Every finding on record at Mount Sinai Hospice and Palliative Care Inc

Condition of Participation: Patient’s Rights. L500

Upon patient record review, 4 of 14 (Patients #5, 6, 7, 8) 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: In the initial nursing comprehensive assessment, the patient is described as Confused, agitated, minimally responsive, disoriented with slurred speech. This patient signed their own consents. Patient #6: In the nursing comprehensive assessment, the patient is described as oriented to person, minimally responsive, and confused. The patient signed consents. The administrator of B & C home also signed. There is no documentation of a legal decision maker for this patient. Patient #7: In the nursing comprehensive assessment, patient is described as disoriented with anxiety and agitation. The nurse instructed B&C owner on techniques to reorient patient. This patient signed their own consents. The administrator of the B & C home also signed consents. There is no documentation of a legal decision maker for this patient. Patient #8: In the comprehensive nursing assessment, the patient is described as alert to time only with confusion and sundowning. This patient signed their own consents. The administrator of the B & C home also signed consents. There is no documentation of a legal decision maker for this patient.

Upon patient record review, 4 of 14 (Patients #5, 6, 7, 8) 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: In the initial nursing comprehensive assessment, the patient is described as confused, agitated, minimally responsive, disoriented with slurred speech. This patient signed their own consents. Patient #6: In the nursing comprehensive assessment, the patient is described as oriented to person, minimally responsive, and confused. The patient signed consents. The administrator of B & C home also signed. There is no documentation of a legal decision maker for this patient. Patient #7: In the nursing comprehensive assessment, patient is described as disoriented with anxiety and agitation. The nurse instructed B&C owner on techniques to reorient patient. This patient signed their own consents. The administrator of the B & C home also signed consents. There is no documentation of a legal decision maker for this patient. Patient #8: In the comprehensive nursing assessment, the patient is described as alert to time only with confusion and sundowning. This patient signed their own consents. The administrator of the B & C home also signed consents. There is no documentation of a legal decision maker for this patient.

Upon patient record review, 4 of 14 (Patients #5, 6, 7, 8) 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: In the initial nursing comprehensive assessment, the patient is described as confused, agitated, minimally responsive, disoriented with slurred speech. This patient signed their own consents. Patient #6: In the nursing comprehensive assessment, the patient is described as oriented to person, minimally responsive, and confused. The patient signed consents. The administrator of B & C home also signed. There is no documentation of a legal decision maker for this patient. Patient #7: In the nursing comprehensive assessment, patient is described as disoriented with anxiety and agitation. The nurse instructed B&C owner on techniques to reorient patient. This patient signed their own consents. The administrator of the B & C home also signed consents. There is no documentation of a legal decision maker for this patient. Patient #8: In the comprehensive nursing assessment, the patient is described as alert to time only with confusion and sundowning. This patient signed their own consents. The administrator of the B & C home also signed consents. There is no documentation of a legal decision maker for this patient.

Upon patient record review, 4 of 14 (Patients #5, 6, 7, 8) did not have evidence of the appropriate documentation for release of confidential information. Patient #5: In the initial nursing comprehensive assessment, the patient is described as confused, agitated, minimally responsive, disoriented with slurred speech. This patient signed their own consents. Patient #6: In the nursing comprehensive assessment, the patient is described as oriented to person, minimally responsive, and confused. The patient signed consents. The administrator of B & C home also signed. There is no documentation of a legal decision maker for this patient. Patient #7: In the nursing comprehensive assessment, patient is described as disoriented with anxiety and agitation. The nurse instructed B&C owner on techniques to reorient patient. This patient signed their own consents. The administrator of the B & C home also signed consents. There is no documentation of a legal decision maker for this patient. Patient #8: In the comprehensive nursing assessment, the patient is described as alert to time only with confusion and sundowning. This patient signed their own consents. The administrator of the B & C home also signed consents. There is no documentation of a legal decision maker for this patient.

Upon patient record review, 4 of 14 (Patient #5,6,7,8) did not have evidence that the patient received information about the services covered under the hospice benefit. Patient #5: In the initial nursing comprehensive assessment, the patient is described as confused, agitated, minimally responsive, disoriented with slurred speech. This patient signed their own consents. Patient #6: In the nursing comprehensive assessment, the patient is described as oriented to person, minimally responsive, and confused. The patient signed consents. The administrator of B & C home also signed. There is no documentation of a legal decision maker for this patient. Patient #7: In the nursing comprehensive assessment, patient is described as disoriented with anxiety and agitation. The nurse instructed B&C owner on techniques to reorient patient. This patient signed their own consents. The administrator of the B & C home also signed consents. There is no documentation of a legal decision maker for this patient. Patient #8: In the comprehensive nursing assessment, the patient is described as alert to time only with confusion and sundowning. This patient signed their own consents. The administrator of the B & C home also signed consents. There is no documentation of a legal decision maker for this patient.

Upon patient record review, 4 of 14(Patient #5,6,7,8) 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: In the initial nursing comprehensive assessment, the patient is described as confused, agitated, minimally responsive, disoriented with slurred speech. This patient signed their own consents. Patient #6: In the nursing comprehensive assessment, the patient is described as oriented to person, minimally responsive, and confused. The patient signed consents. The administrator of B & C home also signed. There is no documentation of a legal decision maker for this patient. Patient #7: In the nursing comprehensive assessment, patient is described as disoriented with anxiety and agitation. The nurse instructed B&C owner on techniques to reorient patient. This patient signed their own consents. The administrator of the B & C home also signed consents. There is no documentation of a legal decision maker for this patient. Patient #8: In the comprehensive nursing assessment, the patient is described as alert to time only with confusion and sundowning. This patient signed their own consents. The administrator of the B & C home also signed consents. There is no documentation of a legal decision maker for this patient.

Upon patient record review 1 of 14 (Patient #8) 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 #8: The patient was admitted 12/02/23. Initial Spiritual care assessment was completed 02/13/24. Initial MSW assessment was completed 12/09/23.

Upon patient record review, 10 of 14 (Patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 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 Patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10: All patients had oxygen on POC as well as DME, but Oxygen was not on the medication profile.

Upon patient record review, 2 of 14 (Patients #8, 10) 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 #8: Patient was admitted 12/02/23. Initial bereavement assessment completed 12/9/23. Patient #10: Patient was admitted 11/26/23. Initial bereavement assessment completed 5/16/24

Upon patient record review, 10 of 14 (Patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10) 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 the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patients #1,2,3,4,5,6,7,8,9,10: Both SC and MSW visit frequencies are ordered from SOC as 1 time for initial assessment and then prn, there is no evidence of a routine frequency.

Upon patient record review, 3 of 14 (Patient #1,5,7) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 1: SC saw patient 05/22/24, 06/14/24, 07/09/24,and 08/02/24. There is only an order for PRN visits with no physician order for visit frequency. Patient 5: During the initial spiritual care assessment, SC documents, "The patient expressed feeling socially isolated from friends, family, and their community of faith, with little to no spiritual support." "I plan to meet with this patient once a month to provide spiritual and emotional support." The frequencies were not revised to meet patient needs. Visits were made by SC 3/11/24, 04/26/24, 05/22/24, 06/24/24, and 07/26/24 without delineation of it being a prn visit and without physician order for visit. Patient 7: In the initial spiritual care assessment, SC states that "I plan to see patient once a month to provide spiritual and emotional support." SC did visits for patient on 03/11/24, 04/24/24, 05/15/24, 06/24/24 and 8/24/24. There were no orders for these visits and none were labeled as a PRN visit.

Upon patient record review 2 of 14 (Patient #4,6) did not have evidence that the IDG ensures that the care and services provided are based on all assessments of the patient and family needs. Patient 4: During the SC initial visit, it was documented that patient was "feeling a lack of spiritual and emotional support and social isolation. He is also lonely. He desires to explore spirituality" There has been no change in SC POC for frequencies to meet the patient's stated needs. During the initial MSW visit, it was documented that patient had a long history of drug abuse and had used until he was too sick to continue. MSW documented, "Patient has increased anger and guilt about the children and gets very tearful" There was no funeral plan. There are no order for MSW visits to meet the patient's stated needs. Patient 6: In the initial spiritual care assessment, it states patient "is experiencing profound feelings of isolation, which is her primary spiritual and emotional challenge." "Regular spiritual care visits will be scheduled to provide her with continuous support." There is no order for visits for a routine frequency for spiritual care. MSW assessment states patient with no family, no caregiver. States MSW will see patient once per cert period, though no order to change frequency made.

Upon observation, there was no evidence the hospice measures, analyzes, and tracks quality indicators, including adverse patient events and other aspects of performance that enable the hospice to assess processes of care, hospice services, and operations. The agencies QAPI program did not include program objectives, patient care disciplines. There was no description of how the program would be administered and coordinated. There was no listed priorities for resolution of problems. There were no scheduled QAPI meetings outside reporting data to the governing body on a quarterly basis.

Upon observation, there was no evidence Quality Assessment and Performance Improvement activities focus on high risk, high volume or problem-prone areas by considering incidence, prevalence, and the severity of problems.

Upon observation, there was no evidence the hospice documents what QAPI projects are being conducted, the reasons for conducting these projects, and the measurable progress achieved on these projects. The QAPI project binder listed the data collected. There was no description of the projects that included the reasons for said projects. The binder did not list measurable progress achieved on these projects.

Upon patient record review, 4 of 14 (Patients #5, 6, 7, 8) 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: In the initial nursing comprehensive assessment, the patient is described as Confused, agitated, minimally responsive, disoriented with slurred speech. This patient signed their own consents. Patient #6: In the nursing comprehensive assessment, the patient is described as oriented to person, minimally responsive, and confused. The patient signed consents. The administrator of B & C home also signed. There is no documentation of a legal decision maker for this patient. Patient #7: In the nursing comprehensive assessment, patient is described as disoriented with anxiety and agitation. The nurse instructed B&C owner on techniques to reorient patient. This patient signed their own consents. The administrator of the B & C home also signed consents. There is no documentation of a legal decision maker for this patient. Patient #8: In the comprehensive nursing assessment, the patient is described as alert to time only with confusion and sundowning. This patient signed their own consents. The administrator of the B & C home also signed consents. There is no documentation of a legal decision maker for this patient.