Every finding on record at Pinnacle Palliative Services Inc.

Upon observation, there was no evidence the Emergency Plan communication plan includes: • A method for sharing information and medical documentation for patients under the hospice's care, as necessary, with other health care providers to maintain the continuity of care • A means, in the event of an evacuation, to release patient information as permitted under 45 CFR 164.510(b)(1)(ii) • A means of providing information about the general condition and location of patients under the facility's care as permitted under 45 CFR 164.510(b)(4) There was not evidence of a patient list with patient information about the general condition and location of patients.

Upon observation, and home visit (Patient #1,#2,#3) did not have evidence that the patient has the right: • To exercise his or her rights as a patient of the hospice • Have one's property and person treated with respect • To not be subjected to discrimination or reprisal for exercising his or her rights The staff member's ID contained only a picture and her name and credentials and no agency name. There was not evidence that patients were able to identify visiting personnel members through agency generated photo identification.

Upon patient record review, 2 of 14 records (Patient #3, 9) 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: During home visit noted, the facility had a bottle of Lisinopril which was labeled 40mg, take 1 tab daily. This medication was not on the hospice medication profile. Also the facility had 2 different instructions for Senna (1 prn and 1 daily). The hospice record contained only the daily instructions. And, the facility had 2 different instructions for Vitamin D3 (1 capsule daily, and 1/2 tab daily). The hospice record contained only the 1/2/tab instructions. Patient #9: The medication profile contained Zithromax 250 mg 1 tab daily for 5-7 days. There was not evidence of specific length of time to administer the drug.

Condition of Participation: Interdisciplinary Group, Care Planning, and Coordination of Services.

Upon observation, and record review, 6 of 14 records (Patient #1,#2,#3,#4,#6,#7) did not contain evidence that the hospice has an interdisciplinary group (IDG) or groups composed of individuals who work together to meet the physical, medical, psychosocial, emotional, and spiritual needs of the hospice patients and families facing terminal illness and bereavement. Interdisciplinary group members must provide the care and services offered by the hospice, and the group, in its entirety, must supervise the care and services. Patient #1 The IDG meetings dated 4/15/25, 4/29/25, 5/13/25 and 5/27/25 did not contain evidence of participation by the spiritual care counselor. There was no evidence of documentation in the record of a signature for the IDG review and (if indicated) a revision of the care plan. Patient #2: The IDG meetings for the dates of 5/13/25 and 5/27/25 did not contain evidence of participation by the spiritual care counselor or the medical director. There was no evidence of documentation in the record of a signature for the IDG review and (if indicated) a revision of the care plan. Patient #3: The IDG meetings for the dates of 5/17/25 and 5/27/25 did not contain evidence of participation by the spiritual care counselor or the medical director. There was no evidence of documentation in the record of a signature for the IDG review and (if indicated) a revision of the care plan. Patient #4: The IDG meetings dated 4/27/25, 5/13/25 and 5/27/25 did not contain evidence of participation by the spiritual care counselor. There was no evidence of documentation in the record of a signature for the IDG review and (if indicated) a revision of the care plan. Patient #6: The IDG meetings dated 5/9/25 and 5/27/25 did not contain evidence of participation by the spiritual care counselor. There was no evidence of documentation in the record of a signature for the IDG review and (if indicated) a revision of the care plan. Patient #7: The IDG meetings dated 5/18/25 and 5/27/25 did not contain evidence of participation by the medical director. There was no evidence of documentation in the record of a signature for the IDG review and (if indicated) a revision of the care plan.

Upon patient record review, 2 of 14 records (Patient #1,#4) did not have evidence in the patient record that the hospice plan of care includes all services necessary for the palliation and management of the terminal illness and related conditions. Patient #1: Both the social worker and the spiritual care provider were involved with the care of the patients. There was not evidence that the hospice has developed an individualized written plan of care for each patient that reflects patient/family goals and interventions based on the psychosocial and spiritual problems identified in the assessments of the patient and family. Patient #4: The spiritual care provider was involved with the care of the patients. There was not evidence that the hospice has developed an individualized written plan of care for each patient that reflects patient/family goals and interventions based on the spiritual problems identified in the assessments of the patient and family.

Upon patient record review, 2 of 14 records (Patient #3,#9) 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 #3: The facility had a bottle of Lisinopril which was labeled 40mg, take 1 tab daily. There was not evidence of an order in the hospice record. Patient #9: The record contained an order for Zithromax 250 mg 1 tab daily for 5-7 days. There was not evidence of specific length of time to administer the drug.

Upon patient record review, 1 of 14 records (Patient #11) 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 #11: The patient was discharged for extended prognosis on 3/28/25. There was no evidence of discharge planning, discussion among the IDG or with the patient regarding discharge. Documentation in visit notes as well as IDG narrative discussion has a focus on the patient's pain, continued decline and need for hospice.

Upon client record review, 9 of 14 records (Patient #2,#3,#4,#5,#6,#7,#8,#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 #2: There was not evidence of an order for an initial visit evaluation /assessment for the social worker. The record indicated that an assessment/visit was conducted on 5/14/25. Patient #3: There was not evidence of an order for an initial visit evaluation /assessment for the social worker. The record indicated that an assessment/visit was conducted on 5/18/25. Patient #4: There was not evidence of an order for an initial visit evaluation /assessment for the social worker. The record indicated that an assessment/visit was conducted on 4/28/25. Patient #5: There was not evidence of an order for an initial visit evaluation /assessment for the social worker or the spiritual care provider. The record indicated that a social worker assessment/visit was conducted on 4/29/25, and the spiritual assessment/visit was conducted on 4/30/25. Patient #6: There was not evidence of an order for an initial visit evaluation /assessment for the social worker. The record indicated that an assessment/visit was conducted on 5/10/25. Patient #7: There was not evidence of an order for an initial visit evaluation /assessment for the social worker. The record indicated that an assessment/visit was conducted on 5/19/25. Patient #8: There was not evidence of an order for an initial visit evaluation /assessment for the social worker or the spiritual care provider. The record indicated that a social worker assessment/visit was conducted on 5/15/25, and the spiritual assessment/visit was conducted on 5/16/25. Patient #9: There was not evidence of an order for an initial visit evaluation /assessment for the social worker or the spiritual care provider. The record indicated that a social worker assessment/visit was conducted on 5/11/25, and the spiritual assessment/visit was conducted on 5/12/25. Patient #10: There was not evidence of an order for an initial visit evaluation /assessment for the social worker or the spiritual care provider. The record indicated that a social worker assessment/visit was conducted on 5/16/25, and the spiritual assessment/visit was conducted on 5/17/25.

Upon observation, there was no evidence the annual report documents the use of volunteers providing day to day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract personnel. There was not a record of the percentage of usage for the year 2024.

Condition of Participation: Medical Director.

Upon contract review, 1 of 4 contracts (Richard Keech) did not have evidence of a contract to fulfill the role of alternate medical director. There was not evidence that the contract specifically identified an alternate medical director. The contracts for the medical director and for the alternate both indicated Medical Director without evidence of a delegation of authority form or an indication of such on the organizational chart. Corrected on site.

Upon observation, there was no evidence the Medical Director or physician designee has the responsibility for the medical component of the hospice's patient care program. When interviewed, and asked about oversite, the Medical Director stated that he speaks with the other physician on the phone, but when asked if there was documentation in regards to oversite, he stated that 'TLC' might have it. He also stated that IDT was on the phone when needed. When asked about QAPI participation, he was unsure what QAPI was.

Upon patient client record review, 2 of 14 records (Patient #5,#8) did not have evidence that each patient record contains: • Signed election statement in accordance with 418.24 Patient #5: The space on the election of benefit form which was for the date that the patient/representative chose to begin the hospice benefit and initiate care was blank. All documents were signed on 4/28/25 which was the day that care was initiated. Corrected on site. Patient #8: The space on the election of benefit form which was for the date that the patient/representative chose to begin the hospice benefit and initiate care was blank. All documents were signed on 5/14/25 which was the day that care was initiated. Corrected on site.

Upon patient client record review, 1 of 14 (Patient #11) 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 #11: The record indicated that the patient was discharged for no longer being appropriate and having an extended prognosis. The record contained both a discharge order and a signed revocation statement and a hospice may not revoke a patient's benefit for them therefore this information is unclear.