Every finding on record at Mlsg Corporation

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: The hospice office contained a refrigerator that contained employee food. In addition, Medications where present for four different patients. These medications where: 1) Lorazepam 2mg/ml with an empty syringe in the same package, 2) Morphine Sulfate Oral Solution 100 mg/5ml, 3) Flu Shot, 5) Lorazepam 0.5 ml tabs - five tabs in bottle, 6) Morphine Sulfate Oral Solution 100mg/5ml - 3 bottles with two unopened and one empty syringe.

Upon personnel record review, 1 of 12 (Personnel #8) 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. Personnel #8 Aide competencies did not include: 1) Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff. 2) Appropriate and safe techniques in personal hygiene and grooming that include - a) Sponge bath, b) Shampoo/ sink, tub, and bed.

Upon patient record review, 1 of 14 (Patient #5) 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 # 5 - aide POC did not have frequency for Perineal Care

Upon patient record review 2 of 14 (Patients #9, 10) 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 # 9 - the aide documented repositioning on 2/25, 2/28, 3/4/2025. This task was not on the patient's aide POC. Change of bed linens was ordered on the aide POC each visit. This was not done on visit dated 2/28/2025 Patient # 10-catheter care for foley ordered for aide to perform each visit on 12/10/2024, this was not completed on 1/10/2025 visit. Aide repositioned patient, not included on aide POC.

Upon patient record review 1 of 14 (Patient #10) did not have evidence in the patient record that the hospice aides report: • Changes in the patient's medical, nursing, rehabilitative, and social needs to a registered nurse, as the changes relate to the plan of care and quality assessment and improvement activities • Hospice aides must also complete appropriate records in compliance with the hospice's policies and procedures. Patient #10 Aide documented a new finding for the patient, stating she had redness in the perineal area. There was no evidence of this finding being reported to the Registered Nurse.

Upon personnel record review, 1 of 14 (Personnel # 8) 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. The supervising nurse must assess an aide's ability to demonstrate initial and continued satisfactory performance in meeting outcome criteria that include all required content. Personnel #8: Documentation of the on-site visit was not present in the Aide's personnel file.

Upon observation, there was no evidence the hospice discussed the policies and procedures for managing the safe use and disposal of controlled drugs with the patient or representative and the family in a language and manner that they understand to ensure that these parties are educated regarding the safe use and disposal of controlled drugs. Upon review of patient's #13 and #14 there was not a discussion with the family regarding the destruction of the medications, including controlled drugs, or what decisions were made regarding the disposal of the medications no longer needed by the patient.

Upon patient record review, 1 of 5 records (Patient #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 #4: The nurse documentation on the 6/3 IDG note, reflects the patient was on O2 at 2 liters however oxygen was not on the medication profile.

Upon patient record review, 3 of 5 (Patient #2, #4, #5) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient based upon findings in the initial and comprehensive assessments. Patient #2: The Chaplains' comprehensive assessment noted depression, isolation, the need to build relationship and monthly visits, however there was no care plan with problems/interventions or goals. Patient #4: The medical record reflects on the 6/3 IDG note, that the patient was on O2 at 2 liters however there was no respiratory problems or interventions/goals noted on the care plan. Patient #5: The spiritual care plan was opened for spiritual distress but there was no intervention noted.

Upon patient record review, 1 of 5 (Patient #4) 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: The patient was on O2 at 2 liters per nasal canula as documented in the medical record but there was no order for the oxygen.

Upon client record review, 1 of 5 records (Patient #1) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1: Missing evidence evidence of a weekly Skilled Nurse visit the weeks of 4/24, 5/8, 5/15, and 5/22.

Upon patient record review, 1 of 4 applicable records (Patient #4) did not have evidence in the patient record that hospice aide assignments and duties include the tasks to be provided and the frequency of the tasks. Patient #4: There was no evidence of a completed Aide care plan in the medical record, however, the aide visits 2 times a week.

Condition of Participation: Initial and Comprehensive Assessment of the Patient.

Upon patient record review 1 of 11 (Patient #8) 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 #8- The patient was admitted on 5/4/22, there was no evidence of an initial nursing assessment completed within 48 hours of the election as part of the comprehensive assessment.

Upon patient record review 2 of 11 (Patient #5 and #8) 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 #5- There was no evidence of a psychosocial assessment of the patient/ family as part of the comprehensive assessment. Patient #8- The patient was admitted on 5/4/22, there was no evidence of a completed comprehensive assessment by any discipline in the medical record at the time of record review on 5/10/22.

Upon patient record review, 8 of 11 (Patient #1, 2, 3, 4, 6, 7, 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 Patient #1, 2, 3, 4, 7, 10, 11- Patient record contained information that the patient was on oxygen. Oxygen was not listed on the medication profile. Patient #3- The medication profile included diclofenac gel to affected area. The site of application was not specified. Patient #4- The medication profile included naloxone 4mg nasal spray, 1 spray each nostril as needed. The indication for use was not specified. Patient #6- Skilled nurse note dated 4/9/22 indicated use of triamcinolone cream 2 x daily. The medication was not included on the medication profile. Patient #10- Duoneb, doxycyline and simvastatin were included on the medication profile. The medication profile did not include the indication for use.

Upon patient record review, 8 of 11 (Patient #1, 2, 3, 4, 5, 6, 8, 11) 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.

Upon patient record review, 1 of 11 (Patient #6) 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 #6- The comprehensive assessment was last updated 4/13/22. There was no evidence of an update at the time of survey.

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

Upon patient record review, 9 of 11 applicable (Patient #1, 2, 3, 5, 6, 7, 8, 9, 10) 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 #1- The patient was being seen by SN and HHA. The plan of care did not include problem statements with goals or interventions for either discipline. Patient is on aspirin. Patient was not assessed for risk of bleeding, no problems, goals or interventions for bleeding risk. Patient #2- The patient was being seen by SN and SC. The plan of care did not include problem statements with goals or interventions for either discipline. Patient #3, 9, 10- The patient was seen by SN, HHA, SC, SW. The plan of care did not include problem statements with goals or interventions for any discipline. Patient #5- Patient is on enoxaparin. Patient was not assessed for risk of bleeding, no problems, goals or interventions for bleeding risk. Patient #6, 7- The patient was seen by SN, SC, SW. The plan of care did not include problem statements with goals or interventions for any discipline. Patient #8 There was no evidence of a plan of care developed. No problems, goals and interventions identified. Patient #9- There was no evidence a plan of care was developed in the medical record.

Upon patient record review, 7 of 11 (Patient #1, 2, 3, 6, 7, 9, 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 measurable outcomes are anticipated from implementing and coordinating the plan of care for each patient by using data elements identified by the hospice and is used as part of the Hospice's QAPI program. Patient #1, 2, 3, 6, 7, 9, 10- The plan of care did not include measurable outcomes.

Upon patient record review, 9 of 11 (Patient #1, 2, 3, 4, 6, 7, 9, 10, 11) 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, 2, 3, 4, 7, 10, 11- Patient record contained information that the patient was on oxygen. There was no evidence of an order for oxygen. Patient #3- The plan of care included diclofenac gel to affected area. The site of application was not specific. Patient #4- The plan of care included naloxone 4mg nasal spray, 1 spray each nostril as needed. The indication for use was not specified. Patient #6- Skilled nurse note dated 4/9/22 indicated use of triamcinolone cream 2 x daily. The no evidence of an order for triamcinolone. Patient #9- Order dated 5/2/22 for wound care: cleanse with normal saline, apply steri-strip every visit and PRN. The order did not include the location of the wound or the ordered frequency of the wound care. Patient #10- Duoneb, doxycyline and simvastatin were included on the plan of care. The order did not include the indication for use.

Upon patient record review, 5 of 11 (Patient #1, 2, 3, 5, 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 equipment and supply needs. Patient #1- The medical record contained information that the patient required oxygen concentrator and supplies, hospital bed and suction machine. The equipment and supplies were not listed on the plan of care. Patient #2-The medical record contained information that the patient required a wheelchair, hospital bed and nebulizer. The equipment and supplies were not listed on the plan of care. Patient #3- The medical record contained information that the patient required oxygen concentrator and supplies, nebulizer and suction machine. The equipment and supplies were not listed on the plan of care. Patient #5- The medical record contained information that the patient required wound care to right leg. The equipment and supplies necessary were not listed on the plan of care. Patient #10- The medical record contained information that the patient required oxygen and had a foley catheter. The equipment and supplies necessary were not listed on the plan of care.

Upon patient record review, 2 of 11 (Patient #3, 6) 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 #3- The IDG/ POC Update was blank for 1/28/22. The patient was admitted 1/19/22, the next POC update was documented on 2/11/22. Patient #6- Last IDG with plan of care update was documented 4/22/22, there was no evidence of an update since then.

Upon patient record review, 10 of 11 (Patient #1, 2, 3, 4, 5, 6, 7, 9, 10, 11) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1- SN documented 5 visits week of 11/16/21 and 1 visit week of 11/21/21. There was no evidence of an order for SN. Patient #2- SN documented visits week of 11/15/21 and 1 visit week of 11/21/21. There was no evidence of an order for SN. Patient #3- SN frequency order was 1 visit, 2-3 PRN. SN documented visits on 1/28/22, 2/2/22, 2/7/22, 2/16/22 and 2/18/22. Order for SC 1 x month. There was no evidence that a visit was made. Patient #4- SN visit frequency was 2w1, then 1 x week, 2-3 PRN. There was evidence of only 1 SN visit week of 3/10/22, 2 SN visits week of 3/20/22 on 3/22/22 and 3/24/22, 2 SN visits week of 4/3/22 on 4/7/22 and 4/9/22. No evidence any of the extra visits were for a PRN need. There was no evidence of SN visits being performed after 4/16/22. Patient #5- SN visit frequency was 2 x week, 2-3 PRN. There was evidence of 4 SN visits documented the week of 1/2/22 on 1/2/22, 1/3/22, 1/4/22 and 1/7/22. There was no evidence that any of the extra visits were for a PRN need. Only 1 visit documented the week of 1/21/22 and no evidence of any additional SN visits following the 1/21/22 visit. SN visit notes indicated that wound care was being performed to right thigh/ upper knee. Cleanse with normal saline, apply betadine. There was no evidence of an order for wound care. Patient #6- SN documented visits on 3/16/22, 3/30/22, 4/9/22 and 4/13/22. There was no evidence of an order for SN. There was no evidence of a SN visit made since 4/13/22. Patient #7- SN visit frequency was 1 x week, 2-3 PRN. There was evidence of 2 visits made on 4/19/22 and 4/20/22 of the same week. No evidence either visit was PRN. No SN visit documented since 4/20/22. Patient #9- SN frequency order 2 x week, no evidence of SN visit since 4/27/22. SC order 1 x month, no evidence of visits made in March or April 2022. Patient #10- SN frequency order 2 x week. Evidence of only 1 SN visit documented on 4/11/22 and 4/30/22. No evidence of SN visit since 4/30/22. Patient #11 SN frequency was ordered 1 x week, there was no evidence of a SN visit the week of 5/1/22. SW frequency ordered 1 x month, there was no evidence of a SW visit since 1/27/22.

Upon patient record review, 3 of 11 (Patient #5, 9, 10) did not have evidence that the IDG shares information on a on-going basis with non-hospice healthcare providers furnishing services unrelated to the terminal illness and related conditions. Patient #5- The patient had orders for wound care and enoxaparin to be administered sub-q daily. The SN frequency was 2 x week. The patient resided in a board and care facility. There was no evidence of who is responsible for the management of the wound and injections. Patient #9- Order dated 5/2/22 for wound care. The patient resides in a board and care facility. There was no evidence of the wound care orders in the facility binder, or identification of who is responsible for wound management or teaching/coordination related to the wound. Patient #10- The patient had a foley catheter. The patient was in a board and care facility. There is no indication who is responsible for the foley care management or teaching/coordination related to the foley.

Condition of Participation: Hospice Aide and Homemaker Services. L607

Upon patient record review, 5 of 7 applicable (Patient #1, 4, 5, 10, 11) 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, 11- There was no evidence of an aide plan of care in the medical record. Patient #4, 10- The tasks of make bed, change linens and straighten room were assigned "as needed". Patient #5- The aide care plan did not include a frequency for any of the tasks assigned.

Upon patient record review 6 of 7 applicable (Patient #1, 3, 4, 5, 9, 10) did not have evidence documentation in the patient record that a hospice aide provides services that are: Ordered by the interdisciplinary group and Included in the plan of care Patient #1- HHA documented visits 11/18/21, 11/20/21 and 11/21/21. There was no evidence of orders for HHA in the medical record. Patient #3- The plan of care included HHA order 2 x week. There was no evidence in the medical record of an HHA visit being made. Patient #4- The plan of care included an HHA order for 2 x week. There was no evidence of an HHA visit being made the week of 3/10/22, only 1 visit documented week of 4/3/22 and 4/10/22, no HHA visit documented after 4/16/22. The HHA visit note for 3/16/22 and 4/16/22 indicated that the aide provided assist with bath-chair and dangle, commode which were not assigned on the plan of care. HHA Visits for 3/19/22, 3/23/22, 3/26/22, 3/30/22, 4/2/22 and 4/6/22 indicated that the aide provided assist chair-bath and reposition which were not assigned on the plan of care. Patient #5- The plan of care included orders for HHA 3 x week. The weeks of 1/2/22 and 1/9/22 only had documentation of 2 HHA visits on 1/5/22 and 1/7/22 and 1/10/22 and 1/12/22. The HHA visit note for the following visits: 1/5/22, 1/10/22, 1/12/22, 1/19/22, 1/21/22, 1/24/22 and 2/2/22 indicated assist with bath-chair which was not assigned on the care plan. Patient #9- The medical record contained orders for HHA 2 x week. There were no HHA visits documented after 4/4/22. Patient #10- The record contained orders for HHA 2 x week. There was no evidence of a visit made the week of 4/11/22. HHA visit note dated 4/18/22 documented assist bath-chair, ambulation, walker, wheelchair, cane which were not assigned tasks on the care plan.

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. There is no evidence the Board of Directors/governing body demonstrated oversight to ensure completion of certification of terminal illness documentation, face to face visits, visit frequencies were established and completed, plans of care were completed and updated, and aide plans of care were developed and followed.

Upon patient record review, 6 of 11 (Patient #1, 2, 3, 6, 7, 8) 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, 2, 3, 6, 7, 8- There was not evidence of a complete physician certification statement in the medical record.

Upon patient record review, 1 of 2 applicable (Patient #9) 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 #9- Admitted 11/2/21, there was no evidence in the medical record of a complete physician certification for benefit period that began 5/1/22.

Upon patient record review, 11 of 11 (Patient #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11) did not have evidence that each patient record contains: • Signed election statement in accordance with 418.24 Patient #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11- The election form utilized by the agency did not include the regulatory changes to include the QIO information and the right for the patient to elect the "Notice of non-covered items, services and drugs".

Upon patient record review, 1 of 11 (Patient #1) did not have evidence that each patient record contains Advance Directives. Patient #1- The medical record indicated that the patient was a DNR, there was no evidence of a DNR in the patient record.