Every finding on record at Passionate Heart Hospice, Inc.

Upon patient record review 2 of 14 (Patient #1, 6) 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 1: The patient was admitted for hospice services on 09.13.2024. The comprehensive assessment for spiritual needs was not completed until 09.25.2024, which exceeds the 5 day requirement. Patient 6: The patient was admitted for hospice services on 08.29.2024. The comprehensive assessment for psychosocial needs was not completed until 09.07.2024, which exceeds the 5 day requirement.

Upon patient record review 2 of 14 (Patient #3, 4) 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: A comprehensive assessment of the patient's spiritual needs was not completed at the time of hospice admission, and has not been completed at any subsequent time. Patient 4: A comprehensive assessment of the patient's psychosocial needs was not completed at the time of hospice admission, and has not been completed at any subsequent time.

Upon patient record review, 14 of 14 (Patient #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 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 Patient #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14: The medication list did not include the patient's ordered oxygen. (corrected onsite for all active patients) Patient 5: On 10.05.2024, an order was entered for Nystatin 100,000 units apply thin coat daily to perineum; however, the medication list did not include this ordered medication. (corrected onsite)

Upon client record review, 4 of 14 (Patient #6, 7, 9, 10) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 6, 9: The plan of care does not include orders for the MSW to visit the patient on an ongoing basis. The MSW has been seeing the patient monthly and all psychosocial needs of the patient and family appear to be met; however, the plan of care does not include an order and frequency for these visits. Patient 7:The plan of care indicates that the MSW will visit the patient 1 x monthly; however, there is no evidence that the MSW made a visit to see the patient during the month of October 2024. Patient 10:The plan of care indicates that the MSW will visit the patient 1 x monthly; however, there is no evidence that the MSW made a visit to see the patient during the months of September or October 2024.

Upon patient client record review, 4 of 14 (Patient #3, 6, 10, 13) did not have evidence that each patient record contains: • Signed election statement in accordance with 418.24 Patient 3, 6, 10, 13: On admission for hospice services, the patient or representative requested the Notification of Noncovered Items & Services. Though the Notice of Noncovered Items & Services form was returned and signed by the patient/representative, the hospice failed to complete this process within 5 days, as required.

Upon review personnel record, 1 of 7 (Personnel #1) did no have evidence that personnel have been fully vaccinated for Covid-19 nor was there evidence of any completed exemptions. It was noted this employee had not been used by the agency in nearly 3 months. Agency held a Governing body meeting during this survey to officially inactive the employee until she provides the required documentation to the agency.

Upon patient record review 1 of 13 (Patient #7) did not have evidence that the hospice Registered Nurse must complete an initial assessment within 48 hours after the election of hospice care in accordance with §418.24 Patient #7: The patient signed election of benefit authorized the benefit to begin on 7/9/21. The RN Initial Assessment was not completed until 7/12/2021.

Upon patient record review 1 of 13 (Patient #7) 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 #7: The patient was admitted on 7/9/2021. The psychosocial assessment was not completed until 7/16/2021 (day 7).

Upon patient record review, 3 of 13 (Patient #2, #7 and #10) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component completed within 5 days of the election of hospice. Patient #2: There was no documentation to indicate an Initial Bereavement Assessment had been conducted. Patient #7: The Initial Bereavement Assessment was not conducted until 7/16/2021. Patient #10: The Initial Bereavement Assessment was not conducted until 4/9/2021.

Upon client record review, 1 of 13 (Patient #7) did not have evidence that the IDG, in collaboration with the attending physician, reviewed, revised and documented in the individualized plan as frequently as the patient's condition requires but no less frequently then every 15 calendar days. Patient #7: The IDG reviewed and revised the plan of care on 7/12/2021, however, it was not reviewed again by the IDG until 8/10/2021 (day 29).

Upon client record review, 4 of 13 (Patients #2, #9, #10 and #12) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #2: Included a Physician order dated 2/9/2022 for MSW [Medical Social Worker] to assess and evaluate the patient with in 5 days. The Social Worker did not assess the patient within the 5 days as ordered. Patient #9: A Social Work visit was conducted on 10/8/2021. There was no update to the Plan of Care that included Social Work visits. Patient #10: Included a Physician order dated 4/9/2021 instructing the Social Worker to make monthly visits. There was no Social Work visit conducted for the month of April. Patient #12: A Chaplain visit was conducted on 9/26/2020. There was no update to the Plan of Care that included Chaplain visits.

Condition of Participation: Infection Control.

Upon observation, there was no evidence the hospice documented the reasons for conducting the QAPI projects, and the measurable progress achieved on those projects. Although the Hospice had documented QAPI projects during the year 2021, there was no documentation to indicate the reason for the QAPI projects chosen or any documentation to indicate the effectiveness of the projects, including, baseline or measurable progress achieved.

Upon observation, there was no evidence the hospice ensures the implementation of a hospice wide Quality Assessment/Performance Improvement (QAPI) program by the designation of a person responsible for coordinating QAPI activities. Although the Agency had a QAPI program, there was no documentation of measurable data to demonstrate the effectiveness of the program, in that, there were no measurable baseline date to indicate why the Improvement Plans had been chosen, or measurable data to show ongoing improvement and/or decline. There was no documentation to indicate who had on-going oversight of the QAPI programs.

Upon patient record review, 4 of 5 applicable (Patients #3, #8, #9, #12) did not have evidence the hospice has a bereavement plan of care for the types of services to be provided and provides services in accordance with the plan of care. Patient #3: the Bereavement Plan of Care dated 2/11/2022, had interventions that included: a condolence card being sent out after IDG and a post death sympathy card. Neither intervention had been completed as of the survey date of 3/10/2022. Patient #8; expired on 12/22/2021 and there was no Bereavement Plan of Care noted in the Clinical Record. Patient #9: expired on 11/16/2021 and there was no Bereavement Plan of Care noted in the Clinical Record. Patient #12: expired on 10/7/2020. On 10/21/2020, the Chaplain documented a phone call to the wife. Emotional and spiritual support was provided during the call and the bereavement counselor planned to follow up with the wife as needed. There was no additional documentation to support any further follow up with the wife or family.

Upon patient record review, 2 of 6 applicable (Patient #1 and #12) did not have evidence in the patient record that the hospice aide assignments and duties included the tasks to be provided and the frequency of those tasks. Patient #1: A communication log dated 12/24/2021 documented the Primary RN for the patient had tested positive for COVID. The Aide conducted two additional visits before the patient tested positive and was quarantined at the facility. The Aide Plan of Care was not updated with potential infection precautions. Patient #12: The Aide Care Plan was not clear in the directions to the Aide, in that the Care plan did not have the vital sign box checked to direct the Aide to take vital signs, however, there were specific instructions noted at the bottom of the Care Plan to notify the RN for patient vital signs outside the listed parameters.

Upon patient record review 3 of 5 (Patient #1, #2 and #12) did not have evidence documentation in the patient record that a hospice aide provides services that are ordered by the IDG and included in the plan of care. Patient #1: An Aide Care Plan dated 12/14/2021 instructed the Aide to provide passive range of motion and to change linens on every visit. There was no documentation to indicate those tasks had been completed on the visit conducted on 1/17/2021. Patient #2: A Physician order dated 2/9/2021was obtained for the Aide to provide services 1 x week. There was no Aide visits conducted during the weeks of 2/6/2021, 2/13/21, and 2/20/2021. Patient #12: A Physician order dated 8/22/2020 was obtained for the Aide to provide services 2 x week. There was only 1 Aide visit conducted during the week of 8/22/2020. On the Aide Care Plan, the Aide was directed to clean and file nails every visit. There was no documentation to indicate the nails were filed and cleaned on the visit conducted on 9/5/2020.

Upon observation, there was no evidence the hospice documents and demonstrates viable and ongoing efforts to recruit and retain volunteers. Based on review of the Volunteer Program for 2020 and 2021, there was no documentation to indicate any recruitment or retention efforts during either year.

Upon personnel record review, 3 of 12 (Personnel #7, #8 and #9) did not have evidence that the hospice employees and contract employees had received orientation on the hospice philosophy.

Upon patient client record review, 2 of 13 (Patient #3 and #7) 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 documents titled, "Patient and Family Informed Consents" and "Signature of Beneficiary or Legal Representative" were signed but had no dates by the signatures of the patient and/or primary caregiver and the hospice staff and on the nursing visit conducted on 2/12/2022, the nurse failed to answer the question of how the medications Morphine and Lorazepam had been disposed. Patient #7: RN visit dated 12/24/2021 stated in the narrative that the patient/caregiver was instructed to call Hospice with any changes in condition. The name of the hospice in the note was not the name of this hospice agency. The Agency was unaware of who the nurse was referencing the patient/primary caregiver to call.

Upon personnel record review, 3 of 6 (Personnel #7, #8, and #9) did not have evidence that personnel credentialing activities were 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 #7: There was no updated PT license in the personnel record. The license had expired on 9/10/2018. Personnel #8: There was no updated OT license in the personnel record. The license had expired on 3/21/2020. Personnel #9: There was no updated ST license in the personnel record. The license had expired on 4/30/2019.

Upon observation, there was missing evidence the agency had a process ensuring the tracking and secure documentation of the vaccination status of personnel for whom COVID–19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations, including, but not limited to, individuals with acute illness secondary to COVID–19, and individuals who received monoclonal antibodies or convalescent plasma for COVID–19 treatment;.