Every finding on record at Pnc Palliative Hospice LLC

Condition of Participation: Initial and Comprehensive Assessment of the Patient.

Upon patient record review, 2 of 14 (Patient #1,#11) 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 #1: Noted on home visit, Iron was in the home and being taken by patient and not on med profile. Patient #11: Noted on home visit, Memantine, Iron, Senna, D3, are in home and taken daily and not on med profile.

Upon patient record review, 2 of 14 (Patient #1,#2) 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 #1,#2: There was no evidence of a bereavement assessment completed within 5 days of the admission.

Upon patient record review, 10 of 14 (Patient #2,#3,#4,#5,#7,#8,#9,#10,#11,#14) 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 #2,#3,#4,#5,#7,#8,#9,#10,#11,#14: There was no evidence after the initial plan of care was written that the IDG documented updates and changes to the plan of care based on the comprehensive assessments.

Condition of Participation: Interdisciplinary Group, Care Planning, and Coordination of Services. L536

Upon patient record review, 2 of 14 (Patient #1,#11) 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: Noted on home visit, Iron was in the home and being taken by patient and no orders present in file. Patient #11: Noted on home visit, Memantine, Iron, Senna, D3, are in home and taken daily and no orders present in file.

Upon patient record review, 10 of 14 (Patient #2,#3,#4,#5,#7,#8,#9,#10,#11,#14) 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 #2,#3,#4,#5,#7,#8,#9,#10,#11,#14: There was no evidence that the plans of care were revised and included information from the updated comprehensive assessment.

Upon client record review, 14 of 14 (Patient #1,#2,#3,#4,#5,#6,#7,#8,#9,#10,#11,#12,#13,#14) 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,#3,#4,#5,#6,#7,#8,#9,#10,#11,#12,#13,#14: The initial plan of care indicated a SW frequency of 1 month 1 however, there were no visits by a SW as the nurse completed the psychosocial assessment.

Upon observation, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient #1, #2, #11: There was no evidence of a barrier for the bag used by the nurse during the home visit.

Upon observation, there was no evidence in the QAPI reports that the hospice maintains a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases. There was no evidence through documentation that the hospice had surveilled communicable diseases of its population in order to identify the criteria for reporting.

Upon personnel record review, 1 of 11 (Personnel #9) did not have evidence that the hospice routinely provide substantially all core services directly by hospice personnel (The hospice issues a W-2 form for the employee). These services include: • Medical social services Personnel #9: The social worker is on contract from Sterling Staffing Solutions.

Upon patient record review, 2 of 14 (Patient #6,#7) did not have evidence the hospice offers bereavement counseling that includes: • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery Patient #6,#7: There was no evidence of a bereavement plan of care noting the services and frequency of service delivery.

Upon personnel record review, 1 of 11 (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.

Condition of Participation: Organization and Administration of Services.

Upon observation, there was no evidence the hospice is directed by a Board of Directors/governing body which assumes full legal authority and responsibility for the operation of the hospice. There was no evidence of TX specific policies, no evidence of annual review of policies, and no evidence of competency assessments for clinical staff. In addition, agency is using contracted social worker as a core employee.

Upon contract review, 1 of 4 (Alt MD) did not have evidence the agreement to furnish any services under arrangement included that the hospice must retain administrative and financial management, and oversight of staff and services for all arranged services, to ensure the provision of quality care. Arranged care/services are supported by written contract/agreement that requires all care/services are: • Authorized by the hospice • Furnished in a safe and effective manner by qualified personnel • Delivered in accordance with the patient's plan of care There was no evidence the alternate medical director contract included language regarding services authorized by hospice, furnished in a safe and effective manner, or delivered in accordance with the patient's plan of care.

Upon personnel record review, 5 of 11 (Personnel #3,#4,#5,#6,#7 ) did not have evidence that the hospice employees have received orientation on their specific job requirements. Personnel #3,#4,#5,#6,#7: The personnel files contained no evidence the employee had received training on their specific job duties.

Upon personnel record review, 7 of 11 (Personnel #1,#2,#3,#4,#5,#6,#7 ) did not have evidence that a skills competency assessment, specific to each discipline had been conducted for all personnel including volunteers initially during orientation. Personnel #1,#2,#3,#4,#5,#6,#7: There was no evidence of a skills competency assessment in the personnel files.

Condition of Participation: Clinical Records.

Upon patient client record review, 8 of 14 (Patient #1,#6,#7,#9,#11,#12,#13,#14) did not have evidence that each patient record contains Physician certification and recertification of terminal illness. Patient #1,#6,#7,#9,#11,#12,#13,#14: The election statement indicated the patient chose an attending MD other than the hospice medical director. However, there was no verbal or written certification by the chosen attending MD.

Upon patient client record review, 1 of 14 (Patient #10) 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 #10: There was no discipline noted after the signature on all nursing notes in the patient chart.

Upon client record review, 1 of 14 (Patient #4) 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 #4: There was no evidence of a completed transfer summary in the patient chart.

Upon client record review, 1 of 14 (Patient #5) 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 Patient #5: There was no evidence of discharge summary sent to attending.

Upon client record review, 1 of 14 (Patient #5) did not have evidence that the discharge summary includes all required information. Patient #5: There was no evidence of a completed discharge summary in the patient chart.

Upon inpatient contract review, 1 of 4 (Harmony GIP/Respite) 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. There was no evidence the contract for GIP and Respite care contained language regarding patient records, discharge summary and availability of records at discharge.

Upon inpatient contract review, 1 of 4 (Harmony GIP/Respite) did not have evidence that the inpatient facility has identified an individual within the facility who is responsible for the implementation of the provisions of the agreement. There was no evidence that the contract for GIP, and respite contained language regarding the inpatient facility identifying a responsible individual.

Upon inpatient contract review, 1 of 4 (Harmony GIP/Respite) did not have evidence of a method for verifying that the requirements for ACHC standard HSP1-8B and CFR 418.108c (1)-418.108c(5)are met. The contract for GIP and respite care contained no evidence of a method for verifying ACHC standards are met.

Upon patient client record review, 1 of 5 (Patient #2) 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 2: Upon record review the CTI narrative by the medical director shows "Primary terminal diagnosis CKD stage 3 with treatment of dialysis, uncontrolled IDDM with SOB with moderate exertion". The plan of care has documented the terminal diagnosis for this patient as Chronic diastolic heart failure with comorbid conditions of COPD and muscle weakness.

Upon patient record review 2 of 5 (Patient #4, #5) 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 #4 Upon admission on 2/21/2022 and to date, a psychosocial assessment has not been completed for this patient. Patient #5 Upon admission on 2/23/2022 and to date a psychosocial assessment has not been completed for this patient.

Upon patient record review, 3 of 5 (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 There is no evidence of a SN visit to update the comprehensive assessment since 1/26/2022. Patient #2 There is no evidence of a SN visit to update the comprehensive assessment since 1/18/2022. Patient #3 There is no evidence of a SN visit to update the comprehensive assessment since 1/28/2022.

Condition of Participation: Interdisciplinary Group, Care Planning, and Coordination of Services. L536

Upon patient record review, 3 of 5 (Patient # 1, 2, 3) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient #1 There is no evidence of a SN visit to assess the patient and family needs and to coordinate activities with other members of the IDG since 1/26/2022. Patient #2 There is no evidence of a SN visit to assess the patient and family needs and to coordinate activities with other members of the IDGsince 1/18/2022. Patient #3 There is no evidence of a SN visit to assess the patient and family needs and to coordinate activities with other members of the IDGsince 1/28/2022.

Upon patient record review, 3 of 5 (Patient #1, #2, #3) 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, Effective 2/4 and to date, the patient record does not indicate frequency orders for any disciplines. Patient #2 Effective 2/6 and to date, the patient record does not indicate frequency orders for any disciplines. Patient #3 Effective 2/4 and to date, the patient record does not indicate frequency orders for any disciplines.

Upon client record review, 3 of 3 applicable (Patient # 1, 2 ,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 #1 There is no evidence the agency reviewed and revised the POC based on the patient's current status including patient goals/outcomes since the start of the current benefit period of 1/16/22 - 3/16/22 Patient #2 There is no evidence the agency reviewed and revised the POC based on the patient's current status including patient goals/outcomes since the start of the current benefit period that started on 2/6/22 Patient #3 There is no evidence the agency reviewed and revised the POC based on the patient's current status including patient goals/outcomes since the start of the current benefit period that started on 2/2/22

Upon client record review, 3 of 5 (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 Patient received SC visits in the month of Feb with no ordered frequencies or PRN orders. Patient #2 Patient received SC visit on 2/19 with no ordered frequencies or PRN orders. Patient #3 Patient received SC visits in the month of Feb with no ordered frequencies or PRN orders.

Condition of Participation: Organization and Administration of Services.

Upon observation, there was no evidence the hospice is directed by a Board of Directors/governing body which assumes full legal authority and responsibility for the operation of the hospice that includes providing care as needed by the patient and family. Patients 1, 2, 3 have not had a SN assessment or plan of care review since the beginning of the current benefit period. There are no visit frequencies ordered and the chaplain is making visits. The agency has also not completed a Recertification of Terminal Illness (CTI) for any of these patients, and Patients 4 and 5 have incomplete CTI's on file. Personnel # 1, hired on 7/1/21 has not had a competency assessment completed.

Upon personnel record review, 1 of 2 (Personnel #1 ) did not have evidence that a skills competency assessment, specific to each discipline had been conducted for all personnel including volunteers initially during orientation. Personnel #1 - Effective hire date of 7/1/21 and to date, there is no skills competency assessment on file.

Upon patient record review, 2 of 5 (Patient # 4, 5) 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 #4 & 5- The CTI that was on file for the initial cert period did not include a physician statement/narrative indicating the need for hospice services. It was a Texas state Medicaid form 3074 that had a blanket pre=printed statement. It did not include a physician narrative directly above the physician signature.

Upon patient record review, 3 of 3 applicable (Patient # 1, 2, 3) did not have evidence that before the recertification period for each patient, the medical director or physician designee must review the patient's clinical information and provide written documentation that it is anticipated that the patient's life expectancy is 6 months or less. Patient #1 There is no evidence of a complete and accurate recertification of terminal illness for the current benefit period effective 1/16/22 and to date. Patient #2 There is no evidence of a complete and accurate recertification of terminal illness for the current benefit period effective 2/6/22 and to date Patient #3 There is no evidence of a complete and accurate recertification of terminal illness for the current benefit period effective 2/2/22 and to date.

Upon personnel record review, 11 of 11 (Personnel #1,2,3,4,5,6,7,8,9,10,11) did not have evidence Emergency Preparedness training including: • Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles • Demonstrate staff knowledge of emergency procedures

Upon patient record review, 4 of 12 (Patient #2,4,8,10) 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.

Upon patient record review, 12 of 12 (Patient #1,2,3,4,5,6,7,8,9,10,11) did not have evidence that the patient chooses a health care provider, including an attending physician.

Upon patient record review, 4 of 12 (Patient #4, 8, 10, 12) did not have evidence of the appropriate documentation for release of confidential information.

Condition of Participation: Initial and Comprehensive Assessment of the Patient.

Upon patient record review 1 of 12 (Patient #9) 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 #9 - SOC 05/20/2021. Spiritual care assessment completed 05/27/2021.

Upon patient record review, 2 of 12 (Patient #9,10) did not have evidence in the patient record that the comprehensive assessment identifies the 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 #9 - Missing evidence a psychosocial assessment was completed. Patient #10 - Missing evidence a spiritual care assessment was completed by any member of the IDG.

Upon patient record review, 10 of 12 (Patient #1,2,3,4,5,6,8,10,11,12) 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 #1,2,3,4,5,6,8,10,11,12 - did not have evidence in the patient record of an initial bereavement assessment.

Upon patient record review, 12 of 12 (Patient #1,2,3,4,5,6,7,8,9,10,11,12) did not have evidence in the patient record that the comprehensive assessment is updated. Agency was unable to locate most documentation for these patients. Unable to determine that visits were made to update the comprehensive assessment.

Condition of Participation: Interdisciplinary Group, Care Planning, and Coordination of Services. L536

Upon patient record review, 10 of 12 (Patient #1,2,3,4,5,6,7,8,9,12) 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 - POC dated 11/15/2021 did not contain visit frequency for the SN. Patient #2 - POC dated 12/31/2021 did not contain visit frequency for the MSW or SC. Patient #3 - POC dated 12/06/2021 did not contain visit frequency for the SC. Patient #4 - POC dated 10/31/2021 did not contain visit frequency for the SC. Patient #5 - POC dated 11/17/2021 did not contain visit frequency for the SC. Patient #6 - POC dated 12/04/2021 did not contain visit frequency for the SN or SC. Patient #7 - POC dated 10/11/2021 did not contain visit frequency for the SN, MSW or SC. Patient #8 - POC dated 09/02/2021 did not contain visit frequency for the SN or SC. Patient #9 - POC dated 05/20/2021 did not contain visit frequency for the SC. Patient #12 - POC dated 01/03/2022 did not contain visit frequency for the MSW or SC.

Upon patient record review, 2 of 12 (Patient #8, 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 #8 - POC 09/12/2021 did not contain any medications but patient has a medication profile on file. Patient #9 - POC 05/20/2021 did not contain any medications but patient has a medication profile on file.

Upon patient record review, 12 of 12 (Patient #1,2,3,4,5,6,7,8,9,10,11,12) 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. Agency provided evidence of IDG meeting sign in sheets but there is no patient documentation demonstrating the plan of care was reviewed and revised if applicable nor documented the patient's progress towards goals/outcomes.

Upon client record review, 3 of 12 (Patient #3, 9, 11) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #3 - POC dated 12/06/2021 did not contain visit frequency for the SC. SN visit frequency 2x week but only one visit made weeks 1-4 and no visits documented week 5 and 6. PT ordered 2wk9 but no visits made by PT. Patient #9 - POC dated 05/20/2021 did not contain visit frequency for the SC. SN visit frequency 2wk8 but only one visit made week 1, one visit made weeks 4-6, 0 visits made week 7 and 1 visits made weeks 8 and 9. Patient#11 - POC dated 08/24/2021 SN visit frequency 2wk9 but SN made 1 visit week for 12 weeks.

Upon patient record review, 1 of 1 applicable patients (Patient #9) did not have evidence the hospice offers bereavement counseling that includes making bereavement services available and developing a plan of care that notes the bereavement services to be offered. Patient #9 - Patient did not have a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery. The only note in the bereavement chart was a sympathy card was sent following patients death.

Upon observation, there was no evidence the hospice provides volunteer orientation and training that is consistent with hospice industry standards.

Upon observation, there was no evidence the hospice documented the cost savings achieved through the use of volunteers.

Condition of Participation: Organization and Administration of Services.

Upon observation, there was no evidence the hospice is directed by a Board of Directors/governing body which assumes full legal authority and responsibility for the operation of the hospice. Agency governing body/administrator did not provide adequate oversight of the agency operations as evidenced by the following things: failure to ensure that all patients complete an election of the hospice benefit and choose an attending physician; failure to ensure the medical director is completing a certification and recertification of the terminal illness; failure to determine all staff are competent in their role and in the services provided to patients; failure to ensure that staff receive training in emergency preparedness; failure to ensure that assessments are completed (timely) and that documentation of patient care is present in the patient record.

Upon personnel record review, 4 of 11 (Personnel #1,4,5,6) did not have evidence that a skills competency assessment was completed initially during orientation.

Upon patient record review, 12 of 12 (Patient #1,2,3,4,5,6,7,8,9,10,11,12) did not have evidence that the medical director or physician designee provides written certification. None of the patients reviewed had an initial certificate of terminal illness completed by the physician.

Upon patient record review, 7 of 7 applicable (Patient #1, 5, 6, 7, 8, 10, 11) did not have evidence that before the recertification period for each patient, the medical director or physician designee must review the patient's clinical information and provide written documentation that it is anticipated that the patient's life expectancy is 6 months or less. None of these patients had a recertification of the terminal illness completed by the physician.

Upon patient client record review, 12 of 12 (Patient #1,2,3,4,5,6,7,8,9,10,11,12) did not have evidence that each patient record contains a signed election statement in accordance with 418.24. None of these patients had an election statement on file.

Upon client record review, 2 of 2 applicable patients (Patient #8,10) did not have evidence that if a patient revokes the election of hospice care or is discharged from hospice that a discharge summary is completed and sent to the physician.