Every finding on record at Qna Hospice Care, Inc.

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 communication plan did not include means for communicating with employees (corrected on site), had primary means for federal,state, tribal regional and local emergency management agencies, no evidence of a secondary means for these agencies.

Upon observation, there was no evidence that during the initial assessment visit in advance of furnishing care, the hospice provided the patient and/or family with verbal (meaning spoken) and written notice of the Patient's Rights and Responsibilities in a language and manner that the patient understands. Consents are all in English, patients are all Armenian speaking.

Upon patient record review 5 of 14 (Patient #6, #9, #10, #11, #12) 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 #6: There was no evidence of a spiritual assessment by SC or SN as part of the comprehensive assessment. Patient #9: There was no evidence of a psychosocial or spiritual assessment by SC/MSW or SN as part of the comprehensive assessment. Patient #10: There was no evidence of a psychosocial assessment by MSW or SN as part of the comprehensive assessment. Patient #11: There was no evidence of a psychosocial assessment by MSW or SN as part of the comprehensive assessment. Patient #12: There was no evidence of a psychosocial assessment by MSW or SN as part of the comprehensive assessment.

Upon patient record review, 5 of 14 (Patient #2, #7, #11,#13,#14) 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: During home visit medication reconciliation found Pantoprazole Sodium 20mg one PO QD, bottle dated 1/2024. Order dated12/1/2023 in record is for Pantoprazole Sodium 40 mg one PO QD. Patient #7: Medication profile dated 6/29/2023 included Salonpas Lidocaine Plus 4-10% topical cream 1 app Q 6HRs PRN muscle pain. There was no evidence of where to apply cream. Patient #11: Medication profile dated 5/26/2023 included Hydrocortisone cream 2.5% topical 1 application 2x day for 7 days to rash. No evidence of an area to apply. Patient #13: Medication profile dated 5/25/2023 included Mupirocin 2% topical ointment 1 app Q 4 hours PRN skin irritation. No evidence of an area to apply. Patient #14: SN SOC notes identify pt. on O2, several nurse notes include use of O2. No evidence on medication profile for O2.

Upon patient record review, 1 of 14 (Patient #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 #9: There was no evidence of a bereavement assessment in the comprehensive assessment.

Upon patient record review, 1 of 14 (Patient #11) 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 #11: SN visits occurred 1/18/2023, 2/7/2023 (20 days), 3/5/2023 (26 days), 3/18/2023, 4/8/2023 (21 days). Patient revoked on 5/27/2023, the last comprehensive evaluation was completed on 5/1/2023 (26 days).

Upon patient record review, 4 of 14 (Patient #7,#9,#11,#14) 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 #7: SN SOC assessment identified high fall risk. No evidence of fall precautions or risk of falls on the POC. Patient #9: SN SOC 2/12/2023 identified problem with pain control (6/10), Oxygen use, colostomy, history if seizures, high risk of falls, aspiration (dysphagia) and skin integrity (Braden 12-high). Plan of care had no problems/goals/interventions on only POC dated 2/17/2023. Patient #11: SN SOC assessment identified high fall risk, Patient on O2 and a Braden score of 12- high risk. Plan of care had no problems/goals/interventions for falls, oxygen and skin integrity. Patient #14: SN SOC assessment identified history of seizures, pt. is on 3 seizure medications, and is on O2. No evidence in the POC of problems/goals/interventions for seizure or oxygen. MSW identified on SOC lack of mortuary/funeral plan. No evidence of problems/goals/interventions for funeral planning.

Upon patient record review, 3 of 14 (Patient #11,#12,#13) 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 #11: SOC frequency order for RN included 1 Q 7-21 days for sup visit. Patient #12: SOC frequency order for RN included 1x for eval./admit,then Q 14-21 days for comprehensive assessment, sup visit or recert. Patient #13: SOC frequency order for RN included 1x for eval./admit,then Q 14-21 days for comprehensive assessment, sup visit or recert.

Upon patient record review, 4 of 14 (Patient #7,#11, #13, #14) 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 #7: Order dated 6/29/2023 included Salonpas Lidocaine Plus 4-10% topical cream 1 app Q 6HRs PRN muscle pain. There was no evidence of where to apply cream. Patient #11: Order dated 5/26/2023 included Hydrocortisone cream 2.5% topical 1 application 2x day for 7 days to rash. No evidence of an area to apply. Patient #13: Order dated 5/25/2023 included Mupirocin 2% topical ointment 1 app Q 4 hours PRN skin irritation. No evidence of an area to apply. Patient #14: SN SOC notes identify pt. on O2, several nurse notes include use of O2. No evidence of an order for O2.

Upon client record review, 1 of 14 (Patient #14) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #14: Orders dated 3/4/2023 SN QOW and1 PRN. RN visits occurred QOW. LVN visited 3/11/2023 and 3/15/2023 without an order.

Upon observation, there was no evidence Dietary counseling services is available to the patient and family to assist them in minimizing the stress and problems that arise from the terminal illness, related conditions and the dying process.

Upon patient record review, 7 of 14 (Patient #4,#5, #6, #9, #10,#12,#14) 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: On SN SOC assessment patient identified as having dysphagia with history of aspiration pneumonia and high fall risk. No evidence on Aide assignment/POC of aspiration precautions or fall risk. Patient #5: On SN SOC assessment patient identified at risk for aspiration. No evidence on Aide assignment/POC of aspiration precautions. Patient #6: On SN SOC assessment patient identified as high fall risk. No evidence on Aide assignment/POC of fall risk. Patient #9: On SN SOC assessment patient identified with seizure history (takes Keppra), and dysphagia, No evidence on Aide assignment/POC of seizure or aspiration precautions. Patient #10: On SN SOC assessment patient identified as high fall risk. No evidence on Aide assignment/POC of fall risk. Patient #12: On SN SOC assessment patient identified with Oxygen. No evidence on Aide assignment/POC of Oxygen precautions. Patient #14: On SN SOC assessment patient identified with seizure history (takes Primidone, Topiramate, Klonopin), and high risk for falls, No evidence on Aide assignment/POC of seizure or fall precautions.

Upon patient record review 1 of 14 (Patient #10) 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 • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #10: Order 5/16/2023 included aide visits 2x week. For SOC 5/14/2023 week one aide visit done without evidence of a missed visit.

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. Last notice of appointments for Administrator, Alt Administrator, and DPCS is from 10/2023, none of these employees remain in the agency personnel roster. There are no GB minutes that show new appointments for these roles. There is approval from CDPH with application and approval for new members dated 12/27/2023.

Upon patient client record review, 1 of 14 (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. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient #2: Election of benefit form documented "to start on 12/1/2023", later in document included "effective on 12/8/2023", and was signed 12/8/2023. Date document in record as start date is 12/8/2023. Unclear documentation due to two different dates.

Upon personnel record review, 3 of 12 (Personnel #10, #11, #12) 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 #10, #11, #12: Document "Been Verified" supplied by Therapy contracted company states it may not be used when evaluating a person for employment. No other criminal background check exists for these three employees. OIG and sex offender registry were provided.