Every finding on record at Odyssey Healthcare Operating A, LP

Upon patient record review, 2 of 5 (Patient #2,3) 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. conditions. Patient 2: Identified as a risk for falls on admit assessment, on the RN assessments, and on the current aide plan of care. No evidence that the plan of care reflected patient/family goals and interventions based on the problems for safety/risk for falls. Corrected on site. Patient #3: The patient has comorbidity of asthma and uses combivent respimat 20 mcg-100mcg inhaler every 6 hours daily. No evidence the plan of care reflected patient/family goals and interventions based on the problems identified related to asthma or shortness of breath. Respiratory chapter on plan of care is open for providing teaching about properly using the inhaler. Corrected on site.

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 current plan of care has 2 separate orders for performing pulse ox. One order states that the hospice nurse is to perform pulse ox during visits for monitoring shortness of breath and report to MD if less than 92%. Another order placed on 05/23/2024 states hospice nurse or facility nurse to perform pulse ox per visit shortness of breath, report to MD if less than 88%. Corrected on site.

Upon patient record review, 1 of 5 (Patient #3) 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: Current aide plan of care has that patient is under droplet precautions. Droplet precautions were discontinued on 05/28/2024. Completed on site.

Upon patient record review 3 of 5 (Patient 1,2,3) 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 aide visit frequency for the current plan of care is once week one, then 2 times a week. No evidence that any aide visits occurred between the start of election and the start of survey, June 3rd, 2024. No missed visit notes entered or physician orders to not perform visits for those weeks. Patient #2: The aide visit frequency for current plan of care is twice a week. No evidence that two visits occurred on the week of May 19th. Only one documented visit for the week of May 19th, occurred on May 21st, 2024. No physician orders to not perform 2 visits for that week or a missed visit note entered. Patient #3: The aide visit frequency for current plan of care is once week one, then 3 times a week. No evidence that three visits occurred on the week of May 26th. Only one documented visit for that week occurred on May 31st, 2024 and one missed visit note was entered for the visit scheduled on May 28th, 2024. No physician orders to not perform the 3rd visit for that week or a missed visit note entered.

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: • A method for sharing information and medical documentation for patients under the hospice's care, as necessary, with other health care providers to maintain the continuity of care • A means, in the event of an evacuation, to release patient information as permitted under 45 CFR 164.510(b)(1)(ii) • A means of providing information about the general condition and location of patients under the facility's care as permitted under 45 CFR 164.510(b)(4)

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

Upon patient record review 2 of 19 records (Patient #10,#13) 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 #10: The patient was admitted on 1/27/24. The record indicated that the spiritual assessment was not completed until 2/7/24. Patient #13: The patient was admitted on 2/22/24. the record indicated that the spiritual care assessment was not completed until 2/29/24.

Upon patient record review 1 of 19 records (Patient #5) did not have evidence in the patient record that the comprehensive assessment identifies the 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 not evidence of a spiritual assessment.

Upon patient record review, 11 of 19 records (Patient #1,#2,#3,#4,#5,#6,#7,#8,#9,#10,#14) 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: DME indicated oxygen supplies, the care plan indicated assess effectiveness of oxygen, and the nurse documentation indicated that the patient was on oxygen 4-5L/min. There was not evidence that oxygen was on the medication profile. Corrected on site. Patient #2: The medication profile contained Acetaminophen 160mg/ml oral solution, 650mg q6h prn pain, Acetaminophen 325mg/10.15ml oral suspension, 10.15ml q4h prn pain, Acetaminophen 650mg rectal suppository q6h prn temp >100, and Hydrocodone 10-Acetaminophen 325/15ml, 15ml q6h prn pain. There was not evidence of a maximum allowable dose per 24 hours. Corrected on site. In addition, Nystatin 100,000 u top powder 2x/day to affected area without evidence of a specific location. Corrected on site. And duplicate orders for Ondansetron; Ondansetron 4mg disintegrate tablets q6h prn and Ondansetron 4mg tablets q4h prn. Corrected on site. Patient #3: The medication profile contained 2 orders for prn Albuterol (in addition to a straight order). Albuterol 2.5mg/3ml via nebulizer q4h prn and Albuterol 90mcg aerosol inhaler q4h prn. Corrected on site. The medication profile at the facility contained Symbicort. There was not evidence that this was on the hospice medication profile. Patient #4: The mediation profile contained Acetaminophen 325mg, 2 tabs q6h prn pain or temperature. There was not evidence of parameters for the elevated temperature. Corrected on site. Patient #5: The medication profile contained oxygen 2L/min prn without evidence of a route. Corrected on site. Patient #6: The mediation profile contained Acetaminophen 650 rectal supp q6h prn pain or temperature. There was not evidence of parameters for the elevated temperature. Corrected on site. Patient #7: Medications on the hospice medication profile included Docusate, Montelukast, Omeprazole and Sennosides. These medications were not presented to the surveyor during the observation visit in the home. Patient #8: The medication profile contained oxygen 4L/min prn without evidence of a route. Corrected on site. In addition, there was a straight order for Docusate daily and Senna daily, and Fleets enema if Bisacodyl is ineffective. Also Bisacodyl 10 mg rectal supp daily prn, and MOM 30 cc daily prn. There was not evidence of which order to use the 2 prn medications and under what conditions to administer the next laxative. Corrected on site. Patient #9: The medication profile contained Acetaminophen 325mg, 2 tabs q4h prn mild pain and Acetaminophen 650mg rectal supp, 1 q6h prn temp >100 or mild pain. There was not evidence of a maximum allowable dose per 24 hours. Corrected on site. In addition, oxygen 2L/min in duplicate dated 11/8/23 and 2/7/24, with no evidence of a route. Corrected on site. And NTG 0.4, 1 under the tongue q5" as needed for chest pain with no evidence of how many doses to take or when to call a physician or to advance to the next treatment. Corrected on site. Patient #10: The medication profile contained Miralax 17 Gm oral powder daily. There was not evidence of a diluent. Corrected on site. Patient #14: The medication profile contained Acetaminophen 650 rectal supp q4h prn for pain or fever without evidence of a parameter for the fever, and Acetaminophen extra strength 500mg q6h prn. There was not evidence of a maximum allowable dose for 24 hours. Corrected on site.

Upon patient record review, 2 of 19 records (Patient #7,#11) 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: The record indicated that the RN conducted a visit on 3/12/24 and the next visit by the RN including an assessment update was not conducted until 3/28/24, which is 16 days. Patient #11: The record indicated an RN assessment was completed on 3/19/24. The next documented assessment by the RN was on 4/5/24.

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

Upon patient record review, 3 of 19 records (Patient #4,#8,#9) 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 #4: The patient was admitted with a diagnosis of Alzheimer's Disease with late onset. The patient was bedbound, combative at times required assistance with 6/6 ADL's was contracted and initially had a FAST score of 7B but had progressed to 7D. There was not evidence the plan of care reflected patient/family goals and interventions based on the problems identified related to neurological status or Alzheimer's disease. Corrected on site Patient #8: The patient was admitted with a diagnosis chronic systolic heart failure. She also had a non ST elevated MI, arteriosclerosis, atrial fib, and hypertension. There was not evidence that the plan of care included goals and interventions related to her cardiac disease. Corrected on site. Patient #9: The patient was admitted with a diagnosis of hypertensive heart disease with chronic kidney disease. She also had hypertension, sick sinus syndrome and was a III to IV NY heart classification, and had been considered for a pacemaker. There was not evidence of problems with goals and interventions related to the patient's cardiac status. Corrected on site.

Upon patient record review, 9 of 19 (Patient #2,#3,#4,#5,#6,#9,#10,#12,#13) 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. Patient #2: The initial visit frequency for the spiritual care counselor was 2 prn. Patient #3,#4,#5,#6,#9,#10,#12,#13: The initial visit frequency for the social worker and the spiritual care counselor was 1 prn.

Upon patient record review, 10 of 19 records (Patient #1,#2,#3,#4,#5,#6,#8,#9,#11,#12,#14) 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: DME indicated oxygen supplies, the care plan indicated assess effectiveness of oxygen, and the nurse documentation indicated that the patient was on oxygen 4-5L/min. There was not evidence of an order for oxygen. Corrected on site. Patient #2: The record contained orders for Acetaminophen 160mg/ml oral solution, 650mg q6h prn pain, Acetaminophen 325mg/10.15ml oral suspension, 10.15ml q4h prn pain, Acetaminophen 650mg rectal suppository q6h prn temp >100, and Hydrocodone 10-Acetaminophen 325/15ml, 15ml q6h prn pain. There was not evidence of a maximum allowable dose per 24 hours. Corrected on site. In addition, Nystatin 100,000 u top powder 2x/day to affected area without evidence of a specific location. Corrected on site. And duplicate orders for Ondansetron; Ondansetron 4mg disintegrate tablets q6h prn and Ondansetron 4mg tablets q4h prn. Corrected on site. Patient #3: The medication profile contained 2 orders for prn Albuterol (in addition to a straight order). Albuterol 2.5mg/3ml via nebulizer q4h prn and Albuterol 90mcg aerosol inhaler q4h prn. Corrected on site. Patient #4: The record contained an order for Acetaminophen 325mg, 2 tabs q6h prn pain or temperature. There was not evidence of parameters for the elevated temperature. Corrected on site. Patient #5: The record contained an order for contained oxygen 2L/min prn without evidence of a route. Corrected on site. Patient #6: The record contained an order for Acetaminophen 650 rectal supp q6h prn pain or temperature. There was not evidence of parameters for the elevated temperature. Corrected on site. Patient #8: The record contained an order for oxygen 4L/min prn without evidence of a route. Corrected on site. In addition, There was a straight order for Docusate daily and Senna daily, and Fleets enema if Bisacodyl is ineffective. Also Bisacodyl 10 mg rectal supp daily prn, and MOM 30 cc daily prn. There was not evidence of which order to use the 2 prn medications and under what conditions to administer the next laxative. Corrected on site. Patient #9: The record contained orders for Acetaminophen 325mg, 2 tabs q4h prn mild pain and Acetaminophen 650mg rectal supp, 1 q6h prn temp >100 or mild pain. There was not evidence of a maximum allowable dose per 24 hours. Corrected on site. In addition, oxygen 2L/min in duplicate dated 11/8/23 and 2/7/24, with no evidence of a route. Corrected on site. And NTG 0.4, 1 under the tongue q5" as needed for chest pain with no evidence of how many doses to take or when to call a physician or to advance to the next treatment. Corrected on site. Patient #10:The record contained an order for Miralax 17 Gm oral powder daily. There was not evidence of a diluent. Corrected on site. Patient #14: The record contained an order for Acetaminophen 650 rectal supp q4h prn for pain or fever without evidence of a parameter for the fever, and Acetaminophen extra strength 500mg q6h prn. There was not evidence of a maximum allowable dose for 24 hours. Corrected on site.

Upon patient record review, 3 of 19 records (Patient #1,#13,#16) 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 #1: The record indicated that the patient had a fall on 1/27/24, and sustained an abrasion to his left flank area. There was also documentation of a wound, stage II in the patient's right gluteal fold, dated 2/15/24. There was not evidence of a revision to the plan of care regarding wounds/skin integrity. Patient #13: The record indicated that the patient had a fall and sustained a wound on his right eyebrow with wound care orders dated 3/19/24. Another set of wound care orders were obtained on 3/25/24 for an abrasion on the patient's right side of his back. There was not evidence that wounds were added to the plan of care. Corrected on site. Patient #16: The record indicated that the patient was discharged for extended prognosis on 10/24/23. There was not evidence that the IDG discussed and planned for the discharge. The IDG meeting was held on 10/18/23, a visit by the social worker was conducted on 10/18 where documentation revealed that the social worker would continue to support the patient and a visit by the skilled nurse was conducted on 10/20/24 with no mention of discharge in any of these visits/documents

Upon client record review, 3 of 19 records (Patient #11,#12,#14) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #11: The RN visit frequency for the benefit period beginning on 2/17/24 was 1 every 2w2, 1w8. The record indicated that visits were conducted on 2/20/24, 2/22/24, and 2/27/24, 2/29/24. In addition the spiritual care counselor visit frequency was 1m1, 2 prn. There was not evidence of a visit by the spiritual care counselor. Also, the record indicated the presence of a Pleurix drain in the patient's abdomen. The certification of terminal illness and nurse documentation indicated that it was being drained 1L/day. There was not evidence that draining the catheter was on the plan of care. Corrected on site. Patient #12: The spiritual care counselor visit frequency was for 1 prn then 2 every 2m2, 1m1 until 4/1/24 when the chaplain visits were discontinued. The record indicated that the spiritual care counselor conducted an evaluation visit on 2/12/24. The routine visit was not conducted until 4/5/24. In addition, the social work visit frequency was 1 prn then 1 every 2m2, 1m1. The only visit by the social worker was documented on 2/28/24 Also, the nurse documentation from 3/26/24 and 3/28/24 indicated that the patient was performing a straight cath 3-7x/week. There was not evidence that this was on the plan of care. Corrected on site. Patient #14: The visit frequency for the spiritual care counselor was 2x/month. The record indicated only 1 visit or missed visit document for January, February, and March.

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 #7, Aide: After washing hands and prior to providing care, the staff member dried his hands with a towel that was hanging in the patient's bathroom.

Upon patient record review, 2 of 19 records (Patient #1,#12) 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, including alerts and precautions that 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: The record indicated that the patient was on Pradaxa 110mg, 1 cap BID. There was not evidence that bleeding precautions were on the aide plan of care. The record also indicated that patient had a fall on 1/27/24. There was not evidence that fall precautions were on the aide plan of care. Patient #12: There was not evidence of a frequency for any of the listed tasks on the aide plan of care. Corrected on site.

Upon patient record review 3 of 19 records (Patient #3,#10,#11) 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 #3: The aide visit frequency was 2x/week effective 2/4/24. The aide visit frequency was discontinued on 4/4/24, effective 4/7/24. The last documented aide visit was 2/29/24. Patient #10: The aide visit frequency effective 1/28/24 was 2w1, 3w11. For the week of 2/25/24-3/2/24, the record indicated only 2 visits. Patient #11: The visit frequency for the aide for the benefit period beginning 2/17/24 was 2w8, 1w1. This was discontinued on 4/8/24, effective 4/7/24. There was not evidence of an aide visit for this benefit period.

Upon patient record review 2 of 19 records (Patient #9,#10) 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 #9: The record indicated an aide supervisory visit was performed on 2/19/24. There was not evidence of another aide supervisory visit until 3/14/24. Patient #10: The record indicated that an aide supervisory visit was completed on 3/19/24. The next documented aide supervisory visit was on 4/3/24.

Upon observation, there was no evidence the annual report documents the use of volunteers providing day to day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract personnel. The documented annual usage for the year 2023 was 1.7%.

Upon personnel record review, 1 of 14 records (Personnel #2) did not have evidence the alternate administrator's personnel record verifies that: • The employee has appropriate education and experience requirements • There is a signed job description for this role • The employee has been orientated to this role Corrected on site.

Upon personnel record review, 2 of 14 records (Personnel #5,#11) did not have evidence that a skills competency assessment, specific to each discipline had been conducted for all personnel including volunteers initially during orientation. Personnel #5,#11: There was not evidence of an initial competency

Upon patient record review, 2 of 19 records (Patient #1,#6) 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: The ICD 10, and plan of care including the plan of care updates indicated that the patient's admitting hospice diagnosis was malignant neoplasm of the right bronchus/lung. The narrative statement by the Medical Director in the initial certification of terminal illness indicated, 'a 92 yo with a terminal diagnosis of severe aortic stenosis, CHF. Secondary diagnoses COPD, Chronic renal failure, and lung cancer.' Patient #6: The ICD 10, and plan of care including the plan of care updates and nurse documentation indicated that the patient's admitting hospice diagnosis was Parkinson's Disease. The narrative statement by the Medical Director in the initial certification of terminal illness indicated, that the patient was admitted with a terminal diagnosis of Alzheimer's Dementia. The patient was bedbound, incontinent and had developed tremors in her hands and legs.

Upon patient client record review, 1 of 19 records (Patient #16) did not evidence that each patient record contains physician orders. The patient was discharged for no longer meeting hospice criteria. There was not evidence of an order from the Medical Director.

Upon patient client record review, 1 of 19 records (Patient #3) 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 #3: The record indicated that the aide did not provide care until 2/13/24. An aide supervisory visit was conducted on 2/1/24 and all questions were answered as if the aide had provided care.

Upon SNF/NF contract review, 1 of 5 contracts (Fremont HC) did not have evidence the contract specifies the provision of hospice services in the facility and that the contract is signed by authorized representatives of the hospice and the SNF/NF or ICF/IID before the provision of hospice services. (The contract was a single resident contract and was dated July 2008).

Upon SNF/NF contract review, 1 of 5 contracts (Fremont HC) did not have evidence of the manner in which the SNF/NF and the hospice are to communicate with each other and how each will document such communications to ensure that the needs of patients are addressed and met 24 hours a day. (The contract was a single resident contract and was dated July 2008).

Upon SNF/NF contract review, 1 of 5 contracts (Fremont HC) 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: • A significant change in a patient's physical, mental, social or emotional status occurs • Clinical complications appear that suggest a need to alter the plan of care • 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 (The contract was a single resident contract and was dated July 2008).

Upon SNF/NF contract review, 1 of 5 contracts (Fremont) 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. (The contract was a single resident contract and was dated July 2008).

Upon SNF/NF contract review, 1 of 5 contracts (Fremont HC) did not have evidence that it is the SNF/NF's responsibility to continue to furnish 24 hour room and board care, meeting the personal care and nursing needs at the same level of care that would have been provided by the family at the facility before hospice care was elected. (The contract was a single resident contract and was dated July 2008).

Upon SNF/NF contract review, 1 of 5 contracts (Fremont) did not have evidence that it is the hospice's responsibility to provide services at the same level and to the same extent as those services would be provided if the SNF/NF resident were in his or her own home. (The contract was a single resident contract and was dated July 2008).

Upon SNF/NF contract review, 1 of 5 contracts (Fremont HC) did not have a delineation of the hospice's responsibilities, which include, but are not limited to the following: providing medical direction and management of the patient; nursing; counseling (including spiritual, dietary and bereavement); social work; provision of medical supplies, durable medical equipment and drugs necessary for the palliation of pain and symptoms associated with the terminal illness and related conditions; and all other hospice services that are necessary for the care of the resident's terminal illness and related conditions. (The contract was a single resident contract and was dated July 2008).

Upon SNF/NF contract review, 1 of 5 contracts (Fremont HC) did not have a provision that the hospice may use the SNF/NF nursing personnel where permitted by state law and as specified by the SNF/NF to assist in the administration of prescribed therapies included in the plan of care only to the extent that the hospice would routinely use the services of a hospice patient's family in implementing the plan of care. (The contract was a single resident contract and was dated July 2008).

Upon SNF/NF contract review, 1 of 5 contracts (Fremont HC) 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. (The contract was a single resident contract and was dated July 2008).

Upon SNF/NF contract review, 1 of 5 contracts (Fremont HC) did not have a delineation of the responsibilities of the hospice and the SNF/NF to provide bereavement services to SNF/NF personnel. (The contract was a single resident contract and was dated July 2008).

Upon client record review, 2 of 19 records (Patient #4,#8) did not have evidence that a written hospice plan of care is established and maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided is in accordance with this hospice plan of care. Patient #4: The visit frequency for the spiritual care counselor for the benefit period beginning 2/13/24 was 1m1 with 2 prn visits. There was not evidence of a visit by the spiritual care counselor. In addition, the visit frequency for the skilled nurse for this benefit period was 2 every 2w2 and 4 prn. The record indicated that visits were conducted on 2/13/24, 2/14/24, and 2/20/24, 2/21/24, 2/23/24. Patient #8: The visit frequency for the spiritual care counselor was 5m1,3m1,2 prn effective 3/1/24. The record revealed that the spiritual care counselor conducted routine visits on 3/6/24, 3/1/24, and 3/21/24.

Upon client record review, 1 of 19 records (Patient #8) did not have evidence that the hospice plan of care identifies the care and services that are needed and specifically identify which provider (nursing facility or hospice) is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care. Patient #8: The record indicated wound care orders dated 3/26/24, to provide wound care to 2 separate wounds, one on the patient's right heel and one on the patient's left heel. Both orders indicated that the hospice nurse or the facility could provide the care. There was not evidence of specifically which provider was to provide the care. Corrected on site.

Upon personnel record review, 1 of 14 records (Personnel #4) 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.

Upon personnel record review, 1 of 14 personnel records (Personnel #11) 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. Personnel #11: There was not evidence of a criminal background check.