Every finding on record at Sacred Heart LLC

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. The Administrator could not identify a contract/agreement with another facility to receive patients in the event the hospice could not provide care during an emergency

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.

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 agency administrator could not find the communication plan.

Upon observation, there was no evidence the Emergency Plan communication plan includes: • A method for sharing information and medical documentation for patients under the hospice's care, as necessary, with other health care providers to maintain the continuity of care • A means, in the event of an evacuation, to release patient information as permitted under 45 CFR 164.510(b)(1)(ii) • A means of providing information about the general condition and location of patients under the facility's care as permitted under 45 CFR 164.510(b)(4) The agency administrator could not find the communication plan.

Upon observation, there was no evidence the agency has conducted exercises to test the emergency plan every two years.

Upon patient record review, 5 of 14 (Patient #1,2,3,5,9) 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 #1,2,3,5,9: There is evidence of an order for oxygen, but oxygen is not on the medication record.

Upon patient record review, 1 of 14 (Patient #6) did not have evidence that each patient and family received education and training provided as appropriate to their responsibilities for the care and services identified in the plan of care. Patient #6: There is evidence in the medical record of an order for wound care. Under the order is a note: the "caregiver is validated to be competent in performing wound care maintenance during non-skilled nurse visits". There is no evidence of education of the caregiver.

Upon patient record review, 2 of 14 (Patient #2,3) 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 #2,3: There is evidence the Social Worker visit schedule is once a month as ordered by the IDG. However there is no Psychosocial problem/intervention/goal in the plan of care.

Upon patient record review, 1 of 14 (Patient #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 #4: There is evidence in nurses note 12/5/25 the patient has a Foley catheter. There is no order for Foley catheter.

Upon client record review, 2 of 14 (Patient #4,10) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #4: There is evidence Spiritual Care visit frequency is x1 per month. There is no visit recorded in January and February 2026. Patient #10: There is evidence in the nursing narrative on admission 1/6/26 the patient has two wounds on Left ankle. The order for wound care is for one of the wounds. The other wound care does not have an order and wound care was provided by the nurse.

Upon observation and home visits, 1 of 3 (Patient #1) there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient #1: During visit the nurse washed hands, put on gloves, and opened bag. The nurse then touched the patient's leg and then went into the bag to remove pulse oximeter without cleaning hands. The nurse did not remove all the equipment from the bag at once, but kept touching the patient and then reaching back inside of the bag again.

Upon patient record review, 1 of 14 (Patient #13) 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 #13: There is evidence of a post bereavement assessment. There is a note on the area for plan of care stating the bereaved refused services. However letters were still sent and the letters do not appear on the Bereavement Plan of Care.

Upon personnel record review, 1 of 13 (Personnel #6) did not have evidence in the hospice aide personnel file that a registered nurse made an annual on-site visit to the location where a patient is receiving care in order to observe and assess each aide while he or she is performing care. The supervising nurse must assess an aide's ability to demonstrate initial and continued satisfactory performance in meeting outcome criteria that include all required content. Personnel #6: There is no evidence in the personnel file of an annual on site visit to a location where a patient is receiving care.

Upon personnel record review, 1 of 14 (Personnel #2) did not have evidence the alternate administrator's personnel record verifies that: • The employee has appropriate education and experience requirements • There is a signed job description for this role • The employee has been orientated to this role Personnel #2: There is no evidence the Alternate administrator was oriented to the role.

Condition of Participation: Medical Director.

Upon patient record review, 8 of 14 (Patient #1,2,4,5,6,8,9,10) did not have evidence that there is a physician's brief narrative explanation of the clinical findings that supports a life expectancy of 6 months or less as part of the certification forms, or as an addendum to the certification forms. Patient #1,2,4,5,6,8,9,10: There is no evidence of a brief narrative that included the patients clinical circumstances to justify certification. Only the diagnosis and comorbidities and certification statement was documented.

Upon client record review, 3 of 14 (Patient #1,2,6) did not have evidence that the physician provides a brief narrative explanation of the clinical findings that supports a life expectancy of 6 months or less as part of the recertification form, or as an addendum to the recertification form. Patient #1,2,6: There is no evidence of a brief narrative that included the patients clinical circumstances to justify recertification. Only the diagnosis and comorbidities and certification statement was documented.

Upon patient client record review, 10 of 14 (Patient #1,2,3,4,5,6,7,8,9,10) did not have evidence that each patient record contains: •Diagnoses related to terminal illness and related conditions •Diagnoses unrelated to terminal illness and related conditions Patients #1-10: There is evidence during the admission, the patient signed a blank "Patient Notification of Hospice Non-Covered Items, Services, and Drugs" form. On the election statement, there is a spot for the patient to check, "yes or no" that they wanted the form. However, neither box was checked.

Upon SNF/NF contract review, 1 of 3 (Sage Creek Post Acute, SNF/GIP contract) did not have a provision that the hospice may use the SNF/NF nursing personnel where permitted by state law and as specified by the SNF/NF to assist in the administration of prescribed therapies included in the plan of care only to the extent that the hospice would routinely use the services of a hospice patient's family in implementing the plan of care. The contract has a statement "A provision that the hospice may use the SNF/NF or ICF/IID nursing personnel where permitted by state law and as specified by the SNF/NF or ICF/IID to assist in the administration of prescribed therapies included in the plan of care only to the extent that the hospice would routinely use the services that "MIRACLE HOSPICE CARE" patient's family in implementing the plan of care. The hospice is Sacred Heart Hospice and has no affiliation with Miracle hospice care.

Upon observation, there was no evidence the hospice provides orientation to personnel of a SNF/NF or ICF/IID regarding the policies and procedures of the provision of care/service including all required content.

Upon personnel record review, 1 of 13 (Personnel #5) did not have evidence that all Medical Social Services are provided by a qualified Medical Social Worker in accordance with the state's Social Work Practice Act, the hospice's policies and procedures and/or job descriptions. Personnel #5: There was no documentation that the MSW serves as an active advisor, consulting with the BSW on assessing the needs of patients and families, developing and updating the social work portion of the plan of care. There is no evidence of supervision by an MSW.

Upon observation, there was no evidence the organizational chart matches the hospice's information submitted to CMS and/or State licensing agencies, and ACHC for ownership and management personnel. The Medical Director was new last year and there is no evidence documentation submitted to CMS, state agencies and ACHC.

Upon patient record review, 4 of 6 (Patient #1, 2, 3, 5) did not have evidence that the patient chooses a health care provider, including an attending physician. Patients 1, 2, 3, 5 elected an attending physician however the attending was not included in the development of the plan of care or an updates to the plan of care.

Upon patient record review, 2 of 6 (Patient #1 and 5) 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 DME for oxygen present but not listed under medication list. Patient #5 Imodium order of 1/16/23 did not contain dose, route, nor frequency.

Upon patient record review, 5 of 6 (Patient #2, 3, 4, 5, 6) 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.

Upon patient record review, 1 of 6 (Patient #3) 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 3 MSW and Chaplain ordered as x1 and prn without a quantity for PRN visits.

Upon patient record review, 1 of 6 (Patient #5) 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 #5 Imodium order of 1/16/23 did not contain a prn indication, dose, route or frequency.

Upon patient record review, 4 of 6 (Patient #1, #3, #5, #6) 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 Back up E-tanks in the home but no order listed as DME. Patient #3 During RN initial assessment the use of walker was identified but walker no order under DME. Patient #5 During RN assessment the use of transfer chair and wheel chair were identified but no order under DME. Patient #6 During RN assessment the walker and Oxygen were identified but no order under DME.

Upon client record review, 2 of 6 (Patient #2, #3) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #2 RN visits completed regularly and there was no evidence of an ordered nursing frequency. Patient #3 patient chart indicated MSW and Chaplain visits to be once then prn but there are no evidence that MSW nor Chaplain made visits.

Upon observation, 2 of 3 patient home visits (Patient #1, #2) there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient #1, #2 RN created clean and dirty areas but accessed the content of the bag, clean and dirty items without glove change.

Upon patient record review, 3 of 6 (Patient #2, 3, 4) 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 #2 CTI 1/16/23 narrative present but does not contain MD signature or signature date. Patient #3 verbal certification dated 1/13/23 has no signature. CTI of 1/13/23 narrative present but does not contain MD signature or signature date. Patient #4 verbal certification dated 12/16/22 has no signature. CTI of 12/16/22 does not contain MD narrative, signature or signature date.

Upon patient client record review, 5 of 6 (Patient #1, #2, #3, #4, #5) 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 Patient #1, #2, #3, #4 request for addendum made at the time of admission but no evidence that they were provided. Patient #5 request for addendum form marked both requesting and not requesting the form but no clarification nor evidence that the addendum was provided.

Upon client record review, 3 of 6 (Patient #4 #5 #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

Upon client record review, 3 of 6 (Patient #4, 5, 6) did not have evidence that the discharge summary includes all required information. Discharge summary did not include: • A summary of the patient's stay, including treatments, symptoms and pain management • The patient's current plan of care • The patient's latest physician orders • Any other documentation that will assist in post-discharge continuity of care or that is requested by the attending physician or receiving facility