Every finding on record at Radiant Hospice Inc.

Upon client record review, 3 of 3 (Patients # 1, 2, 3) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Personnel # 1) Upon review of patient record there was no evidence of scheduled nursing visits in accordance with the current POC for the following dates: 4/2, 4/9, 4/16/2025. Personnel # 2) Upon review of patient record there was no evidence of scheduled nursing visits in accordance with the current POC for the following dates: 4/18/2025. Personnel # 3) Upon review of patient record there was no evidence of scheduled nursing visits in accordance with the current POC for the following dates: 4/3, 4/10, 4/17/2025.

Upon patient record review, 1 of 14 (Patient #4) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient #4: Options for MD choice or decline to choose are blank

Upon patient record review, 2 of 14 (Patient #1, 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 includes Digoxin 0.25 mg qd, but patient says he does not take. Also Rivaroxaban (Xarelto) 20 mg for prophylaxis on medication profile is not clear of description of indication for use. Patient #4: Quetiapine Fumarate 25mg (Seroquel) every evening on med profile, but patient not aware of this medication. Bottle not available.

Upon observation, there was no evidence the hospice has an interdisciplinary group (IDG) or groups composed of individuals who work together to meet the physical, medical, psychosocial, emotional, and spiritual needs of the hospice patients and families facing terminal illness and bereavement. Interdisciplinary group members must provide the care and services offered by the hospice, and the group, in its entirety, must supervise the care and services. Patient #1: No SC signature or notation of participation for IDG meetings 1/10, 1/24, 2/21/25. SC service declined per plan of care. Patient #2: No SC signature or notation of participation for IDG meetings 1/10, 1/24, 2/21/25. SC service declined per plan of care.

Upon patient record review, 3 of 14 (Patient #2, 8, 10) 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 #2: Patient has comorbidity of NIDDM requiring Metformin. The CTI 1/10/25 included documentation of patients appetite 35-25% meals and significant weight loss. No NIDDM, nutrition related problems, goals, interventions on the plan of care. Patient #8: Patient has comorbidity of NIDDM requiring Glimepiride, Trulicity, and there are no related problems, goals and interventions on the plan of care. Patient #10: Patient on long term anticoagulant therapy - Lovenox. There are no related problems, goals, interventions on the plan of care.

Upon patient record review, 5 of 14 (Patient #1, 2, 3, 4, 7) 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 #1: No MSW signature or notation of participation for IDG meetings: 1/10, 1/24, 2/21/25, 3/7/25. MSW service was being provided per patient need/acceptance. Patient #2: No MSW signature or notation of participation for IDG meetings: 1/10, 1/24, 2/21/25, 3/7/25. MSW service was being provided per patient need/acceptance. Patient #3: No MSW or SC signature or notation of participation for IDG meetings: 3/7/25. MSW, SC service were being provided per patient need/acceptance. Patient #4: No MSW signature or notation of participation for IDG meetings 1/10, 1/24, 2/7, 2/21, 3/7/25. MSW, SC service were being provided per patient need/acceptance. Patient #7: No MSW signature or notation of participation for IDG meeting 12/13/24. No SC signature or notation of participation in IDG: 11/15, 11/29, 12/13/24; Both services was being provided per patient need/accedptance. Pre and post discharge meeting notes (12/27/24 and 1/10/25) do not reflect update of discharge planning and that patient was discharged 1/17/25 due to extended prognosis.

Upon patient record review, 2 of 14 (Patient #4, 6) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient #4: On 9/12/24 order for Hospice Aide 2x/week. Service provided 2x/week. IDG care plan frequency section does not include Aide service and/or ordered frequency at all. Patient #6: Admitted 8/31/23. Patient experienced UTI with positive culture results 9/20/23, requiring antibiotic treatment. There were no updates to related IDG problems, goals and interventions.

Upon patient record review, 6 of 14 (Patient #1, 2, 3, 4, 7, 13) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1: MSW note 1/25/25 was blank except time in and out, and was not authenticated with clinician signature. Completed during survey. Patient #2: MSW ordered monthly at SOC and was seen monthly, but no February note in record at time of survey. In addition, the MSW note 1/17/25 was incomplete and was not authenticated with clinician signature. Completed during survey. Patient #3: On 6/10/24 SC order, Plan of Care, IDG Care Plan frequency lists SC declined. However, there are documented SC assessment/reassessment visit notes for 6/10/24 and 8/30/24. There are also visit notes for 11/12/24, 12/16/24, 1/20/25 with narrative plan to continue monthly. No additional visits documented after January. Patient #4: MSW note 1/10/25 was blank except time in and out and was not authenticated with clinician signature. Completed during survey. Patient #7: MSW note 1/5/25 was blank except time in and out, and was not authenticated with clinician signature. Visit note was completed during survey. Patient #13: On 2/27/23 order SC services declined. SC visit documented 10/6/23 with no documented explanation, update to orders/Plan of Care or IDG frequency.

Upon observation, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Visits 1, 2, 3: Nurse did not clean inside of pulse oximetry device before replacing in bag

Upon observation and patient record review 2 of 14 (Patient #5,13), 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. Patients #5, 13: Wound services were being provided by Wound Pro's PA and MD for patient wounds. There is evidence in the record the hospice used a contracted service Omni-wound to provide a weekly core nursing service, wound care, to the patient. There is not evidence in the record that the wound is unrelated to the terminal diagnosis. There is not evidence that nursing specialized care was provided.

Upon personnel record review, 1 of 14 (Personnel #4) 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 #4: Aide competency form used by agency only said "shampoo" and did not specify various types of shampoo such as sink, tub, bed.

Upon patient record review, 2 of 14 (Patient #4, 5) 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: No frequency of visits on Hospice Aide assignment sheet. Patient #5: 1/18/24 order that patient declined Hospice Aide. 2/2/24 order Aide freq 3x/wk, but Hospice Aide frequency 2x on 2/2/24 Hospice Aide Assignment sheet

Upon patient record review 1 of 14 (Patient #5) 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 #5: 2/2/24 order states Aide freq 3x/wk, but 2/2/24 Hospice Aide Assignment sheet has Hospice Aide frequency 2xwk. Patient was seen 2x week in June and week of 7/8/24. Patient was seen 3x weeks of 7/1, 7/15, 7/22, 7/29, 8/5.

Upon patient record review 2 of 14 (Patient #4, 5) 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. Patient #4: There is no documented Hospice Aide Supervisory Visit 2/13-3/10/25. Patient #5: There is no documented Hospice Aide Supervisory Visit 7/11/24-8/14/24.

Upon contract review, (Wound Pro contract) did not have evidence 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 Specialized services were being provided by Wound Pro's PA and MD for patient wounds (Patient#5, 13). There was no documented evidence that the patients' wounds were unrelated to terminal diagnosis. There was a business associates agreement in place, but no actual contract with the Wound Pro provider.

Upon patient record review, 9 of 14 (Patient #1, 2, 3, 4, 6, 7, 8, 11, 13) 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 Patients 1,2, 3, 6, 7, 8, 11, 13: No allocated space to identify effective date of election for this form. Patient #4: MD choice or decline to choose are blank Patient #8: Requested hospice addendum but no evidence provided.

Upon patient record review, 2 of 14 (Patient #7, 11) 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 #7: DC Planning form/note not authenticated with preparer's signature. Patient #11: LVN note 2/6/24 is not authenticated with clinician signature.

Upon patient record review, 4 of 14 (Patient #7, 8, 9, 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 #7: Discharge Summary says informed MD of discharge planning, but no documentation of documents shared/sent in patient discharged for extended prognosis. Patient #8, 9, 10: No evidence discharge summary shared/sent.

Upon patient record review, 1 of 14 (Patient #5) did not have evidence that the discharge summary includes all required information Patient #5: Discharge summary did not include history of wound and specialty service consult. Narrative includes that MSW was evaluation only, when in fact MSW documented monthly visits.

Upon observation, there was no evidence the organizational chart matches the hospice's information submitted to CMS and/or State licensing agencies for ownership and management personnel. Administrator hire date of 1/15/2025. No evidence of 855A was presented to surveyor by end of survey.