Every finding on record at Prime Care Hospice LLC

Upon patient record review, 4 of 19 (Patient #1,#2,#7,#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 #1: During home visit, Eliquis 5 mg Oral Tablet PO BID is on the medication profile and the SN and family confirmed the patient is no longer taking the medication (COS). In addition, Levaquin 1 tablet daily for UTI is on the medication profile, but the patient has Macrodantin in the home for UTI Prophylaxis, and Ativan 0.5 mg at bedtime and q 6 hours is on the medication profile, but the patient has tablets of Ativan for 1 mg with instructions for 1 tablet at bedtime. Patient #2: During home visit, the hospice medication profile indicates the patient is taking 0.5mg of Ativan tablets q 6 hours PRN anxiety, but the ALF medication profile indicates the patient is taking Ativan 2mg/ml, 1 ml q 6 hours for anxiety. Patient #7: The admission assessment narrative indicated the patient was using oxygen at 3L NC. Oxygen is not on the medication profile. Patient #9: The admission assessment indicated the patient was using Oxygen at 2-4L NC and oxygen safety was part of the plan of care. Oxygen was not listed on the medication profile.

Upon client record review, 1 of 19 (Patient #1) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1: On 11-29-24, the SW wrote a missed visit note which indicated cancellation due to a large caseload and conflicting schedule without evidence of accounting for the patient's need. In addition, the plan of care dated 10-16-24 and 11-01-24 indicated SCC visits were 1 x month and there was no evidence of a SCC visit, or missed visit documentation, in October and November of 2024.

Upon patient record review, 3 of 19 (Patient #4,#5,#6) 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 #4,#5,#6: There is no evidence of a post death bereavement plan of care.

Upon patient record review 2 of 19 (Patient #12,#18) 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 Patient #12: The CNA signed a missed visit note on 11-29-24, but there was no documentation regarding the reason for the missed visit. COS Patient #18: On 10-09-24 the CNA documented a missed visit with the reason "out of the office" without evidence of accounting for the patient's needs as written in the plan of care.

Upon patient client record review, 1 of 19 (Patient #14) 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 #14: The START OF CARE on the Hospice Election Statement signed 10-03-24 was left blank without evidence of a date of election.

Upon client record review, 1 of 19 (Patient #19) did not have evidence that the discharge summary includes all required information. Patient #19: There was no evidence of a discharge summary that included a summary of the patient's care, the current plan of care, the latest physician orders or post discharge continuity.

Upon SNF/NF contract review, 1 of 5 (SNF, Marshall Manor) did not have a delineation of the hospice's responsibilities, which include, but are not limited to the following: providing medical direction and management of the patient; nursing; counseling (including spiritual, dietary and bereavement); social work; provision of medical supplies, durable medical equipment and drugs necessary for the palliation of pain and symptoms associated with the terminal illness and related conditions; and all other hospice services that are necessary for the care of the resident's terminal illness and related conditions. SNF Contract: There was no evidence of a delineation of the hospice responsibilities such as medical supplies, durable medical equipment and drugs necessary for the palliation and management of symptoms, as well as medical management of the patient and dietary.

Upon client record review, 1 of 19 (Patient #18) did not have evidence that a written hospice plan of care is established and maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided is in accordance with this hospice plan of care. Patient #18: For the cert period ending in 08-24-24, the plan of care indicated SW visits were 1 x month, however, there was no evidence of a SW visit or documentation of a missed visit, in August of 2024.

Upon patient record review, 1 of 5 (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 Record #4: RN documented in the Comprehensive Assessment that the patient's history included Prostate Cancer, radiation and BPH, requiring Foley catheter in hospital prior to hospice admission. "The patient required straight cath last pm and this am". The Plan of Care / Care Plan did not address urinary retention. Subsequent visits showed, however, patient GU and voiding status was assessed and documented that there was no recurrence.

Upon personnel record review, 1 of 1 applicable (Personnel #1) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient to include shampoo, sink, tub, and bed. Personnel Record #1: The hospice aide has a skills competency checklist, but the form utilized, although detailed, does not include differential for sink, tub and bed shampoo. "Shampoo" competency is completed.

Upon personnel record review, 3 of 3 (Personnel #5, 6, 7) did not have evidence the hospice obtained a criminal background check on all contracted individuals who have direct patient care and access to patient records. Personnel File #5, 6, 7. No information Criminal Background information provided for therapy staff. The therapy staff have not been utilized to provide patient care.

Upon patient record review 2 of 5 (Patient #2, #4) 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 #2: Social Worker assessment was completed on day 6, 11/29/2021. Patient #4: Spiritual Care assessment completed on day 6, 11/24/2021.

Upon patient record review 1 of 5 (Patient #1) 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: No evidence of a comprehensive psychosocial assessment being completed.

Upon patient record review, 2 of 5 (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: No evidence that an initial comprehensive Bereavement assessment was completed. Patient #2: Bereavement assessment was completed on day 6, 11/29/2021.

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

Upon patient record review, 1 of 5 (Patient #3) 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 #3: No nursing goals or interventions listed on the plan of care. Patient initially admitted as GIP on 12/1/2021, no goals or interventions addressing GIP status needs.

Upon patient record review, 2 of 5 (Patient #1, #3) 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 equipment and supply needs. Patient #1: No DME or supplies listed on the POC. Admission note on 11/23/2021 indicates patient has hospital bed, oxygen concentrator, wheelchair and over the bed table. Patient #3: No DME or supplies listed on the POC. Admission documentation notes O2, hospital bed, foley catheter and wheel chair.

Upon patient record review, 3 of 5 (Patient #3, #4, #5) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #3: Patient initially admitted GIP on 12/1/2021. No order for GIP services. Patient seen daily from 12/1 - 12/8. No orders for daily visits. Frequency on plan of care 2w1, 1w1, 7w12. Patient #4: SN frequency on initial plan of care was ordered 1w1, 2w12. Week of 11/21/21, only 1 visit on 11/22. Week of 12/5/21 only 1 visit on 12/6. Patient #5: Chaplain saw patient on 11/30/2021. No orders on POC for patient to be seen by spiritual care.

Upon patient record review 1 of 5 (Patient #4) did not have evidence documentation in the patient record that a hospice aide provides services that are ordered by the interdisciplinary group and included in the plan of care Patient #4: Aide frequency on the Plan of Care is 2 week 12. Week of 11/21/21 there is only evidence of one aide visit on 11/23/21. Week of 11/28/21 there was not evidence of any aide visits being made.

Condition of Participation: Organization and Administration of Services.

Cannot abate Condition level unable to determine if personnel have been oriented to hospice philosophy since previous survey

Cannot abate Condition level unable to determine if personnel have been oriented to specific job requirements since previous survey

Cannot abate Condition level unable to determine if skills competency assessments have been conducted on all personnel including volunteers since previous survey

Upon patient record review, 1 of 1 applicable (Patient #3) 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 #3: SN visit note on 12/8/21 indicates patient was transferred from hospital GIP back to SNF for routine care. No evidence of a transfer summary in patient record.

Condition of Participation: Personnel Qualifications.

Cannot abate Condition level unable to verify credentials/ qualifications have been reviewed/obtained since previous survey

Cannot abate Condition level unable to verify background checks were obtained on contracted individuals since previous survey

Cannot abate Condition level unable to verify background checks were obtained since previous survey.

Upon observation of the Hospice's Emergency Preparedness Plan, there was no evidence the plan included strategies for addressing those emergency events, as were identified by the Hazard Vulnerability Risk Assessment, that would affect the Hospice's ability to provide care. The Hospice had identified their top two risks as: 1) Inclement weather; and 2) Chemical Disaster. There were no strategies established specific to the organizations' response in the event of these potential/anticipated disasters should occur.

Upon observation of the Hospice's Emergency Preparedness Plan, there was no documented evidence that the Emergency Preparedness Plan included the Hospice's process for the cooperation and collaboration with local, tribal, regional, state, and federal emergency preparedness officials' efforts, in order to maintain an integrated response in the event of a disaster.

Upon observation of the Hospice's Emergency Preparedness Plan, there was not evidence of a contract/agreement with an other Facility/Agency/Hospice, to receive Prime Hospice's patients in the event that Prime Hospice cannot provide care to their patients during an emergency.

Upon patient record review, 2 of 13 (Patients #6, 10) 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 #6: SOC was 9/17/2021. Chaplain Assessment was not conducted until 9/24/2021. Patient #10: SOC was 9/10/2021. Social Work Assessment was not conducted until 9/16/2021. Chaplain Assessment was not conducted as of 10/27/2021.

Upon patient record review, 5 of 13 (Patients #2, 3, 8, 9, 10) did not contain a current/accurate medication profile: Patient 2: The SOC Initial Assessment dated 10/21/2021 reflected that the patient was experiencing pain, but "had no pain medication in the home." During a Surveyor attended home visit on 10/26/2021, the Surveyor noted a bottle of Morphine in the patient's home which was dated effective 9/1/2021. The Morphine was not listed on the medication profile. Patient 3: On a nursing noted dated 9/8/21 and 9/10/2021, the RN documented ..."patient reported gas/reflux and pain was relieved with Tums..." and ..."SN recommends to patient's daughter to try Omeprazole for reflux." There was no Tums or Omeprazole listed on the medication profile. Patient 8: On Nursing notes dated 9/4/2021 and 10/19/2021, the RN documented ..."APAP 500mg PRN for pain and Aleve nightly", and ..."Caregiver states has been giving Miralax for comfort..." There was no Tylenol, Aleve or Miralax listed on the medication profile. Patient 9: On nursing notes dated 8/20/2021 and 9/14/2021, the RN documented ..."Patient on 4L of Oxygen" and ..."Patient has been taking laxatives and spouse gave an enema..." There was no Oxygen, laxatives, or enema listed on the medication profile. On 9/14/2021, the RN documented ..."Atropine has been given for secretions..." The Atropine was not listed on the medication profile. Patient 10: On the Initial Nursing Assessment, dated 9/10/2021, the RN documented the patient has "Oxygen 3-4L PRN". The Oxygen was not listed on the medication profile.

Upon patient record review, 2 of 13 (Patients #2, 10) did not have evidence that the comprehensive assessment included a bereavement component, which included 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 #2: There was no initial Bereavement Assessment in the record as of 10/28/2021. Patient #10: The Bereavement Assessment was not conducted until 9/16/2021 (Day 6).

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

Upon patient record review, 3 of 13 (Patients #1, 4, 11) did not have evidence that the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including the following: A detailed statement of both the scope and frequency of services necessary to meet the specific patient and family needs ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patients #1, 4 and 11: The chaplain had visits ordered. There were no Chaplain interventions included on these Plan of Care.

Upon patient record review, 3 of 13 (Patients #4, 7 and 12) did not have evidence that 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: A Physician wound care order dated 8/18/2021 did not include the frequency of the wound care. Patient #7: A Physician order dated 10/10/21, for a 16 French foley catheter. The order did not include the balloon size of the catheter. Patient #12: Physician wound care orders dated 3/10/2021 and 3/25/2021 did not include the party responsible for the wound care.

Upon patient record review, 4 of 13 (Patients #2, 4, 6, 7) did not have evidence that the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs: Patient #2: During the Surveyor attended home visit conducted on 10/26/2021, the Surveyor noted oxygen, nebulizer, and bedside table in the patient's home. This equipment was not listed on the Plan of Care. Patient #4: On the RN visit conducted on 9/14/2021, the nurse documented "hospital bed delivered". There was no order for the hospital bed on the plan of care. Patient #6: On the RN Initial Assessment dated 9/17/2021, the RN documented a low air loss mattress for the patient. This equipment was not listed on the Plan of Care. Patient #7: On the RN visit conducted on 9/13/2021, the RN documented the patient was ambulating with a walker. On a Chaplain visit conducted on 10/5/2021, the Chaplain documented the use of a wheelchair for the patient. This equipment was not listed on the Plan of Care.

Upon patient record review, 7 of 13 (Patients #1, 3, 4, 6, 7, 8, 9) did not have evidence that the IDG had ensured that care and services were provided in accordance with the plan of care: Patient #1: SOC of 6/25/2021 had a visit frequency for Nursing of 2x week. On a document titled "Missed Visit" the nurse documented ..."Decrease SN visits to 1x week for increased Covid." There was no Physician order obtained to change this nursing frequency. Patient #3: SOC of 5/4/2021 had a visit frequency for Nursing of 2x week. On a document titled "Missed Visit" and dated 9/7/2021, the nurse documented ..."Decrease SN visits to 1x week for increased Covid." There was no Physician order obtained to change this nursing frequency. There was also an order for a Chaplain frequency of 2x month. There was only 1 visit made for the month of September 2021. Patient #4: SOC of 8/17/2021 had a Nursing visit conducted on 8/31/21 where the Nurse applied Lanaseptic to the left lower leg wound. The wound order dated 8/18/2021 did not include the use of Lanaseptic. Patient #6: SOC of 9/17/2021 had a visit frequency for Nursing of 2x week. On a document titled "Missed Visit" the nurse documented ..."Decrease SN visits to 1x week for increased Covid." There was no Physician order obtained to change this nursing frequency. Patient #7: On a Nursing visit dated 10/18/2021, the nurse documented ..."foam dressing applied to coccyx...". There was no Physician order for this wound care intervention. Patient #8: On a Nursing visit dated 8/31/2021, the nurse documented ...."foley placed...". There was no Physician order for a foley. Patient #9: SOC of 8/14/2021 had a visit frequency for Nursing of 2x week. On a document titled "Missed Visit" the nurse documented ..."Decrease SN visits to 1x week for increased Covid." There was no Physician order obtained to change this nursing frequency. On a Nursing visit dated 9/11/2021, the RN documented, ..."Instructed to give Morphine 1ml every 3 hours." There was no Physician order for the increase in Morphine.

Upon observation, there was no evidence that the Board of Directors/Governing Body had approved the frequency and detail of the 2021 QAPI Plan data collection.

Upon personnel record review, 1 of 1 applicable (Personnel #8) did not have evidence of having been determined competent for all CMS required aide skills competencies at the time of hire. An RN conducted an Aide skills competency on 1/27/2020-1/28/2020, however, the following skill was not evaluated for: Normal range of motion

Upon patient record review, 4 of 11 applicable (Patients #1, 3, 4, 7) did not have documented evidence that the hospice aide provided services that were: • Ordered by the interdisciplinary group • Included in the plan of care Patient 1: The RN-established Aide plan of care assigned the tasks of weekly nail care and linen change. Neither tasks were completed during the weeks of 9/5/2021, 9/12/2021, and 9/19/2021. Patient 3: The RN-established Aide plan of care dated 07/01/21 assigned the following tasks of a shampoo, and shower with chair 2x week. On the Aide visits conducted on 10/4/2021, 10/5/2021, 10/6/2021, 10/7/2021, 10/8/2021, 10/11/2021, 10/12/2021, 10/13/2021, 10/14,2021 and 10/15/2021 the Aide documented the provision of a Bed bath instead. During the weeks of 10/3/2021 and 10/10/2021 the Aide documented the shampoo at 3 and 4 times a week. Patient 4: The RN-established Aide plan of care dated 08/17/21 assigned the following tasks of a shower 3x week. On the Aide visits 9/27/2021 and 10/4/2021 the Aide documented the provision of Bed bath instead. Patient 7: The RN-established Aide plan of care dated 08/09/21 assigned the following tasks of a shower with a chair 2x week. On the Aide visits 9/23/2021, 10/8/2021, 10/12/2021, 10/15/2021 and 10/19/2021, the Aide documented the provision of Bed bath instead.

Condition of Participation: Organization and Administration of Services.

Upon observation, there was not documented evidence that the Hospice is directed by a Board of Directors/Governing Body which assumes full legal authority and responsibility for the operation of the Hospice, to include oversight of: 1) Quality Assessment/Performance Improvement activities. The meeting notes dated 01/2020, 05/2020, 09/2020, and the last meeting of 01/2021, did not contain reference to the QAPI programming activities; and 2) There was no evidence of their annual review of the Hospice's policies and procedures.

Upon personnel record review, 5 of 8 applicable (Personnel #1, 2, 7, 9, 10) did not have evidence that the hospice employees and contract employees had received orientation on the Hospice Philosophy.

Upon personnel record review, 2 of 11 (Personnel #8, 11) did not have evidence of receipt of the job description at the time of orientation and whenever the job description changes: Personnel #8 and #11: There were no applicable job descriptions located with in the file.

Upon personnel record review, 4 of 6 applicable (Personnel #2, 6, 9, 10) did not have evidence that a skills competency assessment, specific to each discipline, had been conducted for all personnel including volunteers initially during orientation.

Upon patient record review, 1 of 1 applicable (Patient #11) did not have evidence that the hospice had forwarded a transfer summary to the next Hospice provider.

Upon patient record review, 1 of 1 applicable (Patient #10) 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 10: There was no discharge summary in the Clinical Record.

Upon inpatient contract review, 1 of 1 applicable (Treviso Transitional Care) did not contain evidence that a copy of the Discharge Summary will be provided to the Hospice, at the time of each Hospice patient's discharge from an inpatient facility.

Upon SNF contract review, 1 of 1 applicable (Longview Hill Nursing and Rehab Center) did not contain a provision stating that the Hospice must report 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 Administrator within 24 hours of the Hospice becoming aware of the alleged violation.

Condition of Participation: Personnel Qualifications.

Upon personnel record review, 1 of 7 applicable (Personnel #7) did not have evidence that personnel credentialing activities were conducted to verify the qualifications of all credentialed/licensed personnel in the positions they hold at the time of hire, and at renewal. On Personnel #7 the license within the file contained an expiration date of 6/30/2020. The personnel record did not contain evidence to verify the license had been renewed prior to the expiration date.

Upon personnel record review, 3 of 4 applicable (Personnel #5, 6, 9) did not have evidence of criminal background checks having been conducted on all contracted individuals who have direct patient care and access to patient records. Texas Administrative Code, Title 40, SECTION 558.855. Criminal Background Checks: (b) In addition to the requirements in §558.289 of this chapter (relating to Independent Contractors and Arranged Services), hospice contracts to provide inpatient care must require that all contracted entities conduct a criminal history check on contracted staff who have direct client contact or access to client records, to verify each contract staff's criminal history report does not include a conviction that bars employment under Texas Health and Safety Code, §250.006. Personnel #5, 6, 9: There was no evidence of a criminal background check having been conducted, in accordance with the Texas State Regulation.

Upon personnel record review, 1 of 7 applicable (Personnel #11) did not have evidence of criminal background checks having been obtained in accordance with Texas State requirements as follows. Texas Administrative Code, Title 40, SECTION 558.855. Criminal Background Checks: (a) In addition to the requirements in §558.247 of this chapter (relating to Verification of Employability and Use of Unlicensed Persons), a hospice must conduct a criminal history check on all hospice employees and volunteers with direct client contact or access to client records, to verify each employee's or volunteer's criminal history report does not include a conviction that bars employment under Texas Health and Safety Code, §250.006, or a conviction that the hospice determines is a contraindication to employment. Personnel #11: There was no evidence of a criminal background check having been conducted, in accordance with the State Regulation.