Every finding on record at Pro Healthcare Servicing LLC

Upon patient record review, 2 of 14 (Patients #1, #2) 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: Hospice medication profile reconciliation with Assisted Living. The hospice medication profile did not include-Acetaminophen 650 mg PO TID, Cinacalcet 30 mg QD, Eliquis 2.5 mg BID, Gabapentin 300 mg TID, Methocarbamol 750 mg BID, Pantoprazole 40mg QD, Mira lax 17 gm QD, Senna S 8.6/50mg QD and Simvastatin 40mg BT. Corrected on Site. Patient #2: Polyethylene Glycol order with no diluent on med profile. Corrected on Site.

Upon patient record review, 2 of 14 (Patients #1, #2) did not have evidence the plan of care (POC) must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #1: The POC did not include the following medications-Acetaminophen 650 mg PO TID, Cinacalcet 30 mg QD, Eliquis 2.5 mg BID, Gabapentin 300 mg TID, Methocarbamol 750 mg BID, Pantoprazole 40mg QD, Mira lax 17 gm QD, Senna S 8.6/50mg QD and Simvastatin 40mg BT. (Corrected on Site with supplemental order) Patient #2: Polyethylene Glycol order with no diluent on POC. (Corrected on Site with supplemental order)

Upon client record review, 3 of 14 (Patients #1, #4, #9) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1: The POC listed Skilled Nursing visit frequency of 3 X's per week(8/21/24). For Benefit Week there were only 2 visits on 8/21/24 and 8/23/24. Patient #4: The POC listed Spiritual Counselor visit frequency of 1 X per week (7/19/24). There has only been 1 visit on 8/23/24 Patient #9: The SC had been declined since start of care. The SC visited the patient on 8/8/24.

Upon patient record review, 1 of 14 (Patient #14) did not have evidence the hospice offers bereavement counseling that includes: • Development of a bereavement plan of care (POC) that notes the kind of bereavement services to be offered and the frequency of service delivery Patient #14: Did not have Bereavement POC in patient chart.

Upon patient record review 5 of 14 (Patients #1,2,3,8,9) 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 (POC) Patient #1:The POC listed Aide visit frequency of 2 X's per week (8/21/24). For first Benefit Week there was only one visit on 8/23/24. Patient #2: The POC listed Aide visit frequency of 2 X's per week (7/1/24). For first Benefit Week there were no visits made by Aide. Patient #3: The POC listed Aide visit frequency of 2 X's per week (8/30/24). For first Benefit Week there were no visits made by Aide. Patient #8: The POC listed Aide visit frequency of 2 X's per week (7/4/24). For first Benefit Week there was only one visit on 7/5/24 and second Benefit Week no visits made by Aide. Patient #9: The POC listed Aide visit frequency of 2 X's per week (7/19/24). For first Benefit Week there were no visits made by Aide.

Upon patient client record review, 1 of 14 (Patient #4) 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 #4: Had incorrect date on CTI of 8/2/24 instead of 8/22/24. Corrected on Site (Amended in IDG 9/5/24)

Upon client record review, 1 of 14 (Patient #12) did not have evidence that the discharge (DC) summary includes all required information. Patient #12: Did not include plan of care or summary of patient care on DC Summary.

Upon observation, there was no evidence of contracts/agreements with other facilities/agencies/hospices to receive patients in the event the hospice cannot provide care to their patients during an emergency.

Upon observation, there was no evidence the Emergency Plan communication plan includes all of the following: • Names and contact information for the following: • Hospice employees • Patients' physicians • Other hospices

Upon observation, there was no evidence the Emergency Plan communication plan must includes a primary and alternate means for communicating with hospice's employees.

Upon observation, there was no evidence of emergency preparedness training and testing program that is based on the emergency plan, policies and procedures and the communication plan.

Upon observation, there was no evidence the agency has conducted exercises to test the emergency plan every two years. There was not evidence of participation in a full-scale exercise that is community-based every two years.

Condition of Participation: Patient’s Rights. L500

Upon patient record review, 1 of 14 (Patient #5) 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 #5: The record indicated that Admission Consents and the benefit Election statement were signed by POA on 05/22/23. The Medicare Benefit Election Form indicated an effective date to initiate the Hospice Benefit on 05/11/23, Elected Attending order effective date 05/11/23. (The initial/comprehensive assessment was conducted on 5/25/23)

Upon patient record review, 1 of 14 (Patient #5) 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 #5: The record indicated that Admission Consents and the benefit Election statement were signed by POA on 05/22/23. The Medicare Benefit Election Form indicated an effective date to initiate the Hospice Benefit on 05/11/23, Elected Attending order effective date 05/11/23. (The initial/comprehensive assessment was conducted on 5/25/23)

Upon patient record review, 1 of 14 (Patient #5) 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 #5: The record indicated that Admission Consents and the benefit Election statement were signed by POA on 05/22/23. The Medicare Benefit Election Form indicated an effective date to initiate the Hospice Benefit on 05/11/23, Elected Attending order effective date 05/11/23. (The initial/comprehensive assessment was conducted on 5/25/23)

Upon patient record review, 1 of 14 (Patient #5) did not have evidence that the patient has received effective pain management and symptom control from the hospice for conditions related to the terminal illness. Patient #5 Pain assessment documentation no pain however, there is evidence in narrative of reports uncontrolled pain.

Upon patient record review, 1 of 14 (Patient #5) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient #5: The record indicated that Admission Consents and the benefit Election statement were signed by POA on 05/22/23. The Medicare Benefit Election Form indicated an effective date to initiate the Hospice Benefit on 05/11/23, Elected Attending order effective date 05/11/23. (The initial/comprehensive assessment was conducted on 5/25/23)

Upon patient record review, 1 of 14 (Patient #5) did not have evidence of the appropriate documentation for release of confidential information. Patient #5: The record indicated that Admission Consents and the benefit Election statement were signed by POA on 05/22/23. The Medicare Benefit Election Form indicated an effective date to initiate the Hospice Benefit on 05/11/23, Elected Attending order effective date 05/11/23. (The initial/comprehensive assessment was conducted on 5/25/23)

Upon patient record review, 1 of 14 (Patient #5) did not have evidence that the patient received information about the services covered under the hospice benefit. Patient #5: The record indicated that Admission Consents and the benefit Election statement were signed by POA on 05/22/23. The Medicare Benefit Election Form indicated an effective date to initiate the Hospice Benefit on 05/11/23, Elected Attending order effective date 05/11/23. (The initial/comprehensive assessment was conducted on 5/25/23)

Upon patient record review, 1 of 14 (Patient #5) 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 #5: The record indicated that Admission Consents and the benefit Election statement were signed by POA on 05/22/23. The Medicare Benefit Election Form indicated an effective date to initiate the Hospice Benefit on 05/11/23, Elected Attending order effective date 05/11/23. (The initial/comprehensive assessment was conducted on 5/25/23)

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

Upon patient record review, 5 of 14 (Patient #1,#3,#4, #6, #10) 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: documentation indicated that patient has oxygen concentrator in home on, 2 Liters via Nasal Cannula as needed for shortness of breath. No evidence of documentation on Medication Profile for oxygen therapy. Patient #3: Physician orders indicated antibiotic therapy for Ciprofloxacin 500 mg, BID X 7 days ordered on 2/9/24 and 2/22/24, for Urinary Tract infection with no evidence on medication profile. Oxygen therapy ordered for shortness of breath at 3L, via nasal cannula PRN with no evidence on medication profile. Patient Daughter provided Surveyor in home medications during RN visit and observed Tresiba for Diabetes Type 1 management, with no evidence on Medication Profile. Patient # 4: Upon home visit observed oxygen concentrator in room with no evidence of O2 on the medication profile. Patient # 6: record indicated on admission orders from Medical Director on 08/16/23 to discontinue Memantine 10mg one time daily PO and Donepezil 10mg HS with evidence of being active on medication profile. Record indicated oxygen therapy at 3L via nasal cannula PRN, with no evidence on medication profile. Patient #10: record indicated being on continuous oxygen 2L upon rest and 6L upon moderate exertion with no evidence on Medication Profile.

Upon patient record review, 3 of 14 (Patient #1, #3 and #9) 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 There is no evidence of Bereavement Assessment. Patient #3 has no evidence of Bereavement assessment completed for the spouse who is primary caregiver for patient and only documented assessment with daughter. Documentation states spouse is overwhelmed and requesting additional emotional support. Patient #9 Patient admitted on 11/01/23, documentation states missed visit on 11/03/23 for Bereavement Initial assessment with no evidence of follow up Assessment. No evidence that bereavement assessment was completed

Upon patient record review, 10 of 14 (Patient #1,#2,#3,#4,#5,#6,#7,#8,#9,#10) 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: no evidence of RN Comprehensive Assessment every 15 days. The record indicated that the RN performed an assessment, 01/05/24. There was not evidence of an update. Patient #2: no evidence of RN Comprehensive Assessment every 15 days. The record indicated that the RN performed and assessment on 12/19/23.There was not evidence of an update at least every 15 days. Patient #3: no evidence of RN Comprehensive Assessment every 15 days. The record indicated that the RN performed and assessment on 02/05/24There was not evidence of an update at least every 15 days. Patient #4: No evidence of RN Comprehensive Assessment every 15 days. The record indicated that the RN performed and assessment on 01/29/24. There was not evidence of an update at least every 15 days. Patient #5: no evidence of RN Comprehensive Assessment every 15 days. The record indicated that the RN performed and assessment on 05/25/23. Patient #6: no evidence of RN Comprehensive Assessment every 15 days. The record indicated that the RN performed and assessment on 08/16/23. Patient # 7 did not have evidence in medical of updated Comprehensive every 15days.The record indicated that the RN performed and assessment on 12/01/23. Patient #8, did not have evidence in medical of updated Comprehensive every 15 days. The record indicated that the RN performed and assessment on 01/08/24. Patient #9, did not have evidence in medical of updated Comprehensive every 15 days. The record indicated that the RN performed and assessment on 02/29/24. Patient #10, did not have evidence in medical of updated Comprehensive every 15 days. The record indicated that the RN performed and assessment on 12/14/23.

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

Upon patient record review, 1 of 14 (Patient #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 #3: no evidence of wound care assessment or wound care orders upon Initial Comprehensive Assessment on 01/05/24 due to family refusing. There was a wound identified 3/5/24 and there was no evidence of wound assessment or wound care.

Upon patient record review, 1 of 14 (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: Upon admission RN initial assessment, nurse identified suprapubic catheter however, there was no evidence of related problems/goals/interventions.

Upon patient record review, 2 of 14 (Patient #3,#5) 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: No frequencies on the plan of care for SN, SW or Spiritual Care services. Patient #5: Pt admitted 5/25/23. POC/no discipline frequencies until 6/1/23 (SW 5/30 and SCC 5/27)

Upon medical record review 3 of 14 (Patient #1 #3,#4) did not contain 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: dose/frequency/route and if medication is prescribed as PRN, there must be an indicator for the PRN. Patient #1: SN documentation indicated that patient has oxygen concentrator in home on, 2 Liters via Nasal Cannula as needed for shortness of breath. No evidence of order for oxygen. Patient #3:An order dated 2/9/24 indicated for the hospice nurse to flush supra-pubic catheter as needed. A revised order dated 2/25/24 indicated to irrigate SP catheter using a catheter tip syringe with 50-60cc of sterile water prn. There was not evidence of specific frequency or a reason for the flush/irrigation. In addition, an order dated 3/5/24 indicated to provide wound care to the right leg wound by cleaning with wound cleanser, apply bacitracin to the wound bed and cover with kerlix. There was not evidence of a frequency. Oxygen therapy ordered for shortness of breath at 3L, via nasal cannula PRN with no evidence of an order. Patient #4: Upon home visit observed oxygen concentrator in room with no evidence of physician orders upon medical record review.

Upon patient record review, 2 of 14 (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: Pt on O2. Not listed for DME on POC Patient #3: Pt on O2 prn and walker, not on POC

Upon client record review, 1 of 14 (Patient #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 #3: Admitted on 2/5/24. No IDG/POC update until 2/22/24

Upon client record review, 1 of 14 (Patient #3) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #3: LPN documented performing wound care during visit on 02/07/24 by cleansing wound with wound cleanser, applied Meluka topical to wound bed, covered with blue foam and wrapped with sterile gauze and secured with coban without evidence of an Order. LPN documented completing wound care by cleansing wound with normal saline, applied Bacitracin Topical ointment to wound care and covered with dressing without evidence of Physician Order.

Upon patient record review 1 of 14 (Patient #1) did not have evidence that the IDG ensures that the care and services provided are based on all assessments of the patient and family needs. Patient #1 requested Volunteer services per RN Initial Comprehensive Assessment Narrative with no evidence of scheduled Volunteer in Medical record.

Upon observation, there was no evidence the board of directors/governing body approves the frequency and detail of the data collection.

Upon observation, there was no evidence the number and scope of distinct QAPI projects conducted annually is based on the needs of the hospice's population and internal organizational needs and must reflect the scope, complexity, and past performance of the hospice's services and operations. The QAPI program indicated the only PIP was volunteer utilization which has been a project since 2018.

Upon observation, there was no evidence the hospice documents what QAPI projects are being conducted, the reasons for conducting these projects, and the measurable progress achieved on these projects. There was not evidence of new PIPs since 2018

Upon observation, there was no evidence of involvement of the governing body and organizational leaders in the Quality Assessment/Performance Improvement (QAPI) program. Last documented report to the governing body was listed for the year 2022 with the report date of Jan 4, 2023.

Upon observation, there was no evidence the hospice's governing body is responsible for ensuring that the hospice-wide Quality Assessment and Performance Improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness. Th last report of QAPI activities to the governing body was dated 1/4/23 reflecting the year 2022.

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. There was not evidence of a QAPI Coordinator. (Verbal verification by agency staff)

Upon observation, there was no evidence licensed professionals participate in the hospice's QAPI program. There was not evidence of what members of the hospice agency was apart of the QAPI team nor a sign in sheet to verify who had attended the QAPI meetings.

Upon patient record review, 1 of 14 (Patient #3) did not have evidence that Social work services are based on the patient's psychosocial assessment and the patient/family's needs and acceptance of these services. Patient #3: Observation visit. Distress in family. Overwhelmed. No evidence of SW increase in visits. SW frequency 1 x Month.

Condition of Participation: Hospice Aide and Homemaker Services. L607

Upon personnel record review, 1 of 12 (Personnel #3) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: ·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. Personnel #3: No evidence that the aide had a competency evaluation completed while providing care to a patient or with a pseudo-patient.

Upon observation, there was no evidence the Home Health Aide in person competency evaluation is performed by a Registered Nurse in consultation with other skilled professionals, as appropriate.

Upon patient record review, 8 of 14 (Patient #1,#2,#4,#5,#6,#7,#8,#9) did not have evidence in the patient record that hospice aide assignments and duties are: Patient Aide Care Plan documentation states Personal care with no specific task for aide to complete or frequencies in which to complete. • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is no evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. Patients 1, 2, 4, 5, 6, 7, 8, 9 the aide plan of care did not have frequencies for any tasks for the aide to follow.

Upon patient record review 8 of 14 (Patient ##1,#2,#4,#5,#6,#7,#8,#9) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs. Patients 1, 2, 4, 5, 6, 7, 8, 9 did not receive the required 14 day RN supervisory visit throughout their stay in hospice.

Upon personnel record review, 1 of 12 (Personnel # 3) did not have evidence in the hospice aide personnel file that a registered nurse made an annual on-site visit to the location where a patient is receiving care in order to observe and assess each aide while he or she is performing care.

Upon observation, there was no evidence the hospice documented the cost savings achieved through the use of volunteers. Documentation must include the following: • The identification of each position that is occupied by a volunteer • The work time spent by volunteers occupying those positions • Estimates of the dollar costs that the hospice would have incurred if paid employees occupied the positions identified in paragraph (d)(1) of CFR 418.78 for the amount of time specified in paragraph (d)(2) of CFR 418.78

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.

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 not evidence of a meeting by the governing body since January 2023 reflecting an annual review of 2022. There was no evidence governing body provided oversight for QAPI, management and fiscal affairs of hospice such as billing, and annual review of policies and procedures.

Upon contract review, 1 of 4 contracts (Pro Healthcare) did not have evidence of a provision in 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

Upon personnel record review, 1 of 12 (Personnel #4) did not have evidence that the hospice employees have complete orientation on their specific job requirements.

Upon patient record review, 10 of 14 (Patient #1,#2,#3,#4,#5,#6,#7,#8,#9,#10) 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 In addition, 10 of 14 (Patient #1,#2,#3,#4,#5,#6,#7,#8,#9,10) did not have evidence that there is a signed physician's brief narrative explanation of the clinical findings that supports a life expectancy of 6 months or less as part of the certification forms, or as an addendum to the certification forms.

Condition of Participation: Clinical Records.

Upon patient client record review, 2 of 14 (Patient #5, #10) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 Patient #5 upon medical record review, evidence that Admission Consents were signed by POA on 05/22/23 on Medicare Benefit Election Form with effective date to initiate Hospice Benefit on 05/11/23, Elected Attending order effective date 05/11/23. Patient #10, upon medical record review of Medicare Election Form, Patient Name Blank and documented name by admitting RN was misspelled, POA signed Election form with no evidence of date.

Upon patient client record review, 1 of 14 (Patient #4) did not have evidence that each patient record contains Physician certification and recertification of terminal illness. Patient #4: There was not evidence of a certification of terminal illness completed by attending physician.

Upon patient client record review, 1 of 14 (Patient #12) did not evidence that each patient record contains physician orders. Patient #12 was discharged to a non-contracted facility and there was no order for discharge from the medical director.

Upon patient client record review, 4 of 14 (Patient #1,#4,#5,#6) 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 #1: The patient was admitted on 1/5/24. Verbal certification of terminal illness was obtained on this date. There was not evidence of who obtained the verbal certification and on what date it was obtained. Patient #4 with Primary Diagnosis of Senile Degeneration of Brain with conflicting documentation of Neuro Assessment as evidenced by non-responsive, Alert and Oriented X 1, with ability to communicate verbally with agitation. Patient #5: Dementia Diagnosis as Secondary Admitting Diagnosis, Primary Parkinson's Disease upon admission on 05/23/23 with evidence of documentation of RN ICD-10 Code for Primary Diagnosis of Senile Degeneration of Brain with no Physician Change of Diagnosis Order Patient #6 RN admitting documentation of ICD-10 Code Parkinson's Disease 0n 08/16/23 with evidence of Primary Diagnosis documented with evidence of documentation of RN ICD-10 Code for Primary Diagnosis of Senile Degeneration of Brain with no Physician Change of Diagnosis Order

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: No evidence that a discharge summary was sent to the attending physician.

Upon client record review, 2 of 14 ,(Patient #11,#12) did not have evidence that the discharge summary includes all required information No discharge summary.

Upon observation, there was no evidence a copy is provided of the hospice written policies and procedures on the management and disposal of controlled drugs to the patient or patient representative and family. Patient #5 upon medical record review, evidence that Admission Consents were signed by POA on 05/22/23 on Medicare Benefit Election Form with effective date to initiate Hospice Benefit on 05/11/23, Elected Attending order effective date 05/11/23.

Upon observation, there was no evidence the hospice discussed the policies and procedures for managing the safe use and disposal of controlled drugs with the patient or representative and the family in a language and manner that they understand to ensure that these parties are educated regarding the safe use and disposal of controlled drugs. Patient #5 upon medical record review, evidence that Admission Consents were signed by POA on 05/22/23 on Medicare Benefit Election Form with effective date to initiate Hospice Benefit on 05/11/23, Elected Attending order effective date 05/11/23.

Upon client record review, 1 of 14 (Patient #5) did not have evidence that the written policies and procedures for managing controlled drugs was provided and discussed. Patient #5 upon medical record review, evidence that Admission Consents were signed by POA on 05/22/23 on Medicare Benefit Election Form with effective date to initiate Hospice Benefit on 05/11/23, Elected Attending order effective date 05/11/23.

Upon inpatient contract review, 2 of 4 contracts (Fairfax rehab & Nrsg, Mt Vernon Rehab) did not have evidence of a provision that the hospice supplies the inpatient provider with a copy of the patient's plan of care and specifies the inpatient services to be furnished.

Upon inpatient contract review, 2 of 4 contracts (Fairfax Rehab & Nrsg, Mt Vernon Rehab) did not have evidence of a provision 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.

Upon inpatient contract review, 2 of 4 contracts (Fairfax Rehab & Nrsg, Mt Vernon Rehab) did not have evidence of a provision that the hospice retains responsibility for ensuring that the training of personnel who will be providing the patient's care in the inpatient facility has been provided and that a description of the training and the names of those giving the training are documented.

Upon inpatient contract review, 2 of 4 contracts (Fairfax Rehab & Nrsg, Mt Vernon Rehab) did not have evidence of a provision of a method for verifying that the requirements for ACHC standard HSP1-8B and CFR 418.108c (1)-418.108c(5)are met.