Every finding on record at Medicalone Health

Upon observation, there was no evidence that during the initial assessment visit in advance of furnishing care, the hospice provided the patient and/or family with verbal (meaning spoken) and written notice of the Patient's Rights and Responsibilities in a language and manner that the patient understands. Patient #5, Patient was admitted on 9/8/25. Policy for documentation states all charting will be completed in 48 hours. Upon review of this chart, no documentation was completed. The chart was completely empty with a few items documented in the initial nursing assessment.

Upon patient record review, 1 of 5 (Patient #5) 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 #5, Patient was admitted on 9/8/25. Policy for documentation states all charting will be completed in 48 hours. Upon review of this chart, no documentation was completed. The chart was completely empty with a few items documented in the initial nursing assessment.

Upon patient record review, 1 of 5 (Patient #5) 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 #5, Patient was admitted on 9/8/25. Policy for documentation states all charting will be completed in 48 hours. Upon review of this chart, no documentation was completed. The chart was completely empty with a few items documented in the initial nursing assessment.

Upon observation, there was no evidence the patient has the right to voice grievances/complaints regarding treatment or care that is (or fails to be) furnished and lack of respect of property by anyone who is furnishing care/service on behalf of the hospice. Patient #5, Patient was admitted on 9/8/25. Policy for documentation states all charting will be completed in 48 hours. Upon review of this chart, no documentation was completed. The chart was completely empty with a few items documented in the initial nursing assessment.

Upon patient record review, 1 of 5 (Patient #5) did not have evidence that if a state court has not adjudged a patient incompetent, any legal representative designated by the patient in accordance with state law may exercise the patient's rights to the extent allowed by state law. Patient #5, Patient was admitted on 9/8/25. Policy for documentation states all charting will be completed in 48 hours. Upon review of this chart, no documentation was completed. The chart was completely empty with a few items documented in the initial nursing assessment.

Upon client record review, 1 of 5 (Patient #5) did not have evidence that the plan of care included IDG's documentation of the patient's or families level of understanding, involvement and agreement with the plan of care. Patient #5, Patient was admitted on 9/8/25. Policy for documentation states all charting will be completed in 48 hours. Upon review of this chart, no documentation was completed. The chart was completely empty with a few items documented in the initial nursing assessment.

Upon patient record review, 1 of 5 (Patient #5) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient #5, Patient was admitted on 9/8/25. Policy for documentation states all charting will be completed in 48 hours. Upon review of this chart, no documentation was completed. The chart was completely empty with a few items documented in the initial nursing assessment.

Upon patient record review, 1 of 5 (Patient #5) did not have evidence of the appropriate documentation for release of confidential information. Patient #5, Patient was admitted on 9/8/25. Policy for documentation states all charting will be completed in 48 hours. Upon review of this chart, no documentation was completed. The chart was completely empty with a few items documented in the initial nursing assessment.

Upon patient record review, 1 of 5 (Patient #5) did not have evidence that the patient received information about the services covered under the hospice benefit. Patient #5, Patient was admitted on 9/8/25. Policy for documentation states all charting will be completed in 48 hours. Upon review of this chart, no documentation was completed. The chart was completely empty with a few items documented in the initial nursing assessment.

Upon patient record review, 1 of 5 (Patient #5) 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 #5, Patient was admitted on 9/8/25. Policy for documentation states all charting will be completed in 48 hours. Upon review of this chart, no documentation was completed. The chart was completely empty with a few items documented in the initial nursing assessment.

Upon patient record review 1 of 5 (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, Patient was admitted on 9/8/25. Policy for documentation states all charting will be completed in 48 hours. Upon review of this chart, no documentation was completed. The chart was completely empty with a few items documented in the initial nursing assessment.

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 the number and scope of distinct QAPI projects conducted annually.

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. Agency added a QAPI program that is completely empty. No evidence governing body addressed priorities for improved quality of care and patient safety.

Upon personnel record review, 1 of 12 (Personnel #6) 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 #6, Upon reviewing HR file, the spiritual care provider had completed a W-9 form and there was no evidence of a W-4 form in the chart.

Upon personnel record review, 1 of 12 (Personnel #2) did not have evidence that the RN who supervises classroom and practical training possesses a minimum of 2 years nursing experience, at least 1 year of which must be in home care. Personnel #2, No evidence the DPS possesses a minimum of 2 years nursing experience.

Upon patient record review 4 of 5 (Patient #1,2,3,4) 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 care plan directed these cares: ambulatory, w/c, bathroom, incontinence care. No evidence these items were completed by aide note on 8/30/25. Patient #2, Aide care plan directed these cares: dress, diet as tolerate, aspiration precaution. No evidence these items were completed by aide note on 8/23/25. Patient #3, Aide care plan directed these cares: dress, aspiration precaution. No evidence these items were completed by aide note on 8/26/25. Patient #4, Aide care plan directed these cares: dress, regular diet, aspiration precaution. No evidence these items were completed by aide note on 8/18/25.

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 as evidenced by no evidence of the governing body appointed the administrator, employed qualified Director of Clinical Services per agency job description, provided employees for core services as the spiritual care/bereavement coordinator is contract, and ensured Administrator oversight of hospice meeting policies and regulations by ensuring contracts in place and patient care and management oversight.

Upon contract review, 1 of 3 (No LCSW contract) did not have evidence the agreement to furnish any services under arrangement included that the hospice must retain administrative and financial management, and oversight of staff and services for all arranged services, to ensure the provision of quality care. Arranged care/services are supported by written contract/agreement that requires all care/services are: • Authorized by the hospice • Furnished in a safe and effective manner by qualified personnel • Delivered in accordance with the patient's plan of care LCSW has a W 9 for service for supervision of Social worker however, there was no evidence of contract between agency and LCSW.

Upon patient record review, 1 of 5 (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, No evidence of verbal certification or written CTI completed and signed by MD. Patient was admitted on 9/8/25. CTI is blank.

Upon patient record review 1 of 5 (Patient #5) did not have evidence a patient record maintained for each hospice patient. Patient #5, Patient was admitted on 9/8/25. Policy for documentation states all charting will be completed in 48 hours. Upon review of this chart, no documentation was completed. The chart was completely empty with a few items documented in the initial nursing assessment.

Upon patient client record review, 1 of 5 (Patient #5) 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, Patient was admitted on 9/8/25. Policy for documentation states all charting will be completed in 48 hours. Upon review of this chart, no documentation was completed. The chart was completely empty with a few items documented in the initial nursing assessment.

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: There is evidence the patient was admitted on 5/17/25. The spiritual assessment was completed on 5/29/25. Greater than 5 calendar days.

Upon patient record review 1 of 14 (Patient #1) 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: There is evidence the patient was admitted on 7/18/25. The spiritual assessment was not completed.

Upon patient record review, 6 of 14 (Patient #1,2,3,5,6,8) 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: Upon observation of the nursing facility medication record, Quetiapine fumarate 25 mg. BID was listed on the Facility Medication Record but Not on the hospice medication record. (Corrected on site, order obtained from medical director.) Patient #2: There is evidence in the medical record on 7/7/25 an order for Moxifloxacin 0.5%, each eye TID for 5 days. The medication is still on the medication record. Patient #3: There is evidence in the medical record on 6/23/25 of an order for MiraLAX 17 g. daily. The medication instructions do not indicate to dilute the powder with fluid. Patient #5: Upon observation of the facility medication record, Depakote ER 250 mg daily was Not listed on the Facility Medication Record but was on the hospice medication record. Patient #6: There is evidence in the medical record on 7/1/25 an order for Macrobid 100 mg BID for 5 days. The medication is still on the medication record. Additionally, on 5/6/25 the medication Permethrin 5% topical cream, apply and repeat in 7 days. Report if condition persists, Scabies. The medication is still on the medication record. Patient #8: There is evidence in the medical record on 5/22/25 the medication Permethrin 5% topical cream, apply and repeat in 7 days. Report if condition persists, Scabies. The medication is still on the medication record.

Upon patient record review, 2 of 14 (Patient #1,5) 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 #1: There is evidence the patient was admitted on 7/18/25. A bereavement assessment was not completed in 5 days. Patient #5: There is evidence the patient was admitted on 5/12/25. A bereavement assessment was completed on 5/29/25. Greater than 5 days.

Upon patient record review, 1 of 14 (Patient #7) 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 #7: There is no evidence in the medical record that the RN visited the patient from 5/6/25 to 6/3/25. The patient is in an ALF and there was not visit by a RN for coordination and implementation of the plan of care.

Upon patient record review, 2 of 14 (Patient #5,7) 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 #5: There is evidence in the medical record on the Nursing initial assessment 5/12/25 "family want/need funeral plans". MSW was declined by the family. There was no Problem/Intervention/Goal opened to assist family with funeral plans. Patient #7: There is evidence in the medical record on the Nursing initial assessment 5/5/25 "family want/need funeral plans" and "patient has extreme anxiety about diagnosis". MSW was declined. There was no Problem/Intervention/Goal opened for anxiety or to assist with funeral plans.

Upon patient record review, 6 of 14 (Patient #1,2,3,5,6,8) 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 #1: Upon observation of the nursing facility medication record, Quetiapine fumarate 25 mg. BID was listed on the Facility Medication Record but Not on the hospice . (Corrected on site, order obtained from medical director.) Patient #2: There is evidence in the medical record on 7/7/25 an order for Moxifloxacin 0.5%, each eye TID for 5 days. The medication is still on the medical record. Patient #3: There is evidence in the medical record on 6/23/25 of an order for MiraLAX 17 g. daily. The medication instructions do not indicate to dilute the powder with fluid. Patient #5: Upon observation of the facility medication record, Depakote ER 250 mg daily was Not listed on the Facility Medication Record but was on the hospice medical record. Patient #6: There is evidence in the medical record on 7/1/25 an order for Macrobid 100 mg BID for 5 days. The medication is still on the medical record. Additionally, on 5/6/25 the medication Permethrin 5% topical cream, apply and repeat in 7 days. Report if condition persists, Scabies. The medication is still on the medical record. Patient #8: There is evidence in the medical record on 5/22/25 the medication Permethrin 5% topical cream, apply and repeat in 7 days. Report if condition persists, Scabies. The medication is still on the medication record.

Upon client record review, 3 of 14 (Patient #2,3,4) 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 #2,4: There is no evidence in the medical record the IDG on 7/14/25 that the Chaplain participated in the meeting. There is no signature by the chaplain, the hospice does not keep a record of staff participating in IDG. Patient #3: There is no evidence in the medical record the IDG on 7/14/25 that the Chaplain or MSW participated in the meeting. There is no signature by the chaplain or by the MSW, the hospice does not keep a record of staff participating in IDG.

Condition of Participation: Quality Assessment and Performance Improvement.

Upon observation, there was no evidence the board of directors/governing body approves the frequency and detail of the data collection.

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.

Upon observation, there was no evidence of involvement of the governing body and organizational leaders in the Quality Assessment/Performance Improvement (QAPI) program.

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.

Upon observation, there was no evidence the hospice ensures that non-core services are provided to hospice patients and their families according to applicable laws and regulations. Non-core services include Physical Therapy, Occupational Therapy and Speech-Language Pathology. The agency did not have employed non-core personnel nor an executed contract for these services.

Condition of Participation: Hospice Aide and Homemaker Services. L607

Upon personnel record review, 1 of 12 (Personnel #2) did not have evidence that the RN who supervises classroom and practical training possesses a minimum of 2 years nursing experience, at least 1 year of which must be in home care. The RN graduated from nursing school in December 2023. He began working for the hospice in December 2024. He did not have any supervisory experience.

Upon patient record review, 2 of 14 (Patient #3,10) 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 #3: There is evidence in the medical record 6/23/25 of an order for Divalproex 375 mg at HS for seizures. The home health aide plan of care does not indicate seizure precautions. Patient #10: There is evidence in the medical record 11/19/24 of an order for Pradaxa 150 mg BID as a blood thinner. The home health aide plan of care does not indicate bleeding precautions.

Upon patient record review 1 of 14 (Patient #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 is evidence in the medical record of an order on 6/30/25 for Aide visit 1X week. There have not been aide visits since admission.

Upon patient record review 2 of 14 (Patient #4,7) 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 #4: There is evidence in the medical record that the aide visited the patient on 6/23/25 and 6/26/25. There was a supervisory visit by the RN on 7/12/25, but no supervisory note was completed by the RN. Patient #7: There is evidence in the medical record that the aide visited the patient on 5/16/25. There was no supervisory visit/note by the RN between 5/6/25 and 6/4/25.

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 as evidenced by the agency is unable to provide all non-core services (PT/OT/SLP) due to none of these disciplines employed and no evidence of an executed contract. In addition, Director of Clinical Services is not qualified based on California regulations and ACHC standards.

Upon contract review, 1 of 3 (Non-core therapy) did not have evidence the agreement to furnish any services under arrangement included that the hospice must retain administrative and financial management, and oversight of staff and services for all arranged services, to ensure the provision of quality care. Arranged care/services are supported by written contract/agreement that requires all care/services are: • Authorized by the hospice • Furnished in a safe and effective manner by qualified personnel • Delivered in accordance with the patient's plan of care The agency did not have an executed contract for therapy (PT/OT/SLP) services as it had not been signed nor dated.

Upon patient record review, 2 of 14 (Patient #6,10) 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 #6: There is evidence in the medical record the physician did not document a life expectancy of 6 months or less for recertification of benefit period #10 beginning 7/5/25. The physician narrative in the Certification of Terminal Illness stated: "Patient's general condition is now plateauing with no further decline. Patient can be transferred to HHC, f/u with PCP, reassessed for hospice care if her condition deteriorating in the future." (Hospice has not billed for July.) Patient #10: There is evidence in the medical record the physician did not document a life expectancy of 6 months or less for recertification of benefit period #3 beginning 5/18/25. The physician narrative in the Certification of Terminal Illness stated: "Discussed with staff can be discharged to HHC, f/u with PCP, reassessed for hospice care if her condition deteriorating in the future." ( Hospice billed 27 days in May.)

Upon patient client record review, 3 of 14 (Patient #1,4,6) 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 #1,4,6: There is evidence on the Election Statement the effective date of hospice services was left blank.

Upon patient client record review, 10 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 #1-10: There is evidence on the Hospice Election Statement that staff signed the election statement with first name and last initial with out credentials.

Upon inpatient contract review, 1 of 3 (Vacaville) did not have evidence that the hospice patient's inpatient clinical record includes a record of all inpatient services furnished and events regarding care that occurred at the facility; that a copy of the discharge summary be provided to the hospice at the time of discharge; and that a copy of the inpatient clinical record is available to the hospice at the time of discharge.

Upon SNF/NF contract review, 1 of 3 (Vacaville) 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: • 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 3 (Vacaville) 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 3 (Vacaville) 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 3 (Vacaville) did not have a delineation of the responsibilities of the hospice and the SNF/NF to provide bereavement services to SNF/NF personnel.

Condition of Participation: Personnel Qualifications.

Upon personnel record review, 1 of 12 (Personnel #4) did not have evidence that all Medical Social Services are provided by a qualified Medical Social Worker in accordance with the state's Social Work Practice Act, the hospice's policies and procedures and/or job descriptions. There is no evidence of an MSW was serving as an active advisor since 12/1/24 to the BSW.

Upon personnel record review, 1 of 12 (Personnel #12) 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. No evidence of SLP HR file available.

Upon personnel record review, 1 of 12 (Personnel #12) 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. No SLP HR file available.

Upon personnel record review, 1 of 12 (Personnel #7) 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.

Upon patient record review, 3 of 5 records (Patients #2,#3,#4) 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 2: The medication profile contained: duplicative senna PRN orders, one states 1 tab bid prn, one states 2 tabs bid prn, no difference in indication of constipation; duplicative acetaminophen suppository with same dose and instructions except one states indication fever and the other is fever and mild pain; duplicative bisacodyl suppositories with same dose and only difference in instructions with one stating when patient unable to swallow, otherwise same 1 suppository as needed if no bowel movement x 3 days. Corrected on site. Patient 3: The medication profile contained: Zithromax ordered 6/8/22 for five days still listed as current; Seroquel frequency states as needed but instructions state 11/2 tables at night and ½ tab in the morning; duplicative senna scheduled for 2 tabs daily, only difference with instructions is one states hold for loose; duplicative senna prn, only difference with instructions 1 tab twice daily as needed and one states 2 tabs twice daily as needed; duplicative bisacodyl suppository prn, one states patient unable to swallow, both state 1 suppository as needed if no bowel movement x 3 days; acetaminophen suppository duplicative every 6 hours prn, one states for fever if unable to swallow, one states not to exceed 4 gm in 24 hr period for mild pain. Corrected on site. Patient 4: The medication profile contained: Haloperidol tablets duplicative both 0.5mg q6h prn, one for agitation, one for restlessness/agitation, third haldol listed 2mg/ml give 0.5mg immediately as needed for restlessness/hallucination/nausea/vomiting, may repeat in 1 hour if first dose ineffective; Prochlorperazine/Compazine duplicative 10 mg one states 1 tab immediately as needed for nausea or vomiting, may repeat x 1 in 4 hours, other says give 1 tab for nausea or vomiting, repeat in 4 hours and notify hospice if ineffective after 2 consecutive doses.

Upon patient record review, 3 of 5 records (Patients #1,#2,#3) 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 medical record contained nursing documentation upon admission 4/6/22 identifying patient use of an air mattress. There was no evidence of the mattress included as DME on the plan of care. Corrected on site. Patient 2: The medical record contained nursing documentation upon recertification 7/11/22 identifying patient use of hoyer lift. There was no evidence of the lift included as DME on the plan of care. Corrected on site. Patient 3: The medical record contained nursing documentation upon recertification 6/8/22 identifying patient use of air mattress, hoyer lift, shower chair, and commode. There was no evidence of the mattress, lift, shower chair, and commode included as DME on the plan of care. Corrected on site.

Upon patient record review, 2 of 5 records (Patients #2,#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 2: The medical record contained RN visits completed 5/13/22, 5/16/22, 6/8/22, and 7/7/22. There was no evidence of the comprehensive assessment completed no less than every 15 days. Patient 3: The medical record contained RN visits completed 5/11/22, 6/8/22, and 7/7/22. There was no evidence of the comprehensive assessment completed no less than every 15 days.

Upon client record review, 2 of 5 records (Patient #3,#4) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 3: The medical record contained an order for nursing frequency once weekly by LVN and once monthly by the RN. There was evidence of two scheduled nursing visits the week of 7/3/22. Patient 4: The plan of care identifies the nursing frequency as "2 per 2 weeks". There was evidence of two scheduled nursing visits weekly throughout length of service.

Upon patient record review 1 of 1 applicable (Patient #1) 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: The order for aide frequency in the plan of care was three times weekly. The aide visits were completed twice weekly from the week of 5/31/22 to current.

Upon client record review, 1 of 1 applicable record (Patient #4) did not have evidence that the discharge summary includes all required information. Patient 4: The discharge summary that was sent to the physician did not include a summary of the patient's stay, the current plan of care, and the latest orders. Corrected on site.

Upon personnel record review, 1 of 12 files (Personnel #12) 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. Personnel 12: There was no evidence of a criminal background check for the contracted speech pathologist.

Upon observation, there was missing evidence the hospice complies with all applicable federal, state, and local emergency preparedness requirements by establishing an emergency preparedness program that meets the requirements of 42 CFR 418.113 nor an emergency preparedness communication plan that complies with federal, state, and local laws . The agency was not able to evidence an emergency preparedness plan nor an emergency preparedness communication plan. The agency did have a staff phone tree and documented testing activities related a fire in the microwave and earthquake, however, the agency still was not able to demonstrate an emergency plan nor emergency communication plan as outlined in the standards.

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

Upon patient record review, 1 of 6 (Patient #5) 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 #5 RN completed wound assessment and measurements on admission visit 12/21/21, no evidence of a wound assessment or measurements after admission visit. Wound care provided from 12/21/21 until 2/22/22 visit that documented wound healed.

Upon patient record review, 2 of 6 (Patient #2 and #4) 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 #2 initial plan of care and subsequent plan of care updates every two weeks included orders for social work and chaplain 1 time then prn. Patient #4 initial plan of care included order for chaplain 1 time then prn for assessment and eval then prn.

Upon patient record review, 1 of 6 (Patient #1) 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 initial nursing assessment documented caregiver doing straight cath prn verbalized understanding. No evidence of an order for straight cath.

Upon client record review, 5 of 6 (Patient #2, #3, #4, #5, and #6) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #2 initial plan of care and subsequent plan of care updates every two weeks included orders for social work and chaplain 1 time then prn. Social work visit completed on 1/23/22, no evidence of any other visits or refused visits by social work. No evidence of any visits or refused visits by chaplain. Patient #3 initial plan of care and subsequent plan of care updates every two weeks included orders chaplain visit frequency of 1 time and SN 2week and 1prn. One chaplain visit documented on 8/30/21, no further visits or refusal of visits by chaplain. Nursing visits completed on 3/20/22, 3/24/22, 3/25/22, three times this week no evidence of prn visit. RN visits completed on 4/3/22, 4/4/22, 4/5/22, and 4/8/22, four times this week no evidence of prn visit. Patient #4 initial plan of care and subsequent plan of care updates every two weeks included orders for RN 2 per 2 week and 1prn to start on 7/11/21. RN visit completed on 7/9/21, no evidence of an order for this visit. Nursing visits completed 2 times per week from 7/12/21-8/5/21. Patient #5 initial plan of care and subsequent plan of care updates every two weeks included orders for RN 1x/week and 2prn. RN visits completed on 1/31/22 and 2/3/22. Wound care order dated 12/21/21 for buttocks wound to clean with wound cleanser pat dry, apply mepilex foam dressing twice a week until healed. Wound care was completed once a week during nursing visits, no evidence of wound care a second time for each week. RN visits on 1/18/22 and 1/25/22 documented Bacitracin applied to wound, no evidence of order for bacitracin to wound. Patient #6 initial plan of care and subsequent plan of care updates every two weeks included orders for social work and chaplain 1 time assessment then 1 time per month and 1prn. Social work visit completed on 12/23/22 and chaplain visit completed on 2/4/22, no evidence of additional visits or refused visits for social work and chaplain.

Upon observation, there was missing evidence the board of directors/governing body approves the frequency and detail of the data collection.

Upon observation, there was missing evidence of involvement of the governing body and organizational leaders in defining the Quality Assessment/Performance Improvement (QAPI) program.

Upon observation, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient #2 and #3 RN began patient assessment and reached back into clean plastic bag to obtain stethoscope, thermometer, and O2 Sat monitor with dirty gloves.

Upon personnel record review, 1 of 1 applicable (Personnel #4) did not have evidence in the personnel file that aide competency assessment was performed with a patient or pseudo-patient. Personnel #4 Aide competency completed and method of evaluation for all tasks is verbal completion. No evidence of observation with a patient or pseudo patient for the aide competency.

Upon patient record review 1 of 3 applicable (Patient #6) did not have evidence documentation in the patient record that a hospice aide provides services that are ordered by the IDG and included in the plan of care. Patient #6 initial plan of care ordered aide visits as 2x/week. Aide visits completed weekly from 12/20/21-2/24/22. No evidence of a second visit or a refused visit for these weeks.

Upon observation, there was missing evidence the Board of Directors/governing body assumes full legal authority and responsibility for the operation of the hospice including the QAPI program. No evidence that the governing body assumes responsibility for QAPI program such as defining the program and approving the frequency and detail of data collection.

Upon patient client record review, 1 of 6 (Patient #3) did not have evidence that each patient record contains a signed election statement in accordance with 418.24. Patient #3 notification of non-covered services provided to caregiver and signed by caregiver, however, no evidence of the date the caregiver received the notification of non-covered services.