Every finding on record at Pinnacle Home Health & 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#2,#4,#10 - There was no evidence in record that the Patient's Rights and responsibilities was provided in writing to the patient in a language (Spanish) the patient understands.

Upon patient record review, 1 of 14 (Patient #7) did not have evidence that the hospice informed and provided written information to the patient concerning its policies on advance directives, including a description of applicable state law. Patient #7: There is no evidence the consent is signed by a valid POA and there is a valid consent as POA paperwork was not located in patient chart. Patient record indicated that patient has a POA who did sign the consents.

Upon patient record review, 1 of 14 (Patient #7) did not have evidence that the hospice obtained the patient's or representative's signature confirming that they received a copy of the Patient's Rights and Responsibilities. Patient #7: There is no evidence the consent is signed by a valid POA and there is a valid consent as POA paperwork was not located in patient chart. Patient record indicated that patient has a POA who did sign the consents.

Upon patient record review, 1 of 14 (Patient #7) did not have evidence that if a state court has not adjudged a patient incompetent, any legal representative designated by the patient in accordance with state law may exercise the patient's rights to the extent allowed by state law. Patient #7: There is no evidence the consent is signed by a valid POA and there is a valid consent as POA paperwork was not located in patient chart. Patient record indicated that patient has a POA who did sign the consents.

Upon patient record review, 1 of 14 (Patient #7) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient #7: There is no evidence the consent is signed by a valid POA and there is a valid consent as POA paperwork was not located in patient chart. Patient record indicated that patient has a POA who did sign the consents.

Upon patient record review, 1 of 14 (Patient #7) did not have evidence of the appropriate documentation for release of confidential information. Patient #7: There is no evidence the consent is signed by a valid POA and there is a valid consent as POA paperwork was not located in patient chart. Patient record indicated that patient has a POA who did sign the consents.

Upon patient record review, 1 of 14 (Patient #7) did not have evidence that the patient received information about the services covered under the hospice benefit. Patient #7: There is no evidence the consent is signed by a valid POA and there is a valid consent as POA paperwork was not located in patient chart. Patient record indicated that patient has a POA who did sign the consents.

Upon patient record review, 1 of 14 (Patient #7) did not have evidence that the patient received information about the scope of services that the hospice will provide and specific limitations on those services. Patient #7: There is no evidence the consent is signed by a valid POA and there is a valid consent as POA paperwork was not located in patient chart. Patient record indicated that patient has a POA who did sign the consents.

Upon patient record review 5 of 14 (Patient #1,#2,#3,#5,#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#1: There is no evidence of an initial spiritual assessment being completed. Patient#2: Patient was admitted on 6/11/24. The record indicates psychosocial comprehensive assessment completed on 6/27/24. This is greater than 5 calendar days. There is no evidence of an initial spiritual assessment being completed. Patient#3: Patient was admitted on 6/11/24. The record indicates the psychosocial comprehensive assessment was completed on 6/20/24. The record also indicates the spiritual comprehensive assessment was completed on 6/17/24. Both assessments were completed more than 5 calendar days from election of benefit. Patient#5:There is no evidence of an initial spiritual assessment being completed. Patient#6:The record indicates election of benefit was on 5/7/24. The spiritual comprehensive assessment was completed on 5/13/24. This is more than 5 calendar days.

Upon patient record review, 1 of 14 (Patient #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. Patient#3: The election of benefit for this patient was 6/11/24. The record indicates the initial bereavement assessment was completed on 7/17/24.

Upon patient record review, 3 of 14 (Patient #4,#6,#7) 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 record indicates patient has bladder and bowel incontinence. There was not evidence that the plan of care reflected patient problems goals or intervention related to urinary and bowel incontinence. Corrected on site. Patient#6:The record indicates the patient has incontinence, aphasia, diabetes, and cardiovascular diagnosis. There is not evidence that the plan of care reflected problems goals or interventions related to these diagnosis. Corrected on site. Patient#7: The record indicates the patient has a diagnosis of insulin dependent diabetes. According to the patient record the patient is actively prescribed Lispro, Lantus, and Glucagon. There is no evidence that the plan of care reflected problem goals or interventions related to this the diagnosis or the medications associated with the diagnosis. Corrected on site.

Upon patient record review, 2 of 14 (Patient #3,#4) 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#3: The record indicates the order for MSW visit frequency is 1 time per month. There was 1 scheduled visit document in July 2024 and also a PRN visit on 7/26/24. There is no evidence of PRN visit on the order. Corrected on site. Patient#4: The record indicates the order for MSW visit frequency is 1 time per month. There was 1 scheduled visit document in July 2024 and also a PRN visit on 7/26/24. There is no evidence of PRN visit on the order. Corrected on site.

Upon patient record review, 3 of 14 (Patient #1,#2,#3) 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 indicates on 7/31/24 RN assessment that patient was a full code and requested assistance from MSW in reviewing and filling out paperwork for DNR. There is no evidence of follow-up or assistance by MSW. Patient#2: The record indicates that on 6/11/24 the patient was continent of bowel and bladder. On 6/26 nurse documented patient experiencing incontinence of bowel and bladder. There is no evidence of plan of care problems goals or interventions being updated. Patient#3: The record indicates that on 6/28/24 the patient requested information on additional resources. The nurse advised she would notify the MSW who would assist with providing that information. There is no evidence of any follow-up or needs for information being addressed.

Upon client record review, 2 of 14 (Patient #5,#9) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient#5:The record indicated the 5/10/24 order for nurse frequency at 2 times per week. The week of 7/1/24 there was documentation of 3 nurse visits occurring on 7/1,7/3, and 7/5. The week of 7/30/24 was documentation of 3 nurse visits occurring on 7/30, 8/1, and 8/2. Corrected on site. Patient#9: The record indicated the order for nurse frequency at 1 time per week and 3 PRN. The week of 7/14 there was documentation of 2 scheduled visits occurring on 7/16 and 7/17. Corrected on site.

Upon patient record review 1 of 14 (Patient #1) 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 record indicates the order for aide visit frequency is 2 times per week. The week of 8/4/24, 3 aide visits were completed. Corrected on site.

Upon observation, there was no evidence the hospice documents marketing efforts or recruiting efforts to demonstrate viable and ongoing efforts to recruit and retain volunteers.

Upon patient client record review, 1 of 14 (Patient #7) 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 #7: There is no evidence the consent is signed by a valid POA and there is a valid consent as POA paperwork was not located in patient chart. Patient record indicated that patient has a POA who did sign the consents.

Upon patient client record review, 3 of 14 (Patient #2,#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. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records Patient#2:The record indicates a discrepancy in the documentation. Documentation from 6/12/24 RN assessment states that patient signed her own consents. The consent forms were signed by the patient daughter. Patient#3: The record indicates the nurse documentation for visit on 6/12/24 states patient is a full code. The form scanned in with consent indicates patient is DNR.

Upon client record review, 1 of 14 (Patient #12) did not have evidence that the hospice forwarded a summary and a copy of the patient record, if requested, to a facility when transferring the patient to that facility. Patient#12: There is no evidence that a transfer summary was forwarded, nurse documented "needs assistance" on visit note at time of transfer.

Upon client record review, 1 of 14 (Patient #11) did not have evidence that if a patient revokes the election of hospice care or is discharged from hospice in accordance with §418.26, the hospice must forward to the patient's attending physician: • A copy of the hospice discharge summary • The patient's clinical record, if requested Patient#11: There is no evidence of a discharge summary being sent to physician.

Upon client record review, 2 of 14 (Patient #11) did not have evidence that the discharge summary includes all required information. Patient#11: There is no evidence of a discharge summary in patient record.