Every finding on record at Real Assurance Healthcare Services LLC

Upon observation, there was no evidence the Emergency Preparedness plan: • Is based on and includes a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach • 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

Upon observation, there was no evidence the agency has conducted exercises to test the emergency plan every two years. The Administrator/DPCS and clinical staff members could articulate knowledge of the agency's emergency preparedness plan, including expectations for communications in the event of a crisis or disaster. However, there was no evidence the agency or its staff members have participated in exercises or drills as required to test the emergency plan.

Upon patient record review 3 of 5 (Patient #1, 2, 3) 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 1: At the time of hospice admission, or any subsequent time, there is no evidence the comprehensive assessment addressed the psychosocial needs of the patient and family. Patient 2: At the time of hospice admission, or any subsequent time, there is no evidence the comprehensive assessment addressed the spiritual needs of the patient and family. Patient 3: At the time of hospice admission, or any subsequent time, there is no evidence the comprehensive assessment addressed the psychosocial or spiritual needs of the patient and family.

Upon patient record review, 2 of 5 (Patient #1, 3) 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 Patient 1: The patient's medication list does not include the ordered PRN oxygen therapy. (corrected onsite) Patient 3: The patient's medication list does not include the ordered PRN oxygen therapy. Additionally, the medication list indicates diclofenac topical gel 3% apply 1-2g topically q 4 hours PRN pain, but fails to indicate a location for application. (corrected onsite)

Upon patient record review, 3 of 5 (Patient #1, 2, 3) 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 #1, 2, 3 there was no evidence an initial bereavement assessment was completed.

Upon patient record review, 1 of 5 (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 medications and treatments. Patient 3: The plan of care includes an order for diclofenac topical gel 3% apply 1-2g topically q 4 hours PRN pain, but the order fails to indicate a location for application of this topical medication. (corrected onsite)

Upon patient record review, 2 of 5 (Patient #1, 2) 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: The patient utilizes an OTB table, shower chair, and suction machine for management of the terminal illness; however, this DME does not appear on the plan of care. (corrected onsite) Patient 2: The patient utilizes a walker and wheelchair for management of the terminal illness; however, this DME does not appear on the plan of care. (corrected onsite)

Upon patient record review, 1 of 5 (Patient #2) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 2: The patient's plan of care failed to be populated with the required nursing visit frequency. The RN has seen the patient weekly since hospice admission. However, these nursing services failed to be included in the initial or any subsequent updated plan of care. (corrected onsite)

Upon patient record review 1 of 5 (Patient #2) 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 2: Aide visits were ordered for 2 x weekly. On the weeks of 09.08.2024 and 09.15.2024, an aide visited the patient 3 times. On the week of 09.22.2024, an aide visited the patient 4 times. On the weeks of 09.29.2024 and 10.06.2024, an aide visited the patient 3 times.

Upon patient client record review, 1 of 5 (Patient #4) did not have evidence that each patient record contains: • Signed election statement in accordance with 418.24 Patient 4: At the time of hospice admission, the patient/family requested the Notification of Noncovered Services addendum; however, there was no evidence that this document was returned to the patient/family.