Every finding on record at Loma Linda Hospice Care, Inc

Upon personnel record review, 1 of 6 (Personnel #6) did not have evidence in the personnel file that the hospice aide had received at least l2 hours of in-service training during each 12-month period. In-service training may occur while an aide is furnishing care to a patient. Personnel #6: No HR record for aide that has been with the agency for 1 year or more to abate this condition level.

Upon personnel record review, 1 of 6 (Personnel #6) did not have evidence in the hospice aide personnel file that a registered nurse made an annual on-site visit to the location where a patient is receiving care in order to observe and assess each aide while he or she is performing care. Personnel #6: No HR record for aide that has been with the agency for 1 year or more to abate this condition level.

Condition of Participation: Medical Director.

Upon patient record review, agency 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 Unable to abate condition level deficiency as there have been no new admissions since prior survey to demonstrate compliance.

Upon patient record review, 3 of 5 (Patient #1, 2, 3) 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 form does not include physician written certification statement of 6 month or less life expectancy. "Given the advanced nature of the disease, it is my medical opinion that the patient is approaching the final stages of heart failure with a prognosis of six months or less. the patient and family have been counseled on the progression of the condition and are aware of the likely outcomes. " is in the space allocated for RN assessment narrative. Patient #2: Physician narrative includes details that are inconsistent with POC and RN/LVN notes for this patient. The physician references that patient is on oxygen 2lpm 24 seven and that uses multiple inhalers without improvement. Upon review, there is no oxygen ordered or inhalers listed in orders, med profile, POC or RN/LVN notes. Furthermore, "Given the advanced nature of the disease, it is my medical opinion that the patient is approaching the final stages of heart failure with a prognosis of six months or less. the patient and family have been counseled on the progression of the condition and are aware of the likely outcomes" is in the space allocated for RN Assessment narrative. MD narrative ends with plan continue hospice care in view of declining, but does not include related certification of 6 month or less prognosis. Patient #3: The F2F documentation, partially copied to the Certifying Physician Narrative does not include specific prognosis. "Given the advanced stage of COPD, it is my medical opinion that the patient's condition is deteriorating with a life expectancy of six moths or less. The patient and their family have been informed about the prognosis and are aware of the anticipated outcomes" is documented in the space allocated for RN Assessment narrative.

Upon patient client record review, the agency 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 Unable to abate condition level deficiency as there have been no new admissions since prior survey to demonstrate compliance.

Upon personnel record review, 7 of 10 (Personnel #1,2,3,4,5,9,10) did not have evidence Emergency Preparedness training including: • Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles • Demonstrate staff knowledge of emergency procedures • Provide emergency preparedness training at least annually • Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others • Maintain documentation of all emergency preparedness training There is no evidence of emergency preparedness training in the reference employee files.

Upon patient record review, 7 of 14 (Patient #1,2,6,7,8,10,11) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring All referenced patients had orders for "Oxygen 1-5L per NC for shortness of breath or to maintain O2 sat above 90%." Oxygen was not included on the medication profile.

Upon patient record review, 5 of 14 (Patient #1,3,4,6,8) 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 #1-There is no evidence that the RN updated the comprehensive assessment prior to recertification on 08/02/24, the RN was performing supervisory visits however, there was no assessment of the patient. #3-There is no evidence that the RN updated the comprehensive assessment prior to recertification on 07/03/24, the RN was performing supervisory visits however, there was no assessment of the patient.. #4-There is no evidence that the RN updated the comprehensive assessment prior to recertification on 08/21/24, the RN was performing supervisory visits however, there was no assessment of the patient. #6-There is no evidence that the RN updated the comprehensive assessment prior to recertification on 07/22/24, the RN was performing supervisory visits however, there was no assessment of the patient. #8-There is no evidence that the RN updated the comprehensive assessment prior to recertification on 06/24/24.\, the RN was performing supervisory visits however, there was no assessment of the patient.

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 medications and treatments. #8-Plan of care lists oxygen concentrator as DME, but patient did not have oxygen.

Upon patient record review, 1 of 14 (Patient #14) 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 #14-There is no evidence of a post-death bereavement plan of care.

Condition of Participation: Hospice Aide and Homemaker Services. L607

Upon personnel record review, 1 of 10 (Personnel #5) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) ·Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff. ·Reading and recording temperature, pulse, and respiration ·Safe transfer techniques and ambulation. ·Normal range of motion and positioning ·Appropriate and safe techniques in personal hygiene and grooming that include-- ·(A) Bed bath ·(B) Sponge, tub, and shower bath ·(C) Shampoo, sink, tub, and bed ·(D) Nail and skin care ·(E) Oral hygiene ·(F) Toileting and elimination The other subject areas in this section may be evaluated through written examination, oral examination or after observation of a Hospice Aide with a patient. #5-There are no evidence of skills competencies for the aide.

Upon personnel record review, 1 of 10 (Personnel #5) did not have evidence in the personnel file that the hospice aide had received at least l2 hours of in-service training during each 12-month period. In-service training may occur while an aide is furnishing care to a patient. #5-There is no evidence that the aide received 12 hours of in-service training.

Upon patient record review 1 of 14 (Patient #9) 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 #9-Plan of care includes aide frequency of 1 x wk, but no aide visits are documented.

Upon personnel record review, 1 of 10 (Personnel #5) did not have evidence in the hospice aide personnel file that a registered nurse made an annual on-site visit to the location where a patient is receiving care in order to observe and assess each aide while he or she is performing care. #5-There is no evidence in the employee file that a registered nurse made an onsite visit with the aide.

Condition of Participation: Organization and Administration of Services.

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. No oversight by governing body/administrator for valid election of benefit for all patients surveyed, CTI's missing narratives.

Upon observation, there was no evidence the hospice is primarily engaged in providing the following care and services: • Nursing services • Medical social services • Physician services • Counseling services, including spiritual counseling, dietary counseling and bereavement counseling • Hospice aide, volunteer, homemaker services • Physical therapy, occupational therapy, speech-language pathology services • Short-term inpatient care • Medical supplies (including drugs and biologicals) and medical appliance The hospice has a facility name, but no contract for inpatient or respite was produced for review prior to the end of survey. No employee files for therapists were available for review.

Upon personnel record review, 1 of 10 (Personnel #5) did not have evidence the hospice employees and contract employees have received orientation on the hospice philosophy. #5-There is no evidence of orientation on the hospice philosophy in the employee file.

Upon personnel record review, 1 of 10 (Personnel #5) did not have evidence that the hospice employees have received orientation on their specific job requirements. #5-There is no evidence of job specific orientation for the aide.

Condition of Participation: Medical Director.

Upon patient record review, 4 of 14 (Patient #1,4,5,10) 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 #1- CTI dated 12/26/23 does not contain a narrative statement. #4- Narrative statement on CTI dated 2/23/24 states "see separate document" - there is no separate document attached. #5-Narrative statement on CTI dated 02/14/24 states "see separate sheet" - there is no attachment. #10-Narrative statement on CTI dated 02/14/24 states "see separate report" - there is no attachment.

Upon patient record review, 7 of 14 (Patient #1,3,4,5,6,9,10) 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. #1-Narrative statement for CTI dated 08/02/24 does not contain evidence of patient specific data supporting the terminal diagnosis. #3-Narrative statement for CTI dated 07/03/24does not contain evidence of patient specific data supporting the terminal diagnosis. #4-Narrative statement for CTI dated 05/23/24 states "see separate report," not report is attached. Narrative statement for CTI dated 08/21/24 is blank. #5-Narrative statement for CTI dated 05/14/24 states " per review RN assessment, patient is appropriate for benefit period 2. Narrative statement for CTI dated 08/12/24 contains a face to face assessment, but no indication of decline or change in condition from benefit period 2 to 3. #6-Narrative statement on CTI dated 04/23/24 does not contain evidence of information related to the need for hospice services. #9-Narrative statement for CTI dated 06/17/24 does not contain evidence of patient data related to decline or change in condition is included. #10- Narrative statement for CTI dated 08/12/24 contains a face to face assessment, but no indication of decline or change in condition from benefit period 2 to 3.

Condition of Participation: Clinical Records.

Upon patient client record review, 14 of 14 (Patient #1,2,3,4,5,6,7,8,9,10,11,12,13,14) 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 All records are missing the election date on the election statement. Additionally the patients' signatures on the election statements are not dated.

Upon patient client record review, 14 of 14 (Patient #1,2,3,4,5,6,7,8,9,10,11,12,13,14) 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. All records are missing signature dates on consents and admitting clinician signatures are illegible and without credentials.

Upon personnel record review, 1 of 10 (Personnel #8) did not have evidence that all Speech Therapy Services are provided by a qualified licensed Speech-Language Pathologist (SLP) or Audiologist in accordance with the state's Speech-Language Pathology Practice Act and the hospice's policies and procedures and/or job descriptions. #8-There is no evidence of a SLP file to validate licensure.

Upon personnel record review, 1 of 10 (Personnel #7) did not have evidence all Occupational Therapy Services are provided by a qualified licensed Occupational Therapist (OT) in accordance with the state's Occupational Therapy Practice Act and the hospice's policies and procedures and/or job descriptions. #7-There is no evidence of an OT employee file to validate licensure.

Upon personnel record review, 1 of 10 (Personnel #6) did not have evidence all Physical Therapy Services are provided by a qualified licensed Physical Therapist (PT) in accordance with the state's Physical Therapy Practice Act and the hospice's policies and procedures and/or job descriptions. #6-There was no evidence of a PT employee file to validate licensure.

Upon personnel record review, 4 of 10 (Personnel #4,6,7,9) did not have evidence the hospice obtained a criminal background check on all contracted individuals who have direct patient care and access to patient records. There were no criminal background checks found for any contracted individuals.

Upon personnel record review, 6 of 10 (Personnel #1,2,3,5,9,10) 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. There is no evidence of criminal background checks for the referenced employees.