Every finding on record at Mount Zion Hospice Care, Inc.

Upon observation, there was no evidence the Emergency Preparedness plan: • Is based on and includes a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach • Includes strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care There was no evidence of an all-hazards risk assessment.

Upon observation, there was no evidence the Emergency Preparedness plan includes a process for cooperation and collaboration with local, tribal, regional, state, and federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. There was no evidence the plan included a process for collaboration with tribal, regional, state or federal emergency officials.

Upon observation, there was no evidence of contracts/agreements with other facilities/agencies/hospices to receive patients in the event the hospice cannot provide care to their patients during an emergency.

Upon observation, there was no evidence the Emergency Plan communication plan includes all of the following: • Names and contact information for the following: • Hospice employees • Entities providing services under arrangement • Patients' physicians • Other hospices

Upon observation, there was no evidence the Emergency Plan communication plan includes contact information for Federal, state, tribal or regional emergency preparedness staff.

Upon patient record review, 2 of 14 (Patient #9, 12) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient #9, 12: there was no evidence in the record of the patient choosing an attending physician.

Upon patient record review, 5 of 14 (Patient #1,5,6,11,12) 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 #1: The medication profile included diclofenac 1% topical gel with no site indicated for application. Patient #5: The medication profile included Pataday 0.7% extra strength ophthalmic solution 1 drop daily but did not specify which eye(s). Patient #6: The medication profile included diclofenac 1% topical gel with no site indicated for application. Patient #11: There was evidence in the record the patient was on oxygen at 2-5L continuous. Oxygen was not included on the medication profile. The medication profile included atropine ophthalmic 2 drops as needed for secretions with a route of ophthalmic. There was no indication of which eye(s). Intended to be dosed orally. Patient #12: There was evidence in the record the patient was on oxygen at 2-5L continuous. Oxygen was not included on the medication profile. The medication profile also included lorazepam 2mg/mL, give 025mL/0.5mg every 3 hours.

Upon patient record review, 1 of 14 (Patient #4) 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 #4: There was no evidence of an initial bereavement assessment having been completed.

Upon patient record review, 1 of 14 (Patient #1) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days Patient #1: There was no evidence of a comprehensive assessment by the RN in the month of June. All documented visits were performed by the LVN.

Upon patient record review, 4 of 14 (Patient #1,5,6,12) 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 is diabetic and has a history of asthma. The plan of care did not include problems, goals or interventions related to these diagnosis. Patient #5: The patient is diabetic and takes metformin. The plan of care did not include problems, goals or interventions related to diabetes. The plan of care also included treatment intervention for use of calmoseptine ointment but did not include any instructions for use. Patient #6:The patient is diabetic and takes lantus and metformin. The plan of care did not include problems, goals or interventions related to diabetes. Patient #12: The patient was admitted for respiratory failure, had a g-tube, seizures, pain and high risk for skin breakdown. The plan of care did not include problems, goals or interventions related to these identified issues.

Upon patient record review, 6 of 14 (Patient #1,5,6,9,11,12) 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: The plan of care included diclofenac 1% topical gel with no site indicated for application. Patient #5: The plan of care included Pataday 0.7% extra strength ophthalmic solution 1 drop daily but did not specify which eye(s). Patient #6: The plan of care included diclofenac 1% topical gel with no site indicated for application. Patient #9: The record included orders from a wound care clinic dated 6/28/23 for Right anterior leg: cleanse with sterile wound cleanser, pat dry. Fill loosely with collagen powder, cover with dry sterile dressing. Change every 2 days and as needed for soiling or dislodgement. Left lower leg: cleanse with wound cleanser, apply medihoney, collagen powder and cover with dry dressing. Change daily and as needed for soiling or dislodgement. This order was not included in the plan of care, SN did not document providing the care and there is no documentation of who is responsible for the care. Patient #11: There was evidence in the record the patient was on oxygen at 2-5L continuous. Oxygen was not included on the plan of care. The plan of care included atropine ophthalmic 2 drops as needed for secretions with a route of ophthalmic. There was no indication of which eye(s). Intended to be dosed orally. Patient #12: There was evidence in the record the patient was on oxygen at 2-5L continuous. Oxygen was not included on the plan of care. The plan of care also included lorazepam 2mg/mL, give 025mL/0.5mg every 3 hours.

Upon patient record review, 1 of 14 (Patient #12) 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 #12: The record included information that the patient required a hospital bed, oxygen concentrator and nebulizer. These items were not included on the plan of care.

Upon client record review, 9 of 14 (Patient #1,3,4,5,6,7,8,11,12) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1: The orders for SN were 1 x week. There was evidence of 2 SN visits documented the weeks of 7/2, 7/16 and 7/30/23. Patient #3: The order for SN was 1 x week. There was evidence of 2 SN visits documented the weeks of 5/7 and 5/21/23. There was no SN visit documented the weeks of 7/30/23 or 8/6/23. Patient #4: The plan of care included orders for MSW and SC to evaluate. There was no evidence either discipline ever completed an evaluation. Patient #5: The plan of care included orders for SN 1 x week. There was evidence of 2 SN visits the week of 6/11/23 and no SN visit the weeks of 7/2, 7/16 or 7/30/23. Patient #6: The plan of care included orders for SN 1 x week. There was evidence of 2 SN visits the weeks of 6/11, 7/9, 7/23 and 8/6/23. Patient #7: The plan of care included orders for SN 1 x week. There was evidence of 2 SN visits the weeks of 6/25, 7/9, 7/23 and 8/6/23. Patient #8: The plan of care included orders for SN 1 x week. There was no evidence of SN visits the weeks of 7/16 or 7/23/23. There was an order for MSW monthly. No evidence of MSW visit for the months of June, July or August 2023. Patient #11: The plan of care did not include frequency orders for nursing. The SN made visits on the following dates: 5/3, 5/20, 5/23, 5/30, 6/6, 6/13, 6/23, 6/26, 7/7, 7/10, 7/30, 8/6 and 8/14/23. Patient #12: The plan of care included orders for SN 1 x week. There was evidence of 2 SN visits the weeks of 1/26, 1/29 and 2/6/23. There was evidence of a PT visit documented on 1/27/23, the plan of care did not include any orders for PT services.

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 #1: The LVN placed the clean equipment back on the dirty side of the barrier after cleaning.

Upon patient record review 3 of 14 (Patient #3,4,12) 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 Patient #3: The orders for aide were 1 x week. There was no evidence of an aide visit the weeks of 8/6 or 8/13/23. Patient #4: The plan of care included orders for aide 1 x week. There was no evidence aide has ever made a visit. Patient #12: The plan of care included orders for aide 1 x week. There was no evidence of an aide visit for the week of 1/26/23.

Upon patient client record review, 14 of 14 (Patient #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14) did not have evidence that each patient record contains: • Signed election statement in accordance with 418.24 The signed election statement did not include the patient's choice for attending physician, information about the right to elect the notice of non-covered items, services and drugs or the QIO information.

Upon client record review, 2 of 14 (Patient #13, 14) 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 There was no evidence the discharge summaries were sent to the physician.

Upon client record review, 2 of 14 (Patient #13, 14) did not have evidence that the discharge summary includes all required information.