency verified they do not have a hospice licensure in Oregon.