Every finding on record at Safe Mission Hospice & Palliative Care Inc

Upon patient record review, 2 of 5 (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 There was documentation in the recent IDG note that patient was on a mechanical soft diet. There was no evidence of problems, goals and interventions related to that diet noted on patients plan of care. Patient #3 The medical record showed patient has chosen to be a full code. There was no evidence of problems, goals and interventions related to the full code wishes on patients plan of care.

Upon patient record review 2 of 5 (Patient #2,3) 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 - The medical record showed current aide frequency of 2 visits per week. There is evidence that the aide provided care three times per week without an order starting the week of 05/07/25. Documented aide visits completed on: 5/5/25; 5/7/25; 5/9/25; 5/12/25; 5/14/25; 5/16/25; 5/19/25; 5/21/25, and the schedule for today noted the aide was to see patient. Patient #3 - The medical record showed current aide frequency order for 2 visits per week. There is evidence that the aide provided additional care for the week of 04/20/25, documented aide visits completed on 4/23; 4/25 and 4/26; and additional aide care was provided the week of 05/04/25, documented aide visits occurred on 5/7, 5/9 and 5/10.

Upon patient record review, 2 of 14 (Patient #4, 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 #4: During home visit med review, noted meds that were included in hospice medication profile, but not on facility profile: Levothyroxine, Cholecalciferol, Ferrous Sulfate Elixir, Sliding Scale Insulin Regular, MVI liquid, Ascorbic 500 mg tab, B Complex Plus Tab, Eliquis, also medication noted to be included on facility profile, but not listed on current hospice medication profile: Lorazepam, Morphine, Ondansetron, Hyoscyamine. Patient #5: During home visit patient reports to be taking, but that are not included on hospice medication profile: Mirtazapine, Senna, Ibuprofen, Hydrocodone, metformin, Lansoprazole.

Upon patient record review, 1 of 14 (Patient #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 #7: There is no initial bereavement assessment by SC and RN did not complete bereavement screening. The allocated section of comprehensive assessment is blank.

Condition of participation: Interdisciplinary group, care planning, and coordination of services. The hospice must designate an interdisciplinary group or groups as specified in paragraph (a) of this section which, in consultation with the patient's attending physician, must prepare a written plan of care for each patient. The plan of care must specify the hospice care and services necessary to meet the patient and familyspecific needs identified in the comprehensive assessment as such needs relate to the terminal illness and related conditions.

Upon observation and patient record review, 7 of 14 (Patients#1,2,3,4,8,12,13) 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 #1,2,3,4,8,12: No MSW or SC signatures to validate participation in IDGs. The patient was not receiving MSW or SC visits. There is no evidence the IDG was composed of all disciplines to meet the physical, medical, psychosocial, emotional, and spiritual needs of the patient. Patient #13: No SC signature 6/14-8/23, to validate participation in IDGs. The patient was not receiving SC visits. There is no evidence the IDG was composed of all disciplines to meet the physical, medical, psychosocial, emotional, and spiritual needs of the patient.

Upon patient record review, 2 of 14 (Patient #2, 12) 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, 12: Medications include Eliquis with no related problem, goals or interventions identified in the Plan of Care.

Upon patient record review, 1 of 14 (Patient #12) 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 #12: SOC 9/20/24 with 9/20/24 order and IDG plan of care for Volunteer services as needed. No evidence of a routine frequency.

Upon patient record review, 2 of 14 (Patient #2, 8) 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: 11/29/24: Change foley catheter every 3-4 weeks or prn, no indication of prn. Patient #8: 3/16 Sacrococcygeal wound care and Penile Surgical Incision wound care orders do not include frequency wound care to be performed.

Upon patient record review, 4 of 14 (Patient #3, 8, 12, 13) 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 #3: No RN signature to validate participation. The disciplines were actively involved with the patient therefore there was no evidence of collaboration since there was no signature to validate participation. Patient #8: No RN or any discipline signatures for IDG 3/16 and 3/21/25. The disciplines were actively involved with the patient therefore there was no evidence of collaboration since there was no signature to validate participation. Patient #12: No RN signature to validate participation 9/20/24. The disciplines were actively involved with the patient therefore there was no evidence of collaboration since there was no signature to validate participation. Patient #13: No RN note or signature to validate participation 6/14/24. The disciplines were actively involved with the patient therefore there was no evidence of collaboration since there was no signature to validate participation.

Upon patient record review, 3 of 14 (Patient #3, 11, 13) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #3: The SOC 1/21/25 with initial order for MSW within 5 days of admission and monthly to assist. IDG meetings/plan of care thru current meeting also have monthly frequency. No documented MSW visits after 1/25/25 initial MSW assessment. Patient #11: Patient on service 6/16/24-10/16/24 with initial order for MSW within 5 days and monthly. IDG meetings/plan of care thru current meeting also have monthly frequency. No documented MSW visits after 6/21/24 initial MSW assessment. Patient #13: Patient on service 5/20/24-9/1/24 with initial order for MSW within 5 days and monthly. IDG meetings/plan of care thru current meeting also have monthly frequency. No documented MSW visits after 5/21/24 initial MSW assessment.

Upon patient record review, 2 of 14 (Patient #12, 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 #12, 13: Bereavement Care Plan includes periodic letter mailings. EMR shows all mailings to be past due, beyond the first one, with no documented evidence of bereaved decline or other explanation.

Upon personnel record review, 1 of 14 (Personnel #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 #5: The competency checklist utilized by the agency does not specify various types of shampoo, but "shampoo" only. Cannot verify all types as intended.

Upon patient record review, 1 of 14 (Patient #7) 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 #7: Hospice Aide assignment sheet is blank - no tasks assigned.

Upon patient record review 2 of 14 (Patient #1, 7) 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 #1: On 3/8/25 Hospice Aide assignment sheet and 3/8/25 order with aide frequency two times a week. Only one visit provided on March 27, 2025. The aide narrative note states completed all tasks, patient tolerated shower with no complications. The bath assigned by RN is bed bath and bed bath was checked, but the narrative indicates shower was given. Patient #7: Patient admitted 3/13/25 with 3/13/25 order for hospice aide once/week and 3/31/25 order for hospice aide twice/week. Hospice aide notes 3/22, 3/26 are blank except time in and out.

Upon patient record review 5 of 14 (Patient #1, 3, 4, 5, 8) 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 #1: 3/8/25 order for hospice aide 2/wk. Not started until 3/27/25. Supervisory visit 3/22/25 did not reference that services had not yet been initiated and/or any reason. Patient #3: Patient admitted 1/21/25. Only 1 aide supervisory visit documented on 1/30/25. Patient #4: Patient admitted 1/28/25. No documented LVN or aide supervisory visit documented. Patient #5: Patient admitted 3/7/25. No aide supervisory visit documented. Patient #8: Patient admitted 3/16/25. First and only hospice Aide visit note 3/23/25 when aide documented patient refused visits and that wife said patient will only let her help. Initial Order for hospice aide once per week for hygiene and 3/23/25 order that hospice aide declined.

Upon observation, there was no evidence the hospice documents and demonstrates viable and ongoing efforts to recruit and retain volunteers. No documented evidence of volunteer recruiting efforts are provided to surveyor. A paragraph is presented to surveyor near end of survey Dated April 2025 - 1st Quarter that states "We Currently have 1 active volunteer as result of our previous and current active recruitment. Our volunteer hours this quarter come only from administrative hours.....Due to ongoing COVID 19 pandemic, no new recruitment is in place currently and no direct patient care volunteers have been assigned." Reportedly, the "1 Volunteer" resulting from recruitment is the Administrator Alt/ DPCS.

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 418.78 Information provided to surveyor includes hours of service per month and cost savings calculation, it does not specify administrative and/or patient related activities that are applicable to requirements for volunteer service.

Upon observation, there was no evidence the annual report documents the use of volunteers providing day to day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract personnel. Provided list of monthly volunteer hours total was 4.2%.

Upon personnel record review, 1 of 11 (Personnel #6) did not have evidence the hospice employees and contract employees have received orientation on the hospice philosophy. Personnel #6: Orientation is not signed by personnel or trainer.

Upon personnel record review, 1 of 11 (Personnel #7) did not have evidence that a skills competency assessment, specific to each discipline had been conducted for all personnel including volunteers initially during orientation. Personnel #7: No documented competency checklist for bereavement coordinator.

Upon patient client record review, 6 of 14 (Patient #1, 3, 6, 7, 8, 12) 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: The Election Statement choice for non-covered items addendum is blank for both options. The addendum itself is blank. Patient #3: The Election Statement choice for non-covered items addendum is blank for both options. Patient #6: The Election Statement choice for non-covered items addendum is blank for both options. Patient #7: The Election Statement choice for non-covered items addendum is blank for both options. Patient #8: The Election Statement choice for non-covered items addendum is blank for both options. The addendum itself is blank. Patient #12: Patient elected to receive the Notification of non-covered items and services. The non-covered items addendum medication section is blank. Med profile meds not covered by hospice to include ophthalmic drops, diclofenac sodium topical gel, gabapentin, pantoprazole, sertraline.

Upon patient record review, 7 of 14 (Patient #1, 3, 4, 5, 6, 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 #1, 3, 11, 13: Initial psychosocial assessment notes by MSW conclude with MSW will follow up with patient plan of care monthly, but there are no further visits or MSW communication noted. Patient #1: SOC 11/15/24. MSW initial comprehensive and the 11/15/24 IDG psychosocial note conclude with MSW will follow up with hospice plan of care monthly. There are no further visits or MSW communications noted. Patient #4: Patient NPO per staff interview, with Jevity tube feedings. 2/7/25 LVN note says patient is eating well. Patient #5: SN notes not authenticated with signature for 3/7, 3/10, 3/26/25. Patient #6: 3/1/25 MSW Initial assessment note is not authenticated with signature. Patient #8: The patient was admitted 3/16/25. First and only aide visit note 3/23/25 when aide documented patient refused visits and that wife said patient will only let her help. 3/23/25 order that Hospice Aide declined. The 3/21/25 IDG says hospice aide declined. Date of meeting is prior to date of documented decline. In addition, on 3/30/25 aide supervisory visit documented with frequency1/week as of 3/30 and does not reference that patient refused hospice aide services.

Upon patient record review, 1 of 14 (Patient #11) 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 Patients #11: Discharge summary does not include documented evidence that summary was provided to patient's attending MD of choice.

Upon patient record review, 1 of 14 (Patient #10) did not have evidence that a written hospice plan of care is established and maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided is in accordance with this hospice plan of care. Patient #10: Patient in a facility receiving Jevity via peg tube, but rate of feeding specified in RN note is not included in physician order

Upon patient record review, 1 of 14 (Patient #9) did not have evidence that the hospice plan of care identifies the care and services that are needed and specifically identify which provider (nursing facility or hospice) is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care. Patient #9: SNF resident admitted with indwelling Foley catheter. The patient's Plan of Care/Orders do not specifically identify which provider (nursing facility or hospice) is responsible for performing the respective functions of the foley catheter.