Every finding on record at Salvation Hospice Inc

Upon patient record review, 1 of 6 (Patient #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 • Drug therapy currently associated with laboratory monitoring Patient #3: Upon a home visit and reviewing the medication profile to ensure the medications on the plan of care was consistent with what the patient/caregiver states they are taking, it was verified the patient had Zenpep Capsule, delayed release (E.C.) 40,000 Unit one tab oral daily on the medication profile but was not taking the medication. COS. In addition, the patient was taking Entresto 24mg-26mg po QHS and to hold if systolic is less than 110 or HR less than or equal to 60, this was not listed on the medication profile. COS. Also the patient is taking Coreg 3.125mg po BID and to hold if systolic is less than 110 or HR is less than 60, this was not listed on the medication profile. COS.

Upon personnel record review, 1 of 2 personnel files reviewed (Personnel #2) 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 #2: The social worker has a BSW degree and there was no evidence on file that an MSW completed her skills competency assessment.

Upon personnel record review, 1 of 2 personnel files reviewed (Personnel #2) 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 #2: This social worker was not qualified due to not being supervised by an MSW and she was not employed by this hospice before 12/02/2008.

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. Name of agency provided but no formal agreement documented.

Upon observation, there was no evidence the Emergency Plan communication plan must includes a primary and alternate means for communicating with hospice's employees.

Condition of Participation: Initial and Comprehensive Assessment of the Patient.

Upon patient record review 2 of 14 (Patient #2,#5) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient #2: SOC 8/6/2024, spiritual assessment completed 8/16/2024. Patient #5: SOC 12/20/2023, psychosocial assessment done 12/29/2024.

Upon patient record review 9 of 14 (Patient #1,#5,#6,#7,#8,#10,#11,#12,#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 #1,#5,#6,#7,#8,#10,#11,#12,#14: No evidence of a spiritual needs assessment. Patient #14: No evidence of a psychosocial assessment.

Upon patient record review, 5 of 14 (Patient #2,#3,#4,#8,#12) 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 #2: During home visit medication reconciliation found in home and using Vitamin D3 one po QD, not on medication profile. On medication profile and not using Pantoprazole 40 mg po one daily. Patient #3: During home visit medication reconciliation found in home and using Fentanyl Patch 12 Mcq Q 72 hours, not on profile. Patient #4: Medication profile dated 7/31/2024 included Polyethylene Glycol 17GM oral, give one time day for bowel management. No evidence of a diluent. Patient #8: Medication profile dated 7/15/2024 included Diclofenac sodium gel 3% topical apply 1 x day in am. No evidence of a site to apply. Dated 7/15/2024 Salanpas Adhesive patch topical 1 x day apply afternoon, no evidence of an area to apply. Order exists for O2, O2 is not included on medication profile. Corrected on site. Patient #12: Medication profile dated 1/18/2024 included Lidocaine patch 4% transdermal 1 every evening, no evidence of application site.

Upon patient record review, 2 of 14 (Patient #5,#14) 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 #5: SOC 12/20/2023, bereavement assessment completed 12/29/2023. Patient #14: No evidence of a bereavement assessment.

Upon patient record review, 10 of 14 (Patient #1,#2,#3,#4,#6,#8,#9,#10,#12,#14) 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 #1; RN visits made 8/11/2024 and 9/6/2024. No evidence in the patient record that the comprehensive assessment is updated no less frequently than every 15 days. Patient #2: Last RN visit at SOC 8/6/2024. No evidence in the patient record that the comprehensive assessment is updated no less frequently than every 15 days. Patient #3: RN visits occurred 6/18/2024, 7/15/2024 and 7/29/2024- none since. No evidence in the patient record that the comprehensive assessment is updated no less frequently than every 15 days. Patient #4: SOC 7/31/2024, no RN comprehensive visits since SOC. No evidence in the patient record that the comprehensive assessment is updated no less frequently than every 15 days. Patient #6: RN visits occurred on 6/26/24, 7/24/24, 8/14/2024, visit scheduled for 9/4/2024 states :not started". No evidence in the patient record that the comprehensive assessment is updated no less frequently than every 15 days. Patient #8: RN visit occurred on 7/18/2024, none since. Notes for 8/1,8/15,9/2/24 state "not started". No evidence in the patient record that the comprehensive assessment is updated no less frequently than every 15 days. Patient #9: RN visits occurred 6/26, 7/15, and 8/15/2024. Visits for 8/22, 8/26 and 9/12 state "not started". No evidence in the patient record that the comprehensive assessment is updated no less frequently than every 15 days. Patient #10: RN visits occurred 7/16 and 8/23/2024. Visits scheduled for 7/30, 8/13 and 9/9 state "not started". No evidence in the patient record that the comprehensive assessment is updated no less frequently than every 15 days. Patient #12: RN visits 2/28 and 3/22/2024. No evidence in the patient record that the comprehensive assessment is updated no less frequently than every 15 days. Patient #14: RN visits 5/30/2024, none after. No evidence in the patient record that the comprehensive assessment is updated no less frequently than every 15 days.

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

Upon patient record review, 5 of 14 (Patient #1,#2,#3,#9,#11) 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 #1: Pain identified at SOC SN assessment, MSW noted no funeral plans, no evidence in POC of problem/goals/interventions for pain or funeral planning. Patient #2: MSW noted no funeral plans, no evidence in POC of problem/goals/interventions for funeral planning. Corrected on site. Patient #3: MSW noted no funeral plans, no evidence in POC of problem/goals/interventions for funeral planning. patient #9: SOC SN identifies 3+ pitting edema bilateral lower extremities and SOB on exertion. MSW identifies no funeral plans. No evidence in POC of problem/goals/interventions for cardio/respiratory or funeral planning. Corrected on site. Patient #11:SN noted pain on SOC assess, MSW noted no funeral planning, no evidence in POC of problem/goals/interventions for pain and funeral planning.

Upon patient record review, 5 of 14 (Patient #2,#3,#4,#8,#12) 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: During home visit medication reconciliation found in home and using Vitamin D3 one po QD without evidence of an order. Patient #3: During home visit medication reconciliation found in home and using Fentanyl Patch 12 Mcq Q 72 hours without evidence of an order. Patient #4: Order dated 7/31/2024 included Polyethylene Glycol 17GM oral, give one time day for bowel management. No evidence of a diluent. Patient #8: Order dated 7/15/2024 included Diclofenac sodium gel 3% topical apply 1 x day in am. No evidence of a site to apply. Dated 7/15/2024 Salanpas Adhesive patch topical 1 x day apply afternoon, no evidence of an area to apply. corrected on site. Patient #12: Order dated 1/18/2024 included Lidocaine patch 4% transdermal 1 every evening, no evidence of where to apply.

Upon patient record review, 14 of 14 (Patient #1,#2,#3,#4,#5,#6,#7,#8,#9,#10,#11,#12,#13,#14) 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: Had Hospital bed-over bed table,O2 and supplies and recliner chair, however not included on POC Patient #2: Had hospital bed, O2 and supplies, however not included on POC. Patient #3: Had rollator walker, however not included on POC. Patient #4: Had O2 and supplies, E tank and w/c, however not included on POC. Patient #5: No evidence of DME on POC or within documents. Patient #6: Had O2 with supplies, Hospital bed, w/c, nebulizer and supplies, overbed table and walker, however not included on POC. Patinet #7: Had O2 with supplies, Hospital bed, Shower chair, w/c, and wheeled walker, however not included on POC. Patient #8: Had O2 with supplies, hospital bed and over bed table, however not included on POC. Patient #9: Had walker, cane and wound care supplies, however not included on POC. Patient #10: Had bed ½ rails, suction machine, 3:1 commode, nebulizer with supplies and a walker, however not included on POC Patient #11: Had O2 with supplies, nebulizer with supplies, w/c and walker, however not included on POC. Patient #12: Had O2 with supplies, nebulizer with supplies, full bed rails, walker, over bed table and a suction machine, however not included on POC. Patient #13: Had O2 with supplies and suction machine, however not included on POC. Patient #14: Had O2 with supplies, e-tank, overbed table, full rails, walker and w/c, however not included on POC.

Upon patient record review, 1 of 14 (Patient #5) 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 #5: SN notes from 8/15/2024 included difficulty swallowing, pocketing of food and wheezing. No evidence in the updated POC of problems/goals/interventions for aspiration.

Upon client record review, 8 of 14 (Patient #1,#2,#5,#8,#9,#10,#12,#14) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1:SOC SN ordered 1x week, week of 8/11/2024 3 LVN and 1 RN visits made, week of 8/18/24 3 LVN visits made, week 8/25/2024 2 LVN visits made, week of 9/1 1 LVN and 1 RN visit made. Patient #2: SN ordered at 1x week, no SN visits or missed visits for week of 8/25 and 9/8/2024. Patient #5: SN at SOC ordered 1x week. Weeks of 8/8, 9/1 and 9/8/2024 no SN visits made or noted as missed. All state "not started". Patient #8: SN ordered 1x week at SOC. Weeks of 8/25, 9/1 and 9/8/2024 no SN visits made or noted as missed. All state "not started". Patient #9: SC ordered at SOC for 1 x Month. Visits made 7/3, 7/21, 8/2, and 8/7/2024. SN visits ordered 3x week, no visits for weeks of 8/25, 9/2 and 9/8/2024. All scheduled visits state "not started". Patient #10: SN frequency dated 6/5/2024 1x week with 2 PRN. Weeks of 8/11, 8/25, 9/1, 9/8/2024 no evidence of SN visits, several assigned but state "not started" Patient #12: MSW made visit 4/3/2024, no orders for MSW in record. Patient #14:MSW made visit 7/9/2024, no orders for MSW in record. SN visits daily starting 7/10/2024, LVN visit on 7/11/2024 states "not started".

Upon observation, there was no evidence the board of directors/governing body approves the frequency and detail of the data collection. No mention of QAPI in board meeting minutes.

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. Patient #3: RN wearing gloves entered clean bag during patient care several times without cleansing, keeps trash bag within clean bag for disposing of items.

Upon personnel record review, 1 of 13 (Personnel #8) did not have evidence that the hospice routinely provide substantially all core services directly by hospice personnel (The hospice issues a W-2 form for the employee). These services include: • Physician services (may contract for physician services) • Nursing • Medical social services • Counseling Personnel #8: MSW contracted.

Condition of Participation: Hospice Aide and Homemaker Services. L607

Upon personnel record review, 1 of 13 (Personnel #7) 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 #7: No evidence of competency assessment was performed by the aide with a patient or pseud-patient: all items marked as verbal assessment.

Upon patient record review, 6 of 14 (Patient #1,#2,#5,#7,#8,#11) 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 #1: Patient is on O2, no evidence in aide POC of O2 precautions. Patient #2: Dysphagia identified on SN SOC, no evidence of aspiration precautions on aide POC. Patient #5: SN noted difficulty swallowing and pocketing of food on 8/15/2024. No evidence of an updated POC for aide that included risk of aspiration. Patient #7: SN identified risk of aspiration and bleeding on SOC. No evidence on aide POC of at risk for aspiration or bleeding. Patient #8: Patient is on O2, no evidence on aide POC of O2 precautions. Patient #11: SN identified fall risk and dysphagia, no evidence on aide POC of fall and aspiration precautions.

Upon patient record review 8 of 14 (Patient #1,#2, #4,#6,#7,#8,#10,#14) 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: Aide frequency 7/22/2024 1 x week. Week of 9/8/2024 no visit or missed visit. Patient #2: Aide frequency 8/6/2024 2x week. No visits or missed visits week of 8/25, 9/1 and 9/8/2024. Patient #4: Aide ordered visits at SOC 7/31/2024 2x week. Week of 9/1 and 9/8/2024 one visit each week with no notation of missed visits. Patient #6: Aide frequency 5/30/3034 3x week. Week of 7/28- 2 visits, week of 8/4- 2 visits, week of 8/25 - 1 visit, no visits weeks of 9/1 and 9/8/2024. Patient #7: Aide frequency at SOC 8/16/2024 2x week, to start 8/18/2024. No evidence of visits or missed visits since SOC. Patient #8: Aide frequency at SOC 7/5/2024 2x week. One visit week of 8/18/2024, one week of 9/1/2024 and no visits or missed visits week of 9/8/2024. Patient #10: Aide frequency 5/28/2024 3x week. Week of 9/1/2024 had two visits and one dated 9/2/2024 "not started" no notice of missed visit. Patient #14: Aide frequency 6/25/2024 3x week. Two visits made week of 6/25/2024 without a missed visit noted. One dated "not started".

Upon patient record review 5 of 14 (Patient #1,#2,#3,#8,#10) 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: RN visits occurred 8/11/2024 and 9/6/2024. No evidence that a Registered Nurse made an on-site visit to the patient's home no less frequently than every 14 days. Patient #2: RN visits occurred 8/6/2024 none since. No evidence that a Registered Nurse made an on-site visit to the patient's home no less frequently than every 14 days. Patient #3: RN visits occurred 6/18/2024, 7/15/2024 and 7/29/2024- none since. No evidence that a Registered Nurse made an on-site visit to the patient's home no less frequently than every 14 days. Patient #8: RN visit occurred on 7/18/2024, none since. No evidence that a Registered Nurse made an on-site visit to the patient's home no less frequently than every 14 days. Patient #10: RN visits occurred 7/16 and 8/23/2024. none since. No evidence that a Registered Nurse made an on-site visit to the patient's home no less frequently than every 14 days.

Upon observation, there was no evidence BOD/governing body minutes reflect the involvement in the hospice's management and administration of its resources to provide hospice services to patients and families. No evidence of annual evaluation of administrator, adopting and periodically reviewing written bylaws or equivalent, establishing or approving written policies and procedures governing operations along with annual review, human resource management for ensuring Administrator oversight and core disciplines, and involvement/oversight of Quality Assessment/ Performance Improvement.

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. Administrator did not ensure the agency provided all required core disciplines as employees and manage hospice agency ensuring patient needs, such as visits being provided.

Upon patient record review, 3 of 14 (Patient #6,#9,#14) did not have evidence that before the recertification period for each patient, the medical director or physician designee must review the patient's clinical information and provide written documentation that it is anticipated that the patient's life expectancy is 6 months or less. Patient #6: No evidence of certification of terminal illness prior to recertification for BP 2 starting 8/28/2024. Turned in 9/18/2024 Patient #9: No evidence of certification of terminal illness prior to recertification for BP 4 starting 8/16/2024. Turned in 9/18/2024 Patient #14: No evidence of certification of terminal illness prior to recertification for BP 6 (2/19/2024), BP 7 (4/19/2024), BP 8 (6/18/2024). Turned in 9/19/2024

Condition of Participation: Clinical Records.

Upon patient client record review, 10 of 14 (Patient #1,#2,#3,#4,#5,#6,#7,#8,#9,#11) did not have evidence that each patient record contains: • Signed election statement in accordance with 418.24 Patients #1,#2,#3,#4,#5,#6,#7,#8,#9,#11: No evidence of choice of attending on EOB. Patient #1,#4,#5,#6,#7,#8,#11:No evidence of effective date of election

Upon observation, there was no evidence the organization follows their policies and procedures to maintain the the patient's clinical record in confidential manner. Upon agency tour found wound care supplies in storage room with patient names on them.

Upon client record review, 1 of 14 (Patient #11) did not have evidence that the discharge summary includes all required information. Discharge summary is missing current POC, summary of pts stay.

Upon observation, there was no evidence a copy is provided of the hospice written policies and procedures on the management and disposal of controlled drugs to the patient or patient representative and family. Policy exists in policy book, however has never been given to patients/families.

Upon client record review, 14 of 14 (Patient #1,#2,#3,#4,#5,#6,#7,#8,#9,#10,#11,#12,#13,#14) did not have evidence that the written policies and procedures for managing controlled drugs was provided and discussed.

Upon personnel record review, 1 of 13 (Personnel #13) 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 #13: No evidence of a SLP file

Upon personnel record review, 1 of 13 (Personnel #12) did not have evidence all Occupational Therapy Services are provided by a qualified licensed Occupational Therapist (OT) in accordance with the state's Occupational Therapy Practice Act and the hospice's policies and procedures and/or job descriptions. Personnel # 12: No evidence of an OT file.

Upon personnel record review, 4 of 13 (Personnel #8,#10,#12,#13) 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,#10: No evidence of a criminal background check. Personnel #12,#13: No HR files provided for survey.

Upon personnel record review, 8 of 13 (Personnel #1,#2,#3,#4,#5,#6,#7,#9) did not have evidence of criminal background checks being obtained in accordance with state requirements. In the absence of state requirements, criminal background checks are obtained within three months of the date of employment for all states that the individual has lived or worked in the past 3 years. Personnel #1,#2,#3,#4,#5,#6,#7,#9: No evidence of criminal background checks.

Upon patient record review, 1 of 5 (Patient #1) 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 initial plan of care did not have evidence of DME included. The patient has a hospital bed, bedside commode, and shower chair used for the management of the terminal condition. (corrected onsite)

Upon patient client record review, 1 of 5 (Patient #1) 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. Patient 1: The comprehensive initial assessment, dated 09.23.2021, indicates in both the assessment portion of the note and the narrative summary that the patient is using metoprolol 500mg 1 tablet daily by mouth for effective symptom management. This is unclear as metoprolol is not available in a 500mg dosage. The plan of care and medication list does indicate that the patient takes toprolol XL 25mg 1 tablet daily and metformin 500mg 1 tablet twice a day.