Every finding on record at One New Era Investments LLC

Upon review of policy and procedure, emergency preparedness policy did not include the development of arrangements with other hospices and other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to hospice patients.

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 There was no evidence of the required info on the communication plan.

Upon patient record review 1 of 6 records (Patient #6) 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 6: Declined SC, there was no evidence of a spiritual assessment.

Upon patient record review, 1 of 6 records (Patient #2) 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 2: Order dated 5/10/2022 includes O2 4L/M via NC. There was no evidence of a reason for the PRN medication. There was no evidence of the O2 on the medication profile. Corrected on site.

Upon patient record review, 1 of 6 records (Patient #2) 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 2: There is an order dated 5/10/2022 including O2 4/l/M via NC PRN. There was no evidence of the indication for PRN. Corrected on site.

Upon client record review, 1 of 6 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: SN visit ordered 1x week with SOC 3/3/2022. There was no evidence of a SN visit or missed visit for week of 3/27/2022, and week of 5/1/2022.

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. Pt 1: RN utilized two clean bags for medical supplies. Bag one held stethoscope and bp cuff, took notebook that had earlier been placed on TV stand and placed it into the clean bag. Second bag held pen light and pulse ox, repeatedly got in and out of this bag without using hand sanitizer. Pt 3: RN used two clean bags. Bag one was placed on a barrier, place used/dirty pen light on the clean surface of the bag prior to cleaning the pen light.

Upon patient record review 1 of 6 (Patient #2) 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 2: On SOC 5/10/2022 HHA visits ordered 2x week. There was no evidence of HHA visits or missed visits for week of 5/10/2022.

Upon patient record review, 1 of 6 (Patient #5) 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 5: There was a written certification in the file but no narrative. There was no evidence of a narrative explanation of the clinical findings that supports a life expectancy of 6 months or less as part of the certification forms.

Upon patient client record review, 6 of 6 records (Patient #1, #2, #3, #4, #5, #6) did not have evidence that all entries are complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient record Patient 1, 2, 3, 4, 5 and 6 Per policy IM.10 Timelines daily documentation is to be turned in twice a week. The paperwork done off site was held in employees possession until requested to be sent in for survey. There was no evidence of a written cert in the patient record. Physician documented off site, documents scanned into office. Had no evidence of IDG updates every 15 days. All documentation of care plan updates done by RN off site, which were scanned to office after requested.

Upon personnel record review, 1 of 9 (Personnel #6) did not have evidence that personnel credentialing activities are conducted to verify qualifications of all credentialed/licensed personnel in the positions they hold at the time of hire, at renewal or in accordance with specific state practice act requirements. Personnel 6: Per JD SC requirement College degree preferred, Masters of Divinity preferred. In resume states has Masters in Divinity, there was no evidence of a certificate or diploma.

Upon personnel record review, 1 of 1 applicable (Personnel #9) did not have evidence that all Speech Therapy Services are provided by a qualified licensed Speech-Language Pathologist (SLP) or Audiologist in accordance with the state's Speech-Language Pathology Practice Act and the hospice's policies and procedures and/or job descriptions.

Upon personnel record review, 2 of 4 applicable records (Personnel #5, #9) 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. Employee 5: The MD has OIG, and Sexual offender checks, there was no evidence of a criminal background check. Employee 9: SLP file not available, not provided by Therapy company.