Every finding on record at Oaktree Hospice, Inc.

Upon patient record review, 15 of 15 (Patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, and 15) did not contain evidence that these patients had received information about the services covered under the Hospice benefit; specifically the fiscal coverage of their proposed Hospice services: Patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, and 15): For each of these patients, the Hospice's admission Consent form did not provide individualized patient information regarding who their Hospice services would be billed to, and out-of-pocket charges, if any.

Upon patient record review 3 of 15 (Patients #5, 8, and 9) did not contain evidence that the initial Comprehensive Assessment identified 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: SOC 12/05/2024. There was documentation that this patient had refused receipt of the SW discipline/services, to include an initial Comprehensive Assessment visit. Therefore, the admitting RN completed the Psychosocial/Emotional portion of the Comprehensive Assessment. However, the following assessment questions had been left blank by the RN: Marital status, children, primary in-home caregiver, living arrangements, family communication, social interactions, IADLs, support system, housework, meal preparation, finances, and other applicable questions. Patient #8: SOC 12/18/2024. There was documentation that this patient had refused receipt of the SW discipline/services, to include an initial Comprehensive Assessment visit. Therefore, the admitting RN completed the Psychosocial/Emotional portion of the Comprehensive Assessment. However, the following assessment questions had been left blank by the RN: Marital status, children, primary in-home caregiver, living arrangements, family communication, social interactions, IADLs, support system, housework, meal preparation, finances, and other applicable questions. Patient #9: SOC 11/09/2024. There was documentation that this patient had refused receipt of the SW discipline/services, to include an initial Comprehensive Assessment visit. Therefore, the admitting RN completed the Psychosocial/Emotional portion of the Comprehensive Assessment. However, the following assessment questions had been left blank by the RN: Marital status, children, primary in-home caregiver, living arrangements, family communication, social interactions, IADLs, support system, housework, meal preparation, finances, and other applicable questions.

Upon patient record review, 15 of 15 (Patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15) did not contain evidence that the Hospice had 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 #7: The IDG POC dated 02/26/2025 contained only (1) 'open' problem (Genitourinary) with associated interventions and goals. All other problems were 'closed'. However, the RN's IDG entry note for this date reflected that the patient had LLE weakness and was at risk for falls, and had BLE edema. Patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11,12,13,14,15: These patients Plan(s) of Care did not include their individualized Advance Directive preferences, or absence of such/Full Code.

Upon patient record review, 1 of 15 (Patient #4) did not contain evidence that the Plan of Care included all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments: Patient #4: The RN SOC note identified "left lower leg cellulitis, red, inflamed, edema, with several wounds, that will require wound care". A verbal order was obtained 01/15/25 for, "Left foot. Cleanse with normal saline, pat dry, apply triple ATB ointment, and cover with Tegaderm." This is an incomplete order, as it does not include a frequency, nor 'who' will be responsible for such wound care. The Hospice nurse's next home visit was 01/24/25, during which she provided the ordered wound care, but also documented that she had taught the in-home caregiver to provide such wound care on other days.

Upon patient record review, 1 of 15 (Patient #4) did not contain evidence that the Plan of Care included all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs: Patient #4: The RN SOC assessment reflected that the patient had a seated-walker. This was not included in the POC.

Upon patient record review, 4 of 15 (Patients #2, 3, 4 and 6) did not contain evidence that a revised Plan of Care included information from the patient's updated comprehensive assessment(s), and must note the patient's progress towards outcome/goals from the Plan of Care: Patient #2: The last Aide visit was made on 11/07/2024, and these services were discontinued on 11/09/2024. However, the 02/26/2025 IDG POC continues to include, "Aide to visit once per week." Patient #3: The IDG POC dated 02/26/2025 continued to include: 1) MSW to visit for increased IHSS hours. This is not longer current; and 2) PT to Evaluate, and 1x per week x4. This is no longer current, as these PT services were ordered at the SOC 09/08/2024. Patient #4: The RN SOC note identified left lower leg cellulitis, red, inflamed, edema, with several wounds, that will require wound care. A verbal order was obtained 01/15/25 for, "Left foot. Cleanse with normal saline, pat dry, apply triple ATB ointment, and cover with Tegaderm." This wound care treatment was not updated to the 02/26/2025 IDG POC. Patient #6: The IDG POC dated 02/26/2025 included, "Aide declined at admission." This patient has been receiving Aide services from the start of care to current.

Upon patient record review, 4 of 15 (Patients #3, 4, 6 and 10) did not contain evidence that the IDG had ensured that all care and services were provided in accordance with the Plan of Care: Patient #3: The 09/08/24 RN SOC note stated, "Patient needs PT Evaluation." A verbal order was obtained on 09/08/24 for, "PT Evaluation 1x per week x4." There was no documented evidence within the clinical record of any Physical Therapy follow-up. The 09/08/24 RN SOC note stated, "MSW to visit for increased IHHS hours." There is no documented evidence of any Social Worker contact with the patient. There was a documented RN phone call on 09/09/2024 with the patient's wife to discuss this. It was determined that the wife would contact the county office herself. Patient #4: A verbal order was obtained on 01/15/2025 for, "Volunteer 1x per week." The Volunteer made (2) visits during the week's of 01/19-01/25/25 and 02/09-02/15/25. Patient #6: A verbal order was obtained on 02/13/25 for, "PT Evaluation and 1x per week x4." No PT visits had been made. There was no order to cancel this discipline. Patient #10: A verbal order was obtained on 01/22/2025 for, "PT Evaluation and 1x week x4." An RN phone communication note was documented on 02/19/2025 of, "Patient inquired when will I see the PT?" The IDG POC dated 02/26/2025 continued to include, "PT Eval and 1x per week x4." There was no documented evidence within the clinical record of any Physical Therapy follow-up.

Upon observation, there was not evidence that the Hospice investigated all adverse events, incidents, accidents, variances or unusual occurrences that involve patient care, and developed a plan of correction to prevent the same or similar event from occurring again: Patient #8: On 12/21/24 the nurse documented that the patient had fallen on her knees three days ago, gone to the Emergency Room, and was diagnosed with arthritis in all joints. There was no incident report completed, nor subsequent incident investigated.

Upon patient record review, 2 of 15 (Patients #14 and 15) did not contain evidence that the Hospice offers bereavement counseling that includes: • Making bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. Bereavement counseling also extends to residents of a SNF/NF or ICF/IID when appropriate and identified in the bereavement plan of care • Ensuring that bereavement services reflect the needs of the bereaved • Development of a bereavement Plan of Care that notes the kind of bereavement services to be offered and the frequency of such service delivery: Patient #14: Death 10/17/24. A Bereavement Risk Assessment was conducted post-death. At the bottom of this assessment was a plan/statement to, "Provide ongoing emotional counseling", along with an associated listing of what components this counseling might include. However, there was no associated frequency, nor method of contact, with the bereaved. There was no inclusion on a written Bereavement POC that the Hospice had planned on sending a Sympathy Card, nor monthly mailings, although these bereavement interventions had been provided. Patient #15: There was no Bereavement Plan of Care located within the clinical record.

Upon personnel record review, 1 of 12 (Personnel #8) did not contain evidence of a completed Aide Skills Competency assessment that included all CMS-required content, as follows: Personnel #8: DOH 09/30/2024. An Aide Skills Competency assessment was conducted on 09/30/2024. However, the following skills were not evaluated for, as per CMS guidelines. The following skills were not evaluated for while the Aide was providing care/services on a live patient or with a pseudo-patient. All of the below listed skills were assessed for/documented as per 'verbal' evaluation. ·Reading and recording temperature, pulse, and respiration · Bed bath · Sponge, tub, and shower bath · Shampoo, sink, tub, and bed · Nail care · Skin care · Oral hygiene · Toileting and elimination ·Safe transfer techniques and ambulation. ·Normal range of motion and positioning Other subject areas that may be evaluated through written examination, oral examination or after observation of a Hospice Aide with a patient, were not evaluated for: • The physical, emotional, and developmental needs of and ways to work with the populations served by the Hospice.

Upon patient record review, 1 of 15 (Patient #6) did not contain evidence that Hospice Aide assignments and duties were: • 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 • 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 #6: Aide visits had been made between 12/19/2024 and 02/13/2025. There was no Aide Plan of Care/Assignment established for the Aide to follow.

Upon patient record review 1 of 15 (Patient #6) did not contain documented evidence that a Hospice Aide had provided services that were: • 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 #6: A verbal was obtained on 12/5/2025 for, "Aide 2x per week." There were no Aide visits made the week of 12/08-12/14/24. The Aide only made one home visit the weeks of 01/19-01/25/25 and 02/02-02/08/25.

Upon patient record review 2 of 15 (Patients #2 and 6) did not contain documented evidence that a Registered Nurse had 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 #2: Multiple Aide visits were made between 09/26/24 and 11/07/2024. An Aide Supervisory Visit was made on 10/01/24, 10/14/24, and then none further. Patient #6: An Aide Supervisory Visit was made on 01/13/25, and then not until 02/08/2025.

Upon patient record review, 15 of 15 (Patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, and 15) did not contain evidence that each patient record contained: A signed Election of Hospice Benefit Statement in accordance with 418.24. The Hospice's Election of Hospice Benefit form did not specify/identify this Hospice's Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO), for the right to immediate advocacy and BFCC-QIO, nor the contact information for such QIO.

Upon patient record review, 1 of 15 (Patient #4) did not evidence that all entries were clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice: Patient #4: The IDG POC dated 02/26/2025 included two conflicting/unclear entries. One section of this POC listed, "Volunteer once per week", and another section of the same POC listed, "Volunteer declined."

Upon patient record review, 2 of 15 (Patients #12 and 13) did not contain evidence that the Discharge Summary included all CMS-required information: Patient #12: The 01/20/25 DC Summary did not include the following required content: • A summary of the patient's stay, including treatments, symptoms and pain management • The patient's current plan of care • The patient's latest physician orders Patient #13: The 01/20/25 DC Summary did not include the following required content: • A summary of the patient's stay, including treatments, symptoms and pain management • The patient's current plan of care • The patient's latest physician orders

Upon patient record review, 4 of 15 (Patients #1, 3, 7, and 9) did not contain evidence that the Interdisciplinary Group, as part of the review of the Plan of Care, had determined the ability of the patient and/or family to safely self-administer drugs and biologicals to the patient in his or her home. If the patient and/or family are not capable of safely administering drugs and biologicals in the home, the Hospice must address this issue in the patient's plan of care: Patients #1, 3, 7, and 9: For all of these records there was no documentation, reflecting this determination.

Upon inpatient contract review, 1 of 1 (University/GIP/RIP) did not contain evidence of a stipulation, that the Hospice patient's inpatient clinical record shall include: 1) a record of all inpatient services furnished and events regarding care that occurred at the facility; 2) that a copy of the discharge summary shall be provided to the Hospice at the time of discharge; and 3) that a copy of the inpatient clinical record is available to the Hospice at the time of discharge.

Upon inpatient contract review, 1 of 1 (University/GIP/RIP) did not contain evidence of a stipulation that the inpatient facility has identified an individual within the Facility who is responsible for the implementation of the provisions of the agreement.

Upon patient client record review, 1 of 5 (Patient #1) 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. Patient #1: The supplementary physician's order dated 7-16-21, written by nurse, included the name of a different agency. Additionally, the documentation from the MSW visit on 6-10-21 showed that the patient had no advance directives, no copies on file and intended DNR. The DNR form was signed by the physician on 6-9-21.