Every finding on record at Reliant Hospice, Inc.

Upon patient record review, 3 of 3 (Patients #1, 2, 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. Patients 1, 2, 3: The oxygen therapy, ordered at 2L/min via nasal canula as needed for shortness of breath, was not included on the patient's medication list. (corrected onsite)

Upon patient record review, 1 of 3 (Patient #2) 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: The comprehensive initial assessment indicates that the patient is dyspneic on exertion. The patient is on Oxygen and Morphine for shortness of breath. There is no evidence of a respiratory care plan to include goals and interventions to address respiratory comfort. (corrected onsite)

Upon observation, there was no evidence the hospice has developed and maintained an emergency preparedness plan that must be reviewed, and updated at least every two years. The plan was last reviewed and updated on 3/15/2020.

Upon observation, there was no evidence of contracts/agreements with other facilities/agencies/hospices to receive patients in the event the hospice cannot provide care to their patients during an emergency. Corrected on site.

Upon patient record review 4 of 14 (Patient #8, 9, 10, 14) 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 8, 9: There was no evidence of a psychosocial or Spiritual assessment. Patient 10: There was no evidence of a psychosocial assessment. Patient 14: There was no evidence of a spiritual assessment.

Upon patient record review, 5 of 14 records (Patient #1, #2, #3, #8, #11) 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. Patient 1: Medication profile dated 4/6/2022 included oxygen 3-5 LPM via nc. The record also included a physician order dated 4/6/2022 that included oxygen via nc at 2LPM as needed for SOB, may titrate up to 4LPM if O2 sat less than 89%. None of the other noted oxygen orders were included on the medication profile, it is unclear which was accurate. Patient 2: Medication profile included oxygen 3-5L for SOB/Wheeze/Comfort/resp management. The record also contained two different orders for oxygen, both dated 10/17/2019. 1) Oxygen 2-5 liters as needed for SOB; 2Lpm for RR of 21-22 BPM. 3-4 LPM for RR 23-26 BPM, 5L for RR 27-30 BPM. 2) O2 at 2L via NC PRN to manage SOB. Neither of the other noted oxygen orders were included on the medication profile, it is unclear which was accurate. Patient 3: Medication profile dated 7/3/2020 included Miralax powder 17GM 1 scoop oral solution daily for constipation. There was no evidence of a diluent. Patient 8: Medication profile dated 6/10/2022 included O2 2LPM via nc as needed. There was no evidence of an indication for use. Diclofenac 0.1% sodium. There was no indication of site for application. Patient 11: Medication profile dated 12/14/2017 included Amicare gel topically apply to pain site daily as needed. There was no evidence of a pain site for application.

Upon patient record review, 2 of 12 applicable (Patient #2, #7 ) 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 2, 7: There was no evidence of an initial bereavement assessment.

Upon patient record review, 1 of 14 (Patient #8) 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 8: The patient was admitted 6/10/22 and expired on 7/17/22. There was no evidence of an update to the comprehensive assessment during the patients hospice episode.

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

Upon patient record review, 1 of 14 records (Patient #7) 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: On SOC SN initial assessment pt was found to be a high risk for falls. There was no Problem for safety in the Care plan. Patient was on O2, the care plan did not contain an intervention on the respiratory care plan for oxygen.

Upon patient record review, 4 of 14 records (Patient #2, #3, #8, #11) 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 2: Two different orders for O2 on same day 10/17/2019 include 1) O2 2-5 liters as needed for SOB; 2Lpm for RR of 21-22 BPM. 3-4 LPM for RR 23-26 BPM, 5L for RR 27-30 BPM. 2) O2 at 2L via NC PRN to manage SOB. There is also an entry on the HHA POC that states O2 3-5L for SOB/Wheeze/Comfort/resp management. This also exists on the POC. There is no evidence there was a review of all prescription medications. Patient 3: Order dated 7/3/2020 and included in the POC, included Miralax powder 17GM for sol. 1 scoop oral solution daily for constipation. There was no evidence of a diluent. Patient 8: Order dated 6/10/2022 included O2 2LPM via nc as needed. There was no evidence of a reason. Order dated 6/10/2022 included Diclofenac 0.1% sodium ophthalmic sol, 1 application topically to pain site 3x day. There was no evidence of a site. Patient 11: Order and POC dated 12/14/2017 included Amicare gel topically apply to pain site daily as needed. There was no evidence of a pain site.

Upon client record review, 1 of 14 records (Patient #8) 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 8: SOC 6/10/2022, expired 7/17/2022, there was no evidence of an IDG/ plan of care update throughout the benefit period.

Upon patient record review, 1 of 14 (Patient #8) 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 8: Admitted 6/10/22 and expired 7/17/22. The record did not contain evidence of an updated assessment, plan of care or progress toward goals and outcomes at all during the hospice episode of care.

Upon client record review, 1 of 14 (Patient #8) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 8: SOC orders included RN 1-2x week, LVN 1x week. SOC 6/10/2022, expired 7/17/2022, there were no LVN visits after 6/17/2022, and no RN visits after initial SOC assessment.

Condition of Participation: Infection Control.

Upon observation, there was no evidence the board of directors/governing body approves the frequency and detail of the data collection.

Upon patient record review, 4 of 4 applicable (Patient #2, 3, 6, 7) did not have evidence the hospice offers bereavement counseling that includes: • Making bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. Bereavement counseling also extends to residents of a SNF/NF or ICF/IID when appropriate and identified in the bereavement plan of care • Ensuring that bereavement services reflect the needs of the bereaved • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery Patient 2, 3, 6, 7: The record contained no evidence of bereavement services being offered or provided.

Condition of Participation: Hospice Aide and Homemaker Services. L607

Upon personnel record review, 2 of 2 applicable (Personnel #3, #5 ) 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 3 and 5: There was no evidence that the competency assessment was performed by the aide with a patient or pseudo-patient.

Upon patient record review 1 of 10 applicable (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: HHA ordered at SOC and throughout service to be 2x week. For weeks of 7/1/2018, 7/8/2018, 7/15/2018, and 7/22/2018 there was one HHA visit per week with no evidence of missed visits.

Upon observation, there was no evidence the hospice documented the cost savings achieved through the use of volunteers. Documentation must include the following: • The identification of each position that is occupied by a volunteer • The work time spent by volunteers occupying those positions • Estimates of the dollar costs that the hospice would have incurred if paid employees occupied the positions identified in paragraph (d)(1) of CFR 418.78 for the amount of time specified in paragraph (d)(2) of CFR 418. There is no evidence that a calculated cost savings report has ever been completed.

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. Full minutes existed for one meeting of 2014. No evidence of yearly annual review of policies, mention of bylaws or governing body operations, human resource management, QAPI involvement, COVID vaccination tracking and compliance or appointment of a qualified alternate administrator: Alternate administrator job description requires Bachelors degree, with Masters preferred. Personnel #2 is an Associate degreed nurse. There is no evidence of a bachelors degree. .

Upon patient record review, 1 of 14 (Patient #8) did not have evidence that the medical director or physician designee provides written certification that it is anticipated that the patient's life expectancy is 6 months or less if the illness runs its normal course. The physician must consider the following when making this determination: • The primary terminal condition • Related diagnosis • Current subjective and objective medical findings • Current medication and treatment orders • Information about the medical management of any of the patient's conditions unrelated to the terminal illness Patient 8: There was no evidence of a verbal or written certification.

Upon patient record review, 2 of 14 records (Patient #2, #3, #8, #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 8: Narrative from SN dated 6/17/2022 indicated Family to notify Vega Hospice agency if any changes in condition, questions, or concerns. The agency name is Reliant Hospice, No evidence of appropriate authentication. Patient 11: HHA visits dated 11/6, 11/8, 11/10, 11/13, 11/15, 11/17, 11/20, 11/22, 11/24, 11/27, 11/29, 12/2, 12/4, 12/6 and 12/11/2017 were all entered into the EMR by the Alt Admin, none were signed by the HHA.

Upon client record review, 1 of 4 applicable (Patient #4) 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 4: There was no evidence of a discharge summary.

Upon personnel record review, 1 of 10 applicable (Personnel #10) did not have evidence that personnel credentialing activities are conducted to verify qualifications of all credentialed/licensed personnel in the positions they hold at the time of hire, at renewal or in accordance with specific state practice act requirements. Employee 10: No SLP file was supplied, there is no evidence of license verification.

Upon personnel record review, 1 of 1 applicable (Personnel #10) 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 10: There was not a speech therapist file available for review to ensure qualifications.

Upon personnel record review, 3 of 4 applicable (Personnel #8, #9, #10 ) 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: There was no evidence of a criminal background check. Personnel 9: There was no evidence of a criminal background check. Corrected on site. Personnel 10: There was no evidence of a criminal background check.

Upon personnel record review, 3 of 10 (Personnel#8, 9, 10) did not have evidence in the personnel files that all personnel have been fully vaccinated for COVID-19. Personnel #8, 9, 10: COVID vaccination status was not on record.