Every finding on record at Pacific Hearts Hospice, Inc.

Upon observation, there was no evidence that during the initial assessment visit in advance of furnishing care, the hospice provided the patient and/or family with verbal (meaning spoken) and written notice of the Patient's Rights and Responsibilities in a language and manner that the patient understands. Patient #3-The patients date of election and start of care was 09/11/23. The signed patients rights on record is dated 09/13/23 by the responsible party. (corrected on site)

Upon patient record review, 3 of 14 (Patient #1, #3, #4) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient #1, #3, #4-The section on the Hospice election statement regarding whether or not the patient is choosing an attending and/or the name of the chosen attending is blank. (corrected on site)

Upon patient record review, 3 of 14 (Patient #1, #2, #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. Patient #1-The medication profile includes Sertraline 100mg oral 1-2 tabs daily. The profile does not differentiate indications for when to take 1 versus 2 tablets. (corrected on site) Patient #2- The medication profile includes duplicative/unclear doses of Tylenol. The profile includes Tylenol 500 mg 1 tab q4h prn mild pain/fever. The profile also includes Tylenol Extra Strength 500 mg 1 q8h prn pain. A maximal allowable daily dosage for Tylenol (Acetaminophen) is also not included in the profile. (corrected on site) Patient #10-The medication profile includes Lumigan 0.01%1 gtt to affected eye daily in pm. Indications and which eye(s) is not specified on the profile. (corrected on site)

Upon patient record review, 6 of 14 (Patient #1, #2, #4, #5, #6, #7) did not have evidence in the patient record that the comprehensive assessment was performed no less frequently than every 15 days by the RN. Patient #1- Between 12/17/23 and 01/12/24 and 01/14/24 and 02/22/24 the record does not evidence a comprehensive assessment was performed by the RN. All visits performed during these time frames were provided by an LVN. Patient #2- Between 01/16/24 and 02/18/24 the record does not evidence a comprehensive assessment was performed by the RN. All visits performed during these time frames were provided by an LVN. Patient #4-Between 12/15/23 - 01/11/24 and 01/27/24-02/12/24 the record does not evidence a comprehensive assessment was performed by the RN. All visits performed during these time frames were provided by an LVN. Patient #5-Between 01/18/24 and 02/05/24 the record does not evidence a comprehensive assessment was performed by the RN. All visits performed during these time frames were provided by an LVN. Patient #6-Between 01/27/24 and 02/20/24 the record does not evidence a comprehensive assessment was performed by the RN. All visits performed during these time frames were provided by an LVN. Patient #7-Between 12/20/23-01/09/24 the patient refused visits and a comprehensive assessment was not performed.

Upon patient record review, 3 of 14 (Patient #1, #2, #10) did not have evidence the plan of care includes all services necessary for the palliation and management of the terminal illness and related conditions, including specific orders for medications. Patient #1-The 12/16/23 plan of care includes Sertraline 100mg oral 1-2 tabs daily. The plan of care does not differentiate indications for when to take 1 versus 2 tablets. (corrected on site) Patient #2- The 01/16/24 plan of care includes duplicative/unclear doses of Tylenol. The plan of care includes Tylenol 500 mg 1 tab q4h prn mild pain/fever. The plan also includes Tylenol Extra Strength 500 mg 1 q8h prn pain. A maximal allowable daily dosage for Tylenol (Acetaminophen) is also not included in the plan of care. (corrected on site) Patient #10-The 02/03/24 plan of care includes Lumigan 0.01%1 gtt to affected eye daily in pm. Indications and which eye(s) for administration is not specified. (corrected on site)

Upon patient record review, 1 of 14 (Patient # 10) did not have evidence the plan of care includes all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient #10-The patient was admitted on 12/05/23 with a hospital bed, wheelchair and Oxygen. The plan of care does not include the equipment. (corrected on site)

Upon patient record review, 3 of 14 (Patient #1, #4, #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- Nursing is ordered to visit the patient once weekly. The week of 12/17/23 and 12/31/23 nursing visits are not on record. The record only documents telehealth visits performed on 12/22/23 and 01/05/24. The record does not contain orders for Telehealth visits and Telehealth visits may not take the place of on site visits following the end of the Co-Vid 19 pandemic waivers. Patient #4-Nursing is ordered to visit the patient once weekly. The week of 12/17/23 nursing visits are not on record. The record only documents a telehealth visit performed on 12/22/23. The record does not contain orders for Telehealth visits and Telehealth visits may not take the place of on site visits following the end of the Co-Vid 19 pandemic waivers. The week of 12/24/23-12/30/23 a nursing visit is not on record. The nurse documents on 12/30/23 the visit was missed without a reason. Patient #7-Nursing is ordered to visit the patient once weekly. The week of 01/14/24-01/20/24 the only nursing visit on record is performed on 01/14/24 as a telehealth visit The record does not contain orders for Telehealth visits and Telehealth visits may not take the place of on site visits following the end of the Co-Vid 19 pandemic waivers.

Condition of Participation: Hospice Aide and Homemaker Services. L607

Upon personnel record review, 1 of 14 (Personnel #7 ) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) ·Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff. ·Reading and recording temperature, pulse, and respiration ·Safe transfer techniques and ambulation. ·Normal range of motion and positioning ·Appropriate and safe techniques in personal hygiene and grooming that include-- ·(A) Bed bath ·(B) Sponge, tub, and shower bath ·(C) Shampoo, sink, tub, and bed ·(D) Nail and skin care ·(E) Oral hygiene ·(F) Toileting and elimination The other subject areas in this section may be evaluated through written examination, oral examination or after observation of a Hospice Aide with a patient. Personnel#7-The Aide competencies on record dated 07/01/22 and 07/07/23 document the skills were observed by an RN in a lab setting with a mannequin. The skills were not observed with the Aide performing care on a patient.

Upon patient record review, 2 of 14 (Patient #2, #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 #2-The only Aide care plan on record was assigned 07/20/23 upon admission. The care plan is signed by the RN; however the care plan is blank for the tasks to be performed. The care plan only includes a diagnosis. (corrected on site) Patient #3-The Aide care plan does not include bleeding precautions. This is applicable to the care plan as the patient is on Aspirin. (corrected on site)

Upon patient record review 1 of 19 (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-The Aide visited twice weekly between 01/19/24 and 02/15/24. Each of the visit notes only include an electronic signature and a time in and out. The body of the note is blank no evidence of the care provided.

Upon patient record review 2 of 14 (Patient #2, #3) 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 #2- Between 01/19/24 and 02/18/24 the record does not include aide supervisory visits performed by the RN. Patient #3- Between 01/11/24 and 02/02/24 the record does not include aide supervisory visits performed by the RN.

Upon patient record review, 3 of 14 (Patient #1, #2, #3) did not have evidence that the medical director or physician designee provides timely 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 CTI for certification period beginning 12/16/23 does not include an electronic signature by the medical director or physician designee. Patient #2- The CTI for certification period beginning 01/12/24 does not include an electronic signature by the medical director or physician designee. Patient #3- The CTI for certification period beginning 01/09/24 does not include an electronic signature by the medical director or physician designee.

Upon patient client record review, 1 of 14 (Patient #3) 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 #3-The patients date of election and start of care was 09/11/23. The signed patients rights on record is dated 09/13/23 by the responsible party. (corrected on site)

Upon patient record review, 2 of 14 (Patient #1, #2) did not have evidence that each patient record contains Advance Directives. Patient #1-The record indicates the patient is a DNR. The record does not include a copy of the patients DNR paperwork or evidence a copy was requested. (corrected on site) Patient #2-The record indicates the patient has a POA. The record does not include a copy of the patients POA paperwork or evidence a copy was requested. (corrected on site)

Upon patient record review, 5 of 14 (Patient #1, #2, #3, #5, #7) did not have evidence that all entries are accurate 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 records. Patient #1-Nursing visit notes on record dated 12/16/23, 01/13/24, 01/19/24 and 01/23/24 do not include licensing credentials in the electronic signature. (corrected on site) Patient #2-Nursing visit notes on record between 01/16/24 and 02/11/24 do not include licensing credentials in the electronic signature. (corrected on site) Patient #3-The IDG notes 01/18/24, 02/01/24 and 02/15/24 document the Aide was offered and declined. This is an error as the patient is ordered to have Aide visits twice weekly and the patient is receiving aide services. Patient #5-The nursing visit note dated 02/13/24 and performed by the LVN does not include an electronic signature. Patient #7-IDG documentation between 12/21/23-02/15/24 is not electronically signed by the MD or RN. (corrected on site)

Upon patient record review, 2 of 5 (Patient #2, 4) 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 2: The medication profile indicates SalonPas TD apply 1 patch daily. There is no indication of an application site for the medication, though the signed physician's orders contain instructions for use on the lower back. (corrected onsite) Patient 4: Per the care plan and signed physician's orders, the patient utilizes oxygen 2L/min via nasal canula PRN for SOB. However, oxygen does not appear on the patient's medication profile.

Upon patient record review, 1 of 5 (Patient #1) 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 patient requires the use of a catheter for management of the terminal illness. The catheter order, dated 08.10.2022, indicates indwelling catheter to be changed monthly, SN may flush PRN when clogged. This is an incomplete order as it does not specify the size of catheter to be used or the balloon size. (corrected onsite)