Every finding on record at Quality Plus Hospice Inc.

Upon personnel record review, 1 of 13 (Personnel #13) 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 #13: There was not evidence of a criminal background check in the personnel file.

Condition of Participation: Emergency Preparedness

Upon observation, there was no evidence the Emergency Preparedness plan: • Includes strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care No evidence of how to manage the consequences of power failures, natural disasters, and other emergencies that would affect ability to provide care.

Upon observation, there was no evidence the The Emergency Preparedness plan addresses patient population, including, but not limited to: • The ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans The document "Continuity of Operations business plan" is not filled out.

Upon observation, there was no evidence the Emergency Preparedness plan includes a process for cooperation and collaboration with local, tribal, regional, state, and federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation.

Upon observation, there was no evidence the hospice develops and maintains an emergency preparedness communication plan that complies with federal, state, and local laws and must be reviewed and updated every two years. No evidence of a communication plan.

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

Upon patient record review 3 of 6 (Patient #3,#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: No evidence of psychosocial or spiritual needs included in the comprehensive assessment. Patient #3, #5: No evidence spiritual needs included in the comprehensive assessment.

Upon patient record review, 4 of 6 (Patient #1, #2, #3, #4) 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: Med profile does not include routes for med administration, and found Montelukast 10 mg BID in home (order was for 100mg), ASA 81mg PO QD, no evidence on the medication profile for these two medications. Patient #2: On HV found p.t is taking Synthroid 50 mcg one PO QD, Oxybutynin chloride 5mg PO one Q HS, Pilocarpine HCL Op sol. 1%- one drop each eye TID, Dorzolamide 2% Opth. sol one drop each eye BID, Novolin u100 SQ to scale TID (no scale provided), none of these meds are on med profile. On the profile and no longer taking is Glipizide 10mg 1 tab PO BID and Januvia 100mg PO QD- both dc'd in Dec.2023. Lanoxin 0.125mg dc'd many months ago per daughter. Patient #3: SN initial assess included the note: Hydrocodone 5ml Q 8 hrs prn pain via Peg tube (no dosage m per 5ml). During HV this medication was found in home, also Pantoprazole 40mg PO one QD via Peg tube, and Lisinopril 5 mg via peg tube 1 x day (medication profile had Lisinopril as 10mg in error). There was no evidence on the medication profile for these three medications. Patient #4: On nurse's notes day of death 9/21/2023 "O2 in home". No evidence in med. profile for O2.

Upon patient record review, 3 of 6 (Patient #3,#4,#5) 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. Patients #3,#4,#5, No evidence of a bereavement assessment at SOC within 5 days.

Upon patient record review, 2 of 6 (Patient #4,#5) 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 #4: SOC 6/28/2023- SN 1x week, no evidence of SN visits from 7/28/2023-8/14/2023 (17 days), or 8/14/2023-9/20/2023 (37 days), no update to the comprehensive assessment during these dates. Patient #5: SN visits 5/6/2022 and 5/22/2022 (16 days), no evidence of a a comprehensive assessment no less frequently than 15 days.

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

Upon patient record review, 3 of 6 (Patient #3, #4,#6) 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: Pt is identified on SOC (12/10/2023) assessment as having a peg tube, and receiving Isomil 1.5cal 1 can Q 4 hrs.. There is no mention of the peg tube feedings in the POC. Patient #4: SOC 6/28/2023, Dr orders and brief SOC POC. No POC in record after SOC. On Death note documented O2 in home, no evidence of order for or inclusion of O2 on POC. No evidence of problems, goals, and interventions to address fall risk, fluid overload, shortness of breath, pain or comfort measures. Patient #6: SOC orders for 7/24/2022 included SN 1x week, order same day for dressings changes to be done daily. No evidence of problems, goals, and interventions to address wounds or skin care.

Upon patient record review, 4 of 6 (Patient #1,#2,#3,#4) 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: During HV medication reconciliation found Montelukast 10 mg BID in home (order was for 100mg), ASA 81mg PO QD, evidence of orders for these two medications. Patient #2: During HV medication reconciliation found pt is taking Synthroid 50 mcg one PO QD, Oxybutynin chloride 5mg PO one Q HS, Pilocarpine HCL Op sol. 1%- one drop each eye TID, Dorzolamide Opth. sol one drop each eye BID, Novolin u100 SQ to scale TID (no scale provided), none of these meds have Dr. orders. Patient #3: The SOC SN initial assess included: Hydrocodone 5ml Q 8 hrs prn pain via Peg tube. During HV this medication was found in home, also Pantoprazole 40mg PO one QD via Peg tube, and Lisinopril 5 mg via peg tube 1 x day. There was no evidence of orders for these three medications. Pt is identified on SOC assessment as having a peg tube, and receiving Isomil 1.5cal 1 can Q 4 hrs. There is no evidence of orders for the tube feedings. Patient #4: On nurse's note on day of death 9/21/2023 "O2 in home". No evidence of orders for O2.

Upon client record review, 2 of 6 (Patient #4, #5) 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 #4: SOC 6/28/2023-9/21/2023, no evidence of any IDGs in record. Patient #5: Pt on service 12/4/2022-5/27/2023. Last IDG dated 5/11/2023 (16 days).

Upon client record review, 2 of 6 (Patient #4, 6) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #4: SN ordered 1x week, no evidence of SN visits from 7/28/2023-8/14/2023, or 8/14/2023-9/2023. SW ordered 1x Month, no evidence of any SW visits, SC ordered 1x M, no evidence of any SC visits. Patient #6: SOC orders for 7/24/2022 included SN 1x week, order same day for dressings changes to be done daily, no designation of who is to perform these dressing changes. SN visited 7/24, 7/25, 7/26/2022 without orders for daily visits. Visits then resumed at 1x week with no clear order.

Upon observation, there was no evidence the hospice is in compliance with accepted professional standards and principles for all core services which includes nursing services, medical social services and counseling services. The agency does not have evidence of the ability to provide general inpatient level of care. They did not obtain a GIP contract. Upon personnel record review, 4 of 12 (Personnel #3,#4,#5,#8) 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: • Physician services (may contract for physician services) • Nursing • Medical social services • Counseling Personnel #3, #4, #5, #8: No evidence of a withholding W-2/W4 statement to validate employment.

Condition of Participation: Hospice Aide and Homemaker Services. L607

Upon personnel record review, 1 of 12 (Personnel #7) did not have evidence that Hospice Aide Services are provided by a qualified individual in accordance with the appropriate state's regulations, the hospice's policies and procedures and/or job descriptions and the ACHC Glossary of Personnel Qualifications as defined by the Medicare Conditions of Participation. Personnel #7: There was no evidence the aide completed A training program and competency evaluation as specified in CFR 418.76(b) and 418.76(c), A competency evaluation program that meets the requirements of CFR 418.76(c), A nurse aide training and competency evaluation program approved by the state as meeting the requirements of §483.151 through §483.154 and is currently listed in good standing on the state nurse aide registry or A state licensure program. The aide has not be utilized in patient care.

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. The agency administrator and governing body did not provide agency oversight to ensure all core services can be provided to include general inpatient level of care. No evidence that employment of all core staff could be verified through withholding statements. Alternate Medical Director contract was not in place until during the survey. Emergency Preparedness plan was not complete in order for the agency to be prepared to handle emergencies. No evidence of a qualified aide to provide aide services.

Upon patient client record review, 1 of 6 (Patient #1) 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: On SOC assessment DNR is marked "no", on MSW initial assessment DNR is marked "yes", then a note is documented within same record "Not ready to sign OOH DNR at this time. On initial Dr. orders dated 8/3/2023 Dr. has marked an order for DNR. No evidence of clear entries.

Upon client record review, 1 of 6 (Patient #6) 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 #6: Pt transferred to Hospital for further treatment and evaluation, no evidence of a transfer summary or copy of records forwarded.

Upon client record review, 1 of 6 (Patient #6) 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 #6: Revoked services to go in hospital, no evidence of discharge summary sent to attending.

Upon personnel record review, 1 of 12 (Personnel # 12) did not have evidence that all Speech Therapy Services are provided by a qualified licensed Speech-Language Pathologist (SLP) or Audiologist in accordance with the state's Speech-Language Pathology Practice Act and the hospice's policies and procedures and/or job descriptions. Personnel #12: No evidence of a SLP, no record provided.

Upon personnel record review, 4 of 12 (Personnel #6, #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 #6, #10, #11, #12: No evidence of criminal background checks.