Every finding on record at Passages Hospice Care, Inc.

Upon patient record review 1 of 7 (Patient #3) 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 3: Patient admitted 10/22/2024. There is no evidence of initial psychosocial assessment or spiritual assessments in the medical record

Upon patient record review, 2 of 7 (Patient #3,4) 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. 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 3: Patient has a physician's order for oxygen. There is no evidence of oxygen in the patient's medication list. Patient 4: Patient has evidence of contradicting orders for levothyroxine in the medication list as follows: Order 1 reads levothyroxine 100mcg 2.5 tablets by mouth every day except Tuesday and Thursday. Order 2 reads levothyroxine 100mcg 3 tablets by mouth on Tuesday, Thursday, and Saturday.

Upon patient record review, 3 of 7 (Patient #1,2,3) 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. COS Patients 1 and 2: Initial bereavement assessments, dated 08/29/2024, present on survey day 2. Administrator reports she had to request this documentation from the BC multiple times before receiving on 11/07/2024. Patient 3: No Initial bereavement assessment.

Upon patient record review, 3 of 7 (Patient #1,2,3) 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 1, 2, 3: There is no evidence in the medical record that a SN visit was made after 10/22/2024.

Upon patient record review, 1 of 7 (Patient #4) 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: Patient with physician's order for aspirin with indication of blood thinner. There is no evidence in the medical record of bleeding precautions plan of care with problems, goals, interventions.

Upon patient record review, 5 of 7 (Patient #1,2,3,4,5) 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 1,2,3,4,5: Physician's orders for social worker visits are once monthly PRN. Physician's orders for spiritual care visits are once monthly PRN. There is no evidence of physician's orders for scheduled visits for these disciplines. COS for patients 1, 2.

Upon patient record review, 1 of 7 (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: Patient has evidence of contradicting orders for levothyroxine in the plan of care as follows: Order 1 reads levothyroxine 100mcg 2.5 tablets by mouth every day except Tuesday and Thursday. Order 2 reads levothyroxine 100mcg 3 tablets by mouth on Tuesday, Thursday, and Saturday.

Upon patient record review, 1 of 7 (Patient #3) did not have evidence that the IDG in collaboration with the attending physician reviewed, revised and documents the individualized plan as frequently as the patient's condition requires but no less frequently then every 15 calendar days. Patient 3: There is no evidence in the medical record of any IDG after 10/25/2024. COS IDG was held on 11/06/2024. IDG documentation was not filed in patient charts until after deficiency found by surveyor.

Upon patient record review, 3 of 7 (Patient #1,2,3) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 1: There is no evidence in the medical record: SN visit after 10/22/2024. Physician's visit frequency order for SN is once weekly. Patient 2: There is no evidence in the medical record: SN visit after 10/22/2024. Physician's visit frequency order for SN is once weekly. Initial spiritual assessment narrative states SC visits will be conducted monthly. There is no evidence of SC visits made after initial assessment, or documentation of change to this plan. Patient 3: Patient was admitted to hospice on 10/22/2024 with physician's visit frequency order for SN of once weekly. There is no evidence in the medical record or SN visit made after 10/22/2024.

Upon patient record review, 1 of 7 (Patient #1) 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: CTI for benefit period one dated 08/29/2024 - 11/ /2024. COS

Upon inpatient contract review, 1 of 1 (Temple Park) did not have evidence that the hospice patient's inpatient clinical record includes a record of all inpatient services furnished and events regarding care that occurred at the facility; that a copy of the discharge summary be provided to the hospice at the time of discharge; and 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 (Temple Park) did not have evidence that the hospice retains responsibility for ensuring that the training of personnel who will be providing the patient's care in the inpatient facility has been provided and that a description of the training and the names of those giving the training are documented.

Upon SNF/NF contract review, 1 of 1 (Temple Park) 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.

Upon SNF/NF contract review, 1 of 1 (Temple Park) 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.

Upon patient record review, 1 of 6 (Patient #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 #4, MD order dated 12/20/21 Voltaren topical gel 1% 100gm apply topically to affected area BID, Bactrim DS 800/160mg 1 tabl PO BID x10 days. Medications were not updated on Medication profile.

Upon patient record review, 5 of 6 (Patient #1,2,3,4,6) 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 a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs Patient #1,2,3,4,6 had initial MSW and SC orders for eval and 1x/month PRN. There was no established frequency for MSW or SC visits.

Upon client record review, 3 of 6 (Patient #1, 2, 3) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1,2 MD order for MSW and SC 1 x month PRN. Visits were made on both patients 8/16/21 and 9/29/21 without identifying PRN visit or having a specified frequency order. Patient #3 The plan of care did not include orders or interventions for a cheek lesion. The SN documentation included assessment of a cheek lesion.