Every finding on record at Md Choice Hospice Care

Upon patient record review, 1 of 5 (Patient #4) 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 #4 DOD 1/25/24 There is no evidence of post death assessment, bereavement POC or any evidence of post death follow up.

Upon personnel record review, 1 of 7 (Personnel #6) 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 #6 HR file for the medical director contained blank competency sheet with personnel signature and date with no items checked off for skills items nor have preceptor initials nor signatures.

Upon personnel record review, 2 of 12 (Personnel #4, #5 ) 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 Personnel #4,#5: There was no evidence of initial training in Emergency preparedness (orientation forms are blank) for LVN and aide.

Upon patient record review, 1 of 14 (Patient #9) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient #9: There was no evidence the patient chose a health care provider, including an attending physician.

Upon patient record review 1 of 14 (Patient #4) 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 #4: SOC date 11/20/2023. Spiritual needs assessment occurred on 11/30/2023

Upon patient record review 3 of 14 (Patient #2, #6, #11) 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 #2: SOC date 11/22/2023. Spiritual needs assessment dated 11/23/2023 is incomplete and unsigned. No evidence of a spiritual needs assessment. Patient #6: There was no evidence of a psychosocial needs assessment. Patient #11: There was no evidence of a spiritual needs assessment.

Upon patient record review, 3 of 14 (Patient #4, #7, #10) 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 #4: Medication profile dated 11/20/2023 included MS 20mg/ml 0.25ml PO Q 4 hrs. pain moderate to severe, and Norco 5-325 One tab PO Q 4 Hrs PRN pain moderate to severe. There were no parameters of how to dispense which medication. Patient #7: Medication profile dated 10/29/2023 included MS 20mg/ml 0.25ml PO Q 4 hrs. pain moderate to severe, and dated 10/16/2023 Methadone 5mg tab One tab PO BID PRN pain moderate to severe. There were no parameters of how to dispense which medication. Patient #10: Medication list (no evidence of a formal medication profile) dated 5/12/2020 included Tramadol 50mg one POQ 4-6 hrs. PRN pain moderate and MS 20mg/ml,0.5ml SL Q 2hr PRN pain moderate to severe. There were no clear parameters for dispensing.

Upon patient record review, 1 of 14 (Patient #10) 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 #10: There was no evidence of updated visits since initial SN visit on admission.

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

Upon client record review, 1 of 14 (Patient #10) did not have evidence that the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions as identified in the comprehensive assessment. Patient #10: There was no evidence of a plan of care initiated based on comprehensive assessment needs.

Upon patient record review, 6 of 14 (Patient #3, #4, #5, #7, #10, #14) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #3: SOC SN assess identified Braden score of 12-high risk, and a stage l pressure ulcer on coccyx, no evidence of problem/goals interventions for skin integrity. Patient #4: SOC SN assess identified Braden score of 12-high risk, and a stage ll pressure ulcer on coccyx, no evidence of problem/goals interventions for skin integrity. Patient #5: SOC SN assess identified Braden score of 13-high risk, dysphagia at risk for aspiration, no evidence of problem/goals interventions for skin integrity or dysphagia/aspiration risk. Patient #7: SOC SN assess identified Braden score of 14-high risk, no evidence of problem/goals interventions for skin integrity. Patient #10: There was an order for Continuous care, however no there was no evidence of a Plan of care. Patient #14: SOC SN assess identified seizure disorder, dysphagia/aspiration risk, and fall risk of 11-high risk, no evidence of problem/goals interventions for seizure,dysphagia/aspiration or falls.

Upon patient record review, 3 of 14 (Patient #4, #7, #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 medications and treatments. Patient #4: Medication orders dated 11/20/2023 included MS 20mg/ml 0.25ml PO Q 4 hrs. pain moderate to severe, and Norco 5-325 One tab PO Q 4 Hrs PRN pain moderate to severe. There were no parameters of how to dispense which medication. Patient #7: Medication order dated 10/29/2023 included MS 20mg/ml 0.25ml PO Q 4 hrs. pain moderate to severe, and dated 10/16/2023 Methadone 5mg tab One tab PO BID PRN pain moderate to severe. There were no parameters of how to dispense which medication. Patient #10: Medication sheet included dated 5/12/2020 included Tramadol 50mg one POQ 4-6 hrs. PRN pain moderate and MS 20mg/ml,0.5ml SL Q 2hr PRN pain moderate to severe. There were no clear parameters for dispensing and there was no evidence of an order for any medications.

Upon patient record review, 1 of 14 (Patient #3) 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 #3: SN notes dated 11/11/2023 included several new pressure ulcers, no evidence of this information getting into care plan until IDG updated the POC on 11/24/2023.

Upon client record review, 5 of 14 (Patient #1, #2, #11, #12, #13) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1: Order dated 9/27/2023 included PT evaluation and treat. There was no evidence of a PT evaluation. Patient #2: SN order on SOC is 1x wk. For week of 12/4 and 12/11/2023 the LVN visits are incomplete and unsigned. Patient #11: SN orders from SOC 2x week, last SN note dated 9/21/2020, transfer order dated 10/3/2020. Patient #12: SN orders from SOC 1x week, last SN note dated 9/24/2020, transfer order dated 10/2/2020. Patient #13: SN orders from SOC 1x week. Last SN note dated 9/21/2020.

Upon personnel record review, 1 of 14 (Personnel #2) 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: • Physician services (may contract for physician services) • Nursing • Medical social services • Counseling Personnel #2: The RN/Alt. Adm./Alt DPCS was hired as contract staff and performing direct patient care per Administrator however, there was no evidence of extraordinary or other non-routine circumstance.

Upon patient record review, 4 of 14 (Patient #5, #6, #9, #10) 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 #5: No Post bereavement POC developed, no offer of services documented. Patient #6: Expired 1/7/2023, POC in place last correspondence occurred at month 6, month 9 due 11/1/2023 had no evidence of continuation of bereavement plan and no documentation as to why it ended. Patient #9: No Post bereavement POC developed, no offer of services documented. Patient #10: No Post bereavement POC developed, no offer of services documented.

Condition of Participation: Hospice Aide and Homemaker Services. L607

Upon personnel record review, 1 of 12 (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. Personnel #5: There was no evidence a competency assessment was performed by the aide with a patient or pseudo pt.

Upon patient record review, 3 of 14 (Patient #1, #4, #9) 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 #1: On Eliquis anticoagulant, and two medications for seizure disorder, no evidence on Aide assignment of bleeding or seizure precautions. Patient #4: On Eliquis anticoagulant, no evidence on Aide assignment of bleeding precautions. Patient #9: On Eliquis anticoagulant, no evidence on Aide assignment of bleeding precautions.

Upon patient record review 3 of 14 (Patient #1, #2, #4) 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 #1: Aide order dated 9/15/2023 2x week, week of 11/26/2023 there were 4 aide visits. Patient #2: Aide order at SOC 2x week. There were no visits or missed visits documented week 1. Patient #4: Aide order at SOC 2x week. There were no visits or missed visits documented week 1.

Upon patient record review 3 of 14 (Patient #1, #3, #7) 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 #1: Aide ordered 2x week, no evidence of supervisory visit, last dated 11/27/2023. Patient #3: Aide ordered 2x week, last supervisory visits dated 11/16/2023 and 12/2/2023, greater than 14 days apart. Patient #7: Aide ordered 2x week, last supervisory visits dated 10/26/2023 and 11/10/2023, greater than 14 days apart.

Upon observation, there was no evidence volunteers are used in day to day administrative and/or direct patient care roles. Upon arrival to agency informed they had no volunteers, Consultant asked to be a volunteer, corrected on site.

Upon observation, there was no evidence the hospice documents and demonstrates viable and ongoing efforts to recruit and retain volunteers. VC new to role in August, working to build a program, no evidence through current year.

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 was no evidence of any volunteer hours documented this calendar year.

Condition of Participation: Organization and Administration of Services.

Upon personnel record review, 1 of 12 (Personnel # 2) did not have evidence the alternate administrator's personnel record verifies that: • The employee has appropriate education and experience requirements • There is a signed job description for this role • The employee has been orientated to this role Employee #2, There was no evidence of a job description for the alt. admin. or orientation to the role.

Upon personnel record review, 2 of 12 (Personnel #4, #5 ) did not have evidence the hospice employees and contract employees have received orientation on the hospice philosophy. Personnel #4, #5: No evidence of orientation on the hospice philosophy for LVN and aide.

Upon personnel record review, 2 of 12 (Personnel #4, #5 ) did not have evidence that the hospice employees have received orientation on their specific job requirements. Personnel #4, #5: There was no evidence the hospice employees received orientation specific to their specific roles of LVN and aide.

Upon personnel record review, 3 of 12 (Personnel #3, #4, #5) 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 #3, #4, #5: There was no evidence that skills competency assessments were conducted during orientation for LVN, SC/BC, or aide.

Upon observation, there was no evidence the hospice designates a physician to serve as Medical Director which includes: • The Medical Director must be a doctor of medicine or osteopathy who is an employee or is under contract. • When the Medical Director is not available, a physician designated by the hospice assumes the same responsibilities and obligations as the Medical Director. There was no evidence of an alternate medical director.

Upon patient record review, 1 of 14 (Patient #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 Patient #10: There was no evidence of a written certification.

Upon patient client record review, 1 of 14 (Patient #9) 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 #9: EOB lacking date of election and attending physician

Upon patient client record review, 1 of 14 (Patient #10) did not have evidence that each patient record contains Physician certification and recertification of terminal illness.

Upon client record review, 3 of 14 (Patient #11, #12, #13) 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. Patients #11, #12, #13: All three transferred to another hospice, no evidence of a transfer summary sent to agency.

Upon client record review, 1 of 14 (Patient #7) 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 Patient #7: There was no evidence a discharge summary was sent to the attending physician.

Upon observation, there was no evidence that when the hospice provides durable medical equipment under contract, then the DMEPOS provider is accredited by a CMS approved accreditation organization. Contract provided had no evidence of accreditation, call to DME company proved none exists.