Every finding on record at Proactive Hospice, Inc.

Upon observation, there was no evidence BOD/governing body minutes reflect the involvement in the hospice's management and administration of its resources to provide hospice services to patients and families. The agency Administrator/Governing body has not ensured personnel records meet requirements as evidenced by lack of completed I-9 forms, documented hospice orientation, and evidence of skills competency.

Upon personnel record review, 1 of 3 (Personnel #5) did not have evidence the hospice employees and contract employees have received orientation on the hospice philosophy. Personnel #5: There was no evidence of personnel receiving orientation on the hospice philosophy.

Upon personnel record review, 1 of 3 (Personnel #5) did not have evidence that the hospice employees have received orientation on their specific job requirements. Personnel #5: There was no evidence in the personnel records that staff had received job specific orientation.

Upon personnel record review, 1 of 3 (Personnel #5) 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 #5: There was no evidence in the personnel records that employees had received a skills competency, specific to each discipline.

Upon observation, there was no evidence the Emergency Plan communication plan must includes a primary and alternate means for communicating with hospice's employees and Federal, state, tribal, regional, and local emergency management agencies. The current Emergency Plan did not contain evidence of a primary and alternate means of communication with the federal, state, tribal, regional, and local emergency management services.

Upon personnel record review, 2 of 12 (Personnel #'s 8, 12) 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 • Provide emergency preparedness training at least annually • Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others • Maintain documentation of all emergency preparedness training Personnel #'s 8, 12: The employee files did not contain evidence of emergency preparedness training upon hire.

Upon patient record review, 11 of 14 (Patients # 1, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12) did not have evidence in the patient record that the comprehensive assessment takes into consideration the imminence of death. Patient # 1: Patient's comprehensive assessment dated 8/11/25 did not contain evidence that an assessment for imminence of death was completed. Patient # 3: Patient's comprehensive assessment dated 8/8/25 did not contain evidence that an assessment for imminence of death was completed. Patient # 4: Patient's comprehensive assessment dated 3/25/25 did not contain evidence that an assessment for imminence of death was completed. Patient # 5: Patient's comprehensive assessment dated 4/30/25 did not contain evidence that an assessment for imminence of death was completed. Patient # 6: Patient's comprehensive assessment dated 7/2/25 did not contain evidence that an assessment for imminence of death was completed. Patient # 7: Patient's comprehensive assessment dated 8/1/25 did not contain evidence that an assessment for imminence of death was completed. Patient # 8: Patient's comprehensive assessment dated 8/10/25 did not contain evidence that an assessment for imminence of death was completed. Patient # 9: Patient's comprehensive assessment dated 8/23/25 did not contain evidence that an assessment for imminence of death was completed. Patient # 10: Patient's comprehensive assessment dated 9/4/24 did not contain evidence that an assessment for imminence of death was completed. Patient # 11: Patient's comprehensive assessment dated 4/19/25 did not contain evidence that an assessment for imminence of death was completed. Patient # 12: Patient's comprehensive assessment dated 12/12/23 did not contain evidence that an assessment for imminence of death was completed.

Upon patient record review, 1 of 14 (Patient # 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 # 2: Patient's most recent medication profile on the plan of care as of 9/8/25 contained orders for; a) Macrobid 100 mg, oral twice per day; b) Imodium A-D 2 mg, oral every four hours as needed for diarrhea; c) Lexapro 5 mg, oral daily; d) Keflex 500 mg oral, four times per day for seven days; e) Donepezil Hydrochloride 10 mg, oral daily; f) Hydrochlorothiazide 12.5 mg, oral daily; g) Iron 65 mg, oral daily; h) Losartan Potassium 100 mg, oral daily; i) Multivitamin 1 mg, oral daily; j) Nitroglycerin 0.4 mg, sublingual every five minutes as needed for chest pain; and, k) Vitamin D3 2000 IU, oral daily. The patient is no longer taking these medications, the patient did not have these medications in the home as verified by the nurse.

Upon patient record review, 14 of 14 (Patients # 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14) 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. Patients # 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14: The plans of care for all patients did not contain any scope for all of the disciplines that had PRN visit orders. All reviewed patient records contained orders for PRN visits.

Upon patient record review, 1 of 14 (Patient # 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 # 3: During home visit verified that patient had a hospital bed, wheelchair, oxygen concentrator, wipes, chucks, adult briefs. The patient plan of care as of 9/9/25 did not contain the DME and/or supplies in patient's home.

Upon client record review, 12 of 14 (Patient # 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13) 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 # 2: The IDG meetings dated 8/15/25 and 8/29/25 did not contain the MSW signature. Patient # 3: The IDG meetings dated 8/15/25 and 8/29/25 did not contain the MSW signature. Patient # 4: The IDG meetings dated 8/1/25, 8/15/25, and 8/29/25 did not contain the MSW signature. Patient # 5: The IDG meeting dated 8/29/25 did not contain the MSW and MD signatures. Patient # 6: The IDG meetings dated 8/15/25 did not contain the MSW signature, and 8/29/25 did not contain the MSW and MD signatures. Patient # 7: The IDG meetings dated 8/15/25 and 8/29/25 did not contain the MSW and MD signatures. Patient # 8: The IDG meetings dated 8/15/25 and 8/29/25 did not contain the MSW and MD signatures. Patient # 9: The IDG meetings dated 8/29/25 did not contain the MSW signature. Patient # 10: The IDG meeting dated 6/6/25 did not contain the MD signature, and on 5/23/25 did not contain the MSW signature. Patient # 11: The IDG meetings dated 8/15/25 and 8/29/25 did not contain the MSW and MD signatures. Patient # 12: The IDG meetings dated 10/25/25 did not contain the nurse signature. Patient # 13: The IDG meetings dated 12/6/25 did not contain the nurse, MD, or MSW signature.

Upon personnel record review, 1 of 12 (Personnel # 10) 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. Personnel # 10: The employee's file did not contain any evidence of a competency assessment for communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and hospice staff prior to seeing patient's or annually.

Upon patient record review, 3 of 14 (Patient's # 1, 5, 12) did not have evidence in the patient record that hospice aide assignments and duties are: • 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 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. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient # 1: The hospice aide plan of care dated 8/11/25 had the following assigned tasks that did not contain frequencies, a) turn and reposition; b) record bowel movements; c) feeding assistance; d) encourage fluids as tolerated; and, e) change linens. Patient # 5: The hospice aide plan of care dated 5/26/25 had the following assigned tasks that did not contain frequencies, a) record bowel movements; b) feeding assistance; c) and, encourage fluids as tolerated. Patient # 12: The hospice aide plan of care dated 1/14/25 had the following assigned tasks that did not contain frequencies, a) turn and reposition; b) record bowel movements; c) feeding assistance; d) and, encourage fluids as tolerated.

Upon personnel record review, 1 of 12 (Personnel # 10) 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. The supervising nurse must assess an aide's ability to demonstrate initial and continued satisfactory performance in meeting outcome criteria that include all required content. Personnel # 10: The employee's file did not contain evidence that in 2024 the RN made an annual on-site visit to the location where the patient is receiving care to evaluate the aide's performance and competency.

Upon observation, there was no evidence the agency organizes, manages, and administers its resources to provide the hospice care and services to patients, caregivers and families necessary for the palliation and management of the terminal illness and related conditions. The agency Administrator/Governing body has not ensured personnel meet requirements as evidenced by lack of criminal background checks, completed I-9 forms, job descriptions, orientation, initial and annual skills assessments, in-home RN supervision for aide services, state required health examination records, annual performance reviews, confidentiality agreements, OIG checks, TB and Hepatitis B fulfillment requirements, and security/HIPPA protection for employee files. In addition, patient records lacked confidentiality requirement needs as these were also brought into the office by the Administrator. Administrator unable to provide resources such as patient records and employee files as surveyor waited 3.5 hours until he could arrive and bring to office.

Upon personnel record review, 1 of 12 (Personnel # 2) did not have evidence the alternate administrator's personnel record verifies that: • The employee has appropriate education and experience requirements • There is a signed job description for this role • The employee has been orientated to this role Personnel # 2: Employee file did not contain evidence of a signed job description for the role of Alternate Administrator.

Upon personnel record review, 2 of 12 (Personnel #'s 8, 12) did not have evidence the hospice employees and contract employees have received orientation on the hospice philosophy. Personnel #'s 8, 12: The employee files did not contain evidence of orientation on the hospice philosophy.

Upon personnel record review, 3 of 12 (Personnel #'s 8, 11, 12) did not have evidence that the hospice employees have received orientation on their specific job requirements. Personnel #'s 8, 11, 12: The employee files (MD, SC/BC, Volunteer) did not contain evidence of orientation to their job specific requirements.

Upon personnel record review, 9 of 12 (Personnel #'s 1, 2, 3, 4, 8, 9, 10, 11, 12) 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 #'s 1, 2, 3, 4, 8, 9, 10, 11, 12: All of the employee files did not contain evidence of a skills competency assessment for each discipline being conducted during orientation.

Upon observation, there was no evidence the patient record, whether hard copy or in electronic form, is made readily available on request by an appropriate authority. Arrived on site ten minutes after reported time to open. Unable to access employee records, contracts or Hospice MD in order to begin survey. Access given to 3.5 hours after the reported time to open and the surveyor arrival.

Upon personnel record review, 1 of 12 (Personnel # 8) 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 # 8: This contracted employee file did not contain evidence of a criminal background check being completed.

Upon personnel record review, 3 of 12 (Personnel # 1, 10, 12) did not have evidence of criminal background checks being obtained in accordance with state requirements. In the absence of state requirements, criminal background checks are obtained within three months of the date of employment for all states that the individual has lived or worked in the past 3 years. Personnel # 1, 10, 12: The employee files did not contain evidence of a criminal background check being completed at the time of hire.

Upon patient record review, 1 of 5 records (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 4: Comorbidity of DM, goal on SOC nursing assessment for Endocrine includes optimal blood sugar level, supplied with glucometer, strips, alcohol pads, and each assessment by nurse included oversight of Blood Sugar. There was no evidence on the Plan of Care for Problem and interventions for Endocrine.

Upon patient record review, 1 of 1 applicable records (Patient #4) did not have evidence in the patient record that hospice aide assignments and duties are: • 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 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. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient 4: Patient identified as high risk for falls in SOC RN assessment, noted to have weakness and unsteady gate. There was no evidence of Fall risk precautions in the Aide POC.