Every finding on record at Living Hospice Care of Texas, Inc.

Upon patient record review, 5 of 5 (Patient #1,2,3,4,5) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient that included all problems identified in the initial and comprehensive assessments. Patient 1: The plan of care includes ordered frequencies and visits by the social worker and spiritual care provider. There is no evidence of psychosocial or spiritual problems, goals, and interventions included in the current plan of care. Patient 2: The plan of care includes ordered frequency and visits by the social worker. There is no evidence of psychosocial problems, goals, and interventions included in the current plan of care. Patient 3: The plan of care includes ordered frequency and visits by the home health aide. There is no evidence of aide services to assist with ADLs included in the current plan of care. Patient 4: The plan of care includes ordered frequencies and visits by the social worker and spiritual care provider. There is no evidence of psychosocial or spiritual problems, goals, and interventions included in the current plan of care. Patient 5: The plan of care includes ordered frequency and visits by the home health aide. There is no evidence of aide services to assist with ADLs included in the current plan of care. The plan of care also includes ordered frequency and visits by the social worker. There is no evidence of psychosocial problems, goals, and interventions included in the current plan of care.

Upon patient record review, 1 of 5 records (Patient #2) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient 2: The medical record contained nursing documentation 12-28-21 identifying patient use of walker, shower bench, commode, oxygen concentrator, portable oxygen tank, and raised toilet seat. There is no evidence of listed DME included on the current plan of care.

Upon observation and discussion with the agency, there have been no new admissions since the time of the last survey. There are no new patient records to review that would contain the initial certification statement.

Upon patient record review, 2 of 4 applicable (Patients #4,#5) 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 4: The certification of terminal illness is outside allowable 15 day timeframe, dated 12-7-21 for benefit period 12-27-21 - 2-24-21. Patient 5: The certification of terminal illness is outside allowable 15 day timeframe, dated 12-21-21 for benefit period 1-7-21 - 3-7-21.

Upon observation, there was not evidence of a complete Emergency Preparedness plan that included a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. A Hazard Vulnerability Analysis was not on record.

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 agency has conducted exercises to test the emergency plan every two years. The only documented emergency drills are office fire drills which do not meet the requirements.

Upon patient record review, 1 of 13 (Patient #12) 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 #12-The record did not contain consent paperwork which the agency uses to 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.

Upon patient record review, 1 of 13 (Patient #12) 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 #12-The record did not contain consent paperwork to evidence the hospice obtained the patient's or representative's signature confirming that they received a copy of the Patient's Rights and Responsibilities.

Upon patient record review, 1 of 13 (Patient #12) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient #12-The record did not contain consent paperwork to evidence the patient chooses a health care provider, including an attending physician.

Upon patient record review, 1 of 13 (Patient #12) did not have evidence of the appropriate documentation for release of confidential information. Patient #12-The record did not contain consent paperwork to evidence in the patient record the appropriate documentation for release of confidential information

Upon patient record review, 1 of 13 (Patient #12) did not have evidence that the patient received information about the services covered under the hospice benefit. Patient #12-The record did not contain consent paperwork and did not evidence in the patient record that the patient received information about the services covered under the hospice benefit.

Upon patient record review, 1 of 13 (Patient #12) 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 #12-The record did not contain consent paperwork and did not evidence in the patient record that the patient received information about the scope of services that the hospice will provide and specific limitations on those services.

Upon patient record review, 1 of 13 (Patient #12) 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. Patient #12- A medication profile is not on record.

Upon patient record review, 1 of 13 (Patient #12) 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 #12-The patient was admitted 08/01/21. A bereavement risk assessment was not completed until 08/26/21.

Upon patient record review, 11 of 13 (Patient #1, #2, #3, #4, #5, #6, #7, #8, #10, #11, #12 ) 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- The record indicates comprehensive assessment updates were performed 09/08/21, 10/02/21 and 10/20/21. The timeframes are greater than 15 days. All documentation in IDGs/comprehensive assessments were performed by the Social Worker and Chaplain. The findings from the initial nursing assessment are not documented. The IDGs/comprehensive updates do not contain any documentation by the RN regarding changes that have taken place since the initial assessment, information on the patient's progress toward desired outcomes and/or a reassessment of the patient's response to care. The patient was admitted by the RN on 09/08/21. All visits on record 09/09/21-11/02/21 were performed by the LPN. The RN did not visit the patient to update the comprehensive assessment no less frequently than every 15 days. Patient #2- The record indicates IDGs/comprehensive assessment updates were performed 09/11/21, and 10/09/21. The timeframes are greater than 15 days. All documentation at IDGs/comprehensive updates were performed by the Social Worker. The RN did not perform comprehensive assessments/nursing visits between 09/01 and 10/25/21 to evaluate the patients plan of care and progress towards goals. All visits between 09/01/21 and 10/25/21 were performed by the LVN. IDG/comprehensive assessment updated documentation is not on record by the RN. Patient #3- The record indicates IDGs/comprehensive assessment updates were performed 09/15/21, and 10/06/21. The timeframes are greater than 15 days. All documentation at IDGs/comprehensive updates were performed by the Social Worker. IDG/comprehensive assessment updated documentation is not on record by the RN . The RN did not perform comprehensive assessments/nursing visits between 08/16/21 and 10/18/21 to evaluate the patients plan of care and progress towards goals. All visits between 08/16/21 and 10/18/21 were performed by the LVN. Patient #4- All documentation at IDGs/comprehensive updates between 09/11/21 and 10/23/21 were performed by the Social Worker and Chaplain. IDG/comprehensive assessment updated documentation is not on record by the RN. The RN did not perform comprehensive assessments/nursing visits between 09/02/21 and 10/19/21 to evaluate the patients plan of care and progress towards goals. All visits between 09/02/21 and 10/19/21 were performed by the LVN. Patient #5- All documentation at IDGs/comprehensive updates between 07/03/21 and 10/22/21 were performed by the Social Worker and Chaplain. IDG/comprehensive assessment updated documentation is not on record by the RN. The RN did not perform comprehensive assessments/nursing visits between 07/01/21 and 10/21/21 to evaluate the patients plan of care and progress towards goals. All visits between 07/01/21 and 10/21/21 were performed by the LVN. Patient #6- All documentation at IDGs/comprehensive updates between 09/09/21 and 10/06/21 were performed by the Social Worker and Chaplain. IDG/comprehensive assessment updated documentation is not on record by the RN during 09/09/21 and 10/06/21. Patient #7-There are no IDG/comprehensive assessment updates between 08/10/21 and 11/02/21 on record. Patient #8, #10, #11, #12- All documentation at IDGs/comprehensive updates were performed by the Social Worker and/or Chaplain. IDG/comprehensive assessment updated documentation is not on record by the RN.

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

Upon patient record review, 1 of 13 (Patient #11) did not have evidence in the patient record that the written plan of care is developed by the IDG, in consultation with the patient's attending physician. Patient #11- There was no evidence of a plan of care in the record.

Upon patient record review, 7 of 13 (Patient #1, #3, #4, #5, #10, #11, #12 ) 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-The patient was admitted on 09/08/21 by the nurse practitioner. There are no further RN visits on record. All visits between 9/8/21 and 10/06/21 have been performed by an LPN. On 10/05/21 the LVN documents there are new open areas on the patients scrotum and DTI to L heel. There is no evidence the findings were reported to the RN and/or RN oversight in the care planning and supervision of nursing services. Patient #3- On 08/11/21 orders were received for wound care to the patients Right foot fifth toe. All visits on record 08/16/21 to 10/18/21 were performed by the LVN. There is no documentation on record that the RN was involved in continuous assessment of the patients wound. Patient #4- On the nursing visit 09/06/21/physician order 09/06/21 the LVN documents the patient has pain of 7/8 standing on rt leg and was unable to walk. The physician gave an order for a doppler and Norco for pain. The next nursing visit did not occur until until 09/16/21 by the LPN and did not address whether or not the patient obtained the doppler and/or results. Visit notes 10/14 and 10/21 were also performed by the LPN and did not address whether or not the patient obtained the doppler and/or results. The RN did not visit until 10/27/21 and the visit note also did not address the ordered doppler and/or patients response to Norco. Patient #5-The NP performed the initial assessment 06/30/21. All subsequent visits were performed by the LPN 07/01/21-10/20/21. There are no further documentation/assessments on record by the RN other than LVN supervision stating the family is pleased with the services and the LVN follows the plan of care. Patient #10-On 10/22/21 the record documents the LVN visited the patient who had an infected boil on the stomach. Orders for antibiotic and wound care were received. There are no further nursing visits on record following 10/22/21 to evaluate the patients wound and no documentation of follow up from the RN. Patient #11-The RN admitted the patient with pneumonia and a sacral wound on 09/04/21 and visits were made by the LVN 09/07/21, 09/14/21 and 09/20/21 before transferring to another hospice. The RN did not develop a plan of care for the patient to coordinate activities with other members of the IDG and/or for delegating care to the LVN. Patient #12-The RN admitted the 54 year old patient on 08/01/21 with lung cancer and a PEG tube. A plan of care was not developed with interventions and a medication profile was not developed. All subsequent visits on record were performed by the LVN 08/04/21-10/07/21. There is no evidence an RN has been assigned to perform continuous assessment. The initial nursing evaluation documents the patient requested a shower chair. There is no evidence the RN ensured the patient received a shower chair.

Upon patient record review, 11 of 13 (Patient #1, #2, #3, #4, #5, #6, #7, #8, #10, #12, #13) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. Patient #1-The agency has a paper care plan beginning 09/08/21 signed by the physician which does not include Nursing, Spiritual Care or Social Worker goals. Patient #2- The initial 05/25/21 plan of care does not include Nursing, Spiritual Care or Social Worker goals. There are also no revised plans of care on record with goals. Patient #3- The initial 08/02/21 plan of care does not include Nursing, Spiritual Care or Social Worker goals. Patient #4-The patient was admitted on 01/12/21 and an initial plan of care is not on record. The 09/11/21 plan of care on record does not include Nursing, Spiritual Care or Social Worker goals. The 09/11/21 also does not include goals and interventions for pain identified on the 09/06/21 nursing documentation. Patient #5-The agency has a paper care plan beginning 06/30/21 signed by the physician which does not include Spiritual Care or Social Worker goals. Patient #6- The patient was admitted 05/12/21 and an initial plan of care is not on record. A plan of care was developed on 10/13/21 which does not include social worker interventions and goals. Patient #8-The patient was admitted 04/06/21 and an initial plan of care is not on record. A plan of care was developed on 05/21/21which does not include social worker interventions and goals. Patient #9-The 09/19/20 plan of care does not include Spiritual Care or Social Worker goals. Patient #10-The last plan of care on record is 07/09/21 and does not include Social Worker goals Patient #12-The agency has a paper care plan beginning 08/01/21 signed by the physician which does not include Nursing, Social Worker, or Aide goals. Patient #13-The plan of care dated 12/31/20 does not include Nursing Social Worker or Chaplain goals or interventions.

Upon patient record review, 5 of 13 (Patient #1, #2, #3, #4, #13) did not have evidence that the plan of care includes all services necessary for the palliation and management of the terminal illness and related conditions which including interventions to manage pain and symptoms. Patient #1-The agency has a paper care plan signed by the physician 09/08/21 which does not include interventions to manage pain and symptoms. Patient #2- The agency has a paper care plan signed by the physician 05/25/21 which does not include interventions to manage pain and symptoms. Patient #3- The agency has a paper care plan signed by the physician 08/02/21 which does not include interventions to manage pain and symptoms. Patient #4-The agency does not have a plan of care on record that includes interventions to manage Rt leg pain as documented on the 09/06/21 nursing visit note and physician orders. Patient #13-The 12/31/20 plan of care does not include any interventions to manage pain and symptoms.

Upon patient record review, 11 of 13 (Patient #1, #2, #3, #4, #5, #6, #8, #9, #10, #12, #13) 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 a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs Patient #1- The agency has a paper initial care care plan dated 09/08/21 which does not include the frequency for nursing, social worker or chaplain. There are also no nursing interventions on the plan of care. Patient #2- The agency has a paper initial care plan dated 05/25/21 which does not include the frequency for nursing, social worker or chaplain. There are also no nursing, social worker or chaplain interventions on the plan of care. Patient #3- The agency has a paper initial care plan dated 08/02/21 which does not include the frequency for nursing or social worker. There are also no nursing or social worker interventions on the plan of care. Aide visits are on record. The Aide was provided an Assignment sheet and instructions to provided care. There are no physician orders on record for Aide services. Patient #4- The 09/11/21 plan of care does not include Social Worker or Chaplain interventions/scope of services to be provided. Patient #5- The 06/30/21 plan of care does not include Social Worker or Chaplain interventions/scope of services to be provided. Patient #6-The patient was admitted 05/12/21 and an initial plan of care is not on record. A plan of care was developed 10/13/21 which does not include Social Worker scope of services to be provided. Aide visits are on record. The Aide was provided an Assignment sheet and instructions to provided care. There are no physician orders on record for Aide services. Patient #8-The most current plan of care is from 05/21/21 and the orders do not contain interventions for nursing, social worker or Chaplain services. Aide visits are on record. The Aide was provided an Assignment sheet and instructions to provided care. There are no physician orders on record for Aide services. Patient #9-The plan of care 09/19/20 does not include interventions for Social Worker and Chaplain services. Patient #10-The plan of care 07/09/21 does not include interventions for Social Worker. Patient #12 -The agency has a paper initial care care plan dated 08/01/21 which does not include the frequency for nursing, social worker ,or Aide. There are also no nursing or aide interventions on the plan of care. Patient #13-The plan of care 12/31/20 includes a frequency for Nursing, Social Worker and Chaplain. The orders do not include the scope of services to be provided.

Upon patient record review, 8 of 13 (Patient #1, #2, #3, #4, #5, #8, #10, #12) 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 agency has a paper plan of care dated 09/08/21 signed by the MD which does not include medications and/or treatments. Patient #2-The agency has a paper plan of care dated 05/25/21 signed by the MD which does not include medications and/or treatments. Patient #3-The agency has a paper plan of care dated 08/02/21 signed by the MD which does not include medications and/or treatments. On 08/11/21 an order was received for a stage 2 pressure ulcer to the Rt foot fifth toe. Orders include cleansing the site with saline, pat dry, apply hydrogel and cover with gauze. The frequency of dressing changes are not specified in the order. Patient #4-The plan of care 09/11/21 does not include medications. Patient #5-The plan of care 06/30/21 does not include medications. Patient #8-The plan of care 05/21/21 identifies a problem of pressure ulcer heel wound. The plan does not address the management of the wound including treatments to be provided. Patient #10- On 10/22/21 an order was written to update the plan of care as follows: Wound care to be performed three times a week. Flush with wound cleanser, pat dry with 4X4 and pack with Iodoform. Cover with Abd and fasten with tape. The site of the wound care is not specified in the order. Patient #12-The plan of care 08/01/21 does not include medications. The patient was admitted with a PEG tube. The plan of care does not include any interventions for nursing.

Upon patient record review, 5 of 12 applicable (Patient #1, #3, #4, #5, #12) 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 agency has a paper care plan dated 09/08/21 which does not include equipment and supply needs. According to the nurses initial assessment on 09/08/21 the patient needs chux, pull ups, wipes and gloves. Patient #3-The agency has a paper care plan dated 08/02/21 which does not include equipment and supply needs. According to the nurses initial assessment on 08/02/21 the patient has a shower bench, hospital bed, transfer board, walker and wheelchair. Patient #4-The agency plan of care 09/11/21 does not include equipment and supply needs. According to the nurses initial assessment on 01/12/21 the patient needs grab bars, hospital bed, and has a cane. Patient #5- The agency plan of care 06/30/21 does not include equipment and supply needs. According to the nurses initial assessment on 06/30/21 the patient needs a hospital bed and wheelchair. Patient #12-The agency has a paper care plan dated 08/01/21 which does not include equipment and supply needs. On admission the patient requested a shower chair.

Upon patient record review, 7 of 13 (Patient #1, #2, #3, #5, #6, #7, #12) 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- The record indicates IDGs were held 09/08/21, 10/02/21 and 10/20/21 to revise the plan of care. The timeframes are greater than 15 days. Revised plans of care every 15 days are not on record. Patient #2- The record indicates IDGs were held 09/11/21 and 10/09/21 to revise the plan of care. The timeframes are greater than 15 days. Revised plans of care every 15 days are not on record. Patient #3- The record indicates IDGs were held 09/15/21 and 10/06/21 to revise the plan of care. The timeframes are greater than 15 days. Revised plans of care every 15 days are not on record. Patient #5-The record indicates IDGs were held 07/03/21, 07/30/21, 08/26/21 and 09/17/21 to revise the plan of care. The timeframes are greater than 15 days. Revised plans of care every 15 days are not on record. Patient #6-The record indicates IDGs were held 09/09/21 and 10/16/21 to revise the plan of care. The timeframes are greater than 15 days. Patient #7- The record does not contain IDGs between 08/10/21-11/2/21 to evaluate/revise the plan of care. The timeframes are greater than 15 days. Patient #12-The record indicates IDGs were held 08/06/21 and 09/17/21 and 10/29/21 to revise the plan of care. The timeframes are greater than 15 days.

Upon patient record review, 10 of 12 applicable (Patient #1, #2, #3, #4, #5, #6, #7, #8, #10, #12) 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-The record indicates IDGs were held 09/08/21, 10/02/21 and 10/20/21 to revise the plan of care. All documentation at IDGs were by the Social Worker and Chaplain. The IDGs/revised plans of care do not contain any documentation by the RN to note information on the patient's progress toward desired outcomes. Patient #2-The record indicates IDGs were held 09/11/21 and 10/09/21 to revise the plan of care. All documentation at IDGs were by the Social Worker. The IDGs/revised plans of care do not contain any documentation by the RN.. Patient #3-The record indicates IDGs were held 09/15/21 and 10/06/21 to revise the plan of care. All documentation at IDGs were by the Social Worker. The IDGs/revised plans of care do not contain any documentation by the RN. On 10/19/21 a revised plan of care is on record. The patient has a pressure ulcer to the rt fifth toe. The RN did not revise the plan of care to include wound care problems, interventions and goals. Patient #4-The patients revised plan of care on 09/11/21 does not address pain as a problem and was not updated to include interventions for pain. Pain was identified on 09/06/21 when the nurse documents the patient had a pain level of 7/8 in right leg and was unable to walk. The MD subsequently ordered a doppler and pain medication. Patient #5-The record indicates IDGs were held 07/03/21, 07/30/21,08/26/21, 09/17/21, 09/27/21, 10/07/21 and 10/22/21 to revise the plan of care. All documentation at IDGs were by the Social Worker and Chaplain. The IDGs/revised plans of care do not contain any documentation by the RN. The patient was recertified 09/28/21 without a revised plan of care. Patient #6-The record indicates IDGs were held 09/09/21 and 10/06/21to revise the plan of care. All documentation was provided by the Social Worker. Patient #7- The record does not contain IDGs between 08/10/21-11/2/21 to evaluate/revise the plan of care. There are no revisions on record past 07/14/21. Patient #8-The record indicates IDGs were held 09/23/21 and 10/08/21 and 10/22/21 to revise the plan of care. All documentation was provided by the Social Worker and Chaplain. The nurse did not document updates to the plan of care. Patient #10- IDGs between 08/19/21 and 10/20/21 to revise the plan of care only included Social Worker documentation. The last plan of care update by nursing occurred on 07/09/21. Patient #12 IDGs between 08/06/21 and 10/29/21 to revise the plan of care only included Social Worker documentation. There are no plan of care updates on record by nursing.

Upon patient record review, 8 of 13 (Patient #1, #2, #3 , #5, #6, #8, #10, #12 ) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1, #2, #3, #5, #12- The plans of care on record did not include discipline frequencies, interventions, goals of care, medications and treatment orders for care that was provided. Patient #10- On 10/22/21 nursing orders were obtained for wound care three times weekly. There are no visits documented past 10/22/21 on record and no documentation regarding missed visits. Patient #12-The initial plan of care 08/01/21 documents the patient refused Chaplain services. The Chaplain visited 08/26/21. There are no orders on record for Chaplain services.

Upon patient record review 1 of 13 (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-The initial nursing assessment states the patient needs an aide 3 times weekly. There is no documentation that an order was received and aide care plan was developed. There are no Aide visits on record and no further documentation regarding the needs for an aide.

Upon observation, the governing body minutes did not evidence: Decision making, Adopting and periodically reviewing written bylaws or equivalent, Establishing or approving written policies and procedures governing operations, Human resource management, Community needs planning, Oversight of the management and fiscal affairs of the hospice or Annual review of the policies and procedures.

Upon personnel record review, 5 of 11 applicable (Personnel #3, #4, #5, #8, #13 ) did not have evidence that a complete skills competency assessment, specific to each discipline had been conducted for all personnel including volunteers initially during orientation. Personnel#3-The initial competency was incomplete. The competency assessment did not include the date skills were validated and/or validation method. Personnel #4-The initial competency on record was a self assessment competency. The RN supervisor documented that the RN verbalized the competencies. Personnel #5-The initial competency on record was a self assessment competency signed by the Administrator/RN. There is not evidence on record the BSW had a competency performed by an MSW. Personnel #8-There was not a skills competency on record for Volunteer Coordinator. Personnel #13-The LVN competency was signed by an RN and documents skills were reviewed and determined competent. There was no validation method on record.

Condition of Participation: Medical Director.

Upon patient record review, 12 of 13 (Patient #1, #2, #3, #4, #5, #6, #7, #8, #10, #11, #12, #13) 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 #1- A Certification of Terminal Illness is not on record. Patient #2- The initial CTI contains a nursing narrative with findings from the 05/25/21 visit note copied into the physician narrative. Patient #3- The initial CTI documentation is a narrative from the initial nursing assessment which documents the patients diagnosis, supply needs, anticipated visit frequency and past medical history, which was copied into the physician narrative. Patient #4-The patient was admitted on 01/12/21 and an initial CTI is not on record. Patient #5- The initial CTI narrative is a nursing note narrative from the nurses visit on 06/30/21 and documents SN greeted at door by patients daughter . The narrative and findings were copied into the physician narrative. Patient #6-The 05/21/21 CTI is a nursing narrative from the 05/21/21 visit copied into the physician certification. Patient #7- The 02/11/21 CTI is a nursing narrative from the 02/11/21 visit copied into the physician certification. Patient #8-The patient was admitted 04/26/21 and the record does not contain an initial CTI. Patient #10 -An initial CTI is not on record. Patient #11-An initial CTI is not on record. Patient #12-An initial CTI is not on record. Patient #13- An initial CTI is not on record.

Upon patient record review, 8 of 8 applicable (Patient #2, #4, #5, #6, #7, #8, #9, #10) 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 #2- The recertification CTI 08/23/21 is a nursing note narrative which documents arriving at the patients home, setting up a pill box and teaching provided. Patient #4-The patient was recertified on 09/09/21 and a recertification CTI is not on record. Patient #5- The patient was recertified 09/28/21 and a written certification of terminal illness is not on record Patient #6-The patient was recertified 08/10/21 and a recertification CTI is not on record. Patient #7- The record does not contain a recertification CTI for the period beginning 10/09/21. Patient #8- There is not a recertification CTI for the recertification period beginning 09/23/21 on record. Patient #9- A CTI for the recertification period 09/15/20 is not on record. Patient #10- A recertification CTI is not on record for benefit periods beginning 05/04/21, 08/02/21 or 10/01/21

Upon patient record review, 12 of 12 applicable (#1, #2, #3, #4, #5, #6, #7, #8, #10, #11, #12, #13) did not evidence the agency has a complete election statement in accordance with 418.24 and/or signed copies of the notice of patient rights in accordance with 418.52. The records did not contain the updated requirements for the election statement that went into effect on October 2020. Notification of the beneficiary’s right to request in writing, the “Patient Notification of Hospice Non-Covered Items, Services, and Drugs” addendum that includes information and rationale for why the hospice has determined items, drugs, or services unrelated to terminal illness and that immediate advocacy is available through the Beneficiary and Family-Centered Care Quality Organization (BFCCQIO) if the beneficiary disagrees with the hospice’s determination. Patient #12-Signed patient rights and an election statement are not on record.

Upon patient record review, 2 of 13 (Patient #1, #12) did not have evidence that all entries complete and accurate. Patient #1- On 10/05/21 the LVN documents the patient has a new open area to the scrotum and DTI to the left heel. The visit note does not include a specific description of the wound and or DTI to the heel. The record contains two social work visits documented on 09/08/21. One assessment documents a time of 18:30-19:30. One assessment documents a time of 19:30-20:30. (duplicate documentation/time in and out error) Patient #12-On the initial nursing assessment 08/01/21 the nurse documents the patient declines the Home Health Aide and family assists with shower. The documentation also documents Aide to be provided daily. (discrepancies in documentation).

Upon patient record review, 1 of 1 applicable (Patient #11) did not have evidence that the hospice forwarded a summary and a copy of the patient record, if requested, to a facility when transferring the patient to that facility. Patient #11-The patient was transferred to another Hospice 09/27/21. A transfer summary is not on record.

Upon patient record review, 2 of 2 applicable (Patient #11, #13) did not have evidence that the discharge summary includes all required information. Patient #11-The patient was transferred to another hospice 09/27/21 and a discharge summary is not on record. Patient #13- The patient revoked the Hospice election on 02/10/21. A discharge summary is not on record.

Upon personnel record review, 1 of 13 (Personnel #4) did not have evidence of a complete criminal background check. Personnel #4- The results of the criminal background check are not on record.