Every finding on record at Sana Care Inc.

Upon patient record review 3 of 3 records (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: No psychosocial comprehensive assessment completed. Patient #2: No psychosocial comprehensive assessment completed. Patient #3: No psychosocial comprehensive assessment completed.

Upon patient record review, 3 of 3 records (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. Patient #1, #2, #3 were all missing an initial bereavement assessment.

Upon patient record review, 2 of 2 applicable (Patient #2,#3) 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 had no evidence that a bereavement plan of care was established for the bereaved family.

Upon personnel record review, 1 of 1 applicable record (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 was no evidence of a signed job description for Alternate Administrator/DPCS. This was corrected on-site

Upon personnel record review, 1 of 11 personnel (Personnel #3) did not have evidence the hospice employees and contract employees have received orientation on the hospice philosophy. Personnel #3: There was no evidence that the LVN had completed the hospice philosophy training. The LVN had not returned her signature stating she had completed the self study.

Upon personnel record review, 1 of 1 applicable (Personnel #11) 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.

Upon personnel record review, 1 of 1 applicable (Personnel #10) 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.

Upon personnel record review, 1 of 1 applicable (Personnel #9) did not have evidence all Physical Therapy Services are provided by a qualified licensed Physical Therapist (PT) in accordance with the state's Physical Therapy Practice Act and the hospice's policies and procedures and/or job descriptions.

Upon personnel record review, 3 of 5 applicable (Personnel #9, 10 and 11) 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.

Upon observation, there was no evidence of emergency preparedness training and testing program that is based on the emergency plan, policies and procedures and the communication plan.

Upon personnel record review, 7 of 7 applicable (Personnel #1,2,3,4,5,6,7) did not have evidence Emergency Preparedness training including: • Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles • Demonstrate staff knowledge of emergency procedures • Provide emergency preparedness training at least annually • Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others • Maintain documentation of all emergency preparedness training

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

Upon patient record review, 1 of 8 (Patient #8) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient #8: no documentation that patient elected their own attending physician. Consent was left blank.

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

Upon patient record review 2 of 8 (Patient #2,8) 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: MSW eval completed 7 days after start of care. Patient #8: MSW eval completed 20 days after start of care.

Upon patient record review 6 of 8 (Patient #1,2,4,5,6,8) 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: No SC assessment completed. Patient #2: No SC assessment completed. Patient #4: No SC or MSW assessment completed. Patient #5: No SC or MSW assessment completed. Patient #6: No SC or MSW assessment completed. Patient #8: No SC assessment completed.

Upon patient record review, 3 of 8 (Patient #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. 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: O2 order read O2 at 3L to 5L/NC as needed. No reason documented on medication profile. Patient #2: O2 2l/nc prn resp distress, oxygen was not documented on Medication profile. Patient #3: O2 4l/nc was not added to medication profile.

Upon patient record review, 8 of 8 (Patient #1,2,3,4,5,6,7,8) 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 #1,2,3,4,5,6,7,8, all were missing initial bereavement assessment.

Upon patient record review, 3 of 8 (Patient #6, 7, 8) 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 #6, 7, 8: No documentation of code status or Advance directive on plan of care.

Upon patient record review, 1 of 8 (Patient #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 medications and treatments. Patient #2: MD order on 6/19/20 states wound care treatment as ordered, no direction given.

Upon client record review, 3 of 8 (Patient #1,2,4) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1: MSW visits on 5/11/21, 6/9/21, 7/29/21, 8/4/21 without an order frequency. Patient #2: SN frequency written on 3/27/20 for 2 to 3 visits per week. Week of 4/19/20, 5/3/40, 5/10/20, 5/24/20, 6/7/20 all had only 1 visit for that week. Patient #4: SN frequency written on 3/11/22 for 2x/week. No SN visits first 2 weeks.

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.

Condition of Participation: Hospice Aide and Homemaker Services. L607

Upon personnel record review, 1 of 1 applicable (Personnel #4) 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. No documentation of competency assessment completed on aide.

Upon patient record review 3 of 3 applicable (Patient #1,4,7) 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: Aide documented shave given when not listed on plan of care on 7/20/21, 8/5/21, 8/18/21. Patient #4: HHA documented on 3/24/22 up in chair-no, assist OOB-no, bedside commode-no, pt laundry-no, these tasks indicated to complete on aide POC. Patient #7: HHA ordered 2x/week, no visits made.

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. There was no evidence of oversight provided by the governing body as evidence by the lack of staff competencies, lack of job descriptions and training, no evidence of credentials and backgrounds checks for contracted therapy staff, incomplete certification of terminal illness documents, and no evidence of completed comprehensive assessments for the patients under the care of the agency. No documented meeting minutes for the governing body. Upon personnel record review, 1 of 1 applicable (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 did not have job description in personnel file for Alt Admin/Alt DPS position.

Upon personnel record review, 10 of 10 (Personnel #1,2,3,4,5,6,7,8,9,10) did not have evidence the hospice employees and contract employees have received orientation on the hospice philosophy.

Upon personnel record review, 9 of 9 applicable (Personnel #1,2,3,5,6,7,8,9,10) did not have evidence that a skills competency assessment, specific to each discipline had been conducted for all personnel including volunteers initially during orientation. No documentation of skill competency assessment completed by appropriate person in personnel file. Individuals completed their own assessment.

Upon patient record review, 7 of 8 (Patient #1,2,3,4,5,6,8) 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 #1: no signature for CTI on 5/7/21. Patient #2: no signature for CTI on 3/27/20. Patient #3: no signature for CTI on 8/10/21. Patient #4: no signature for CTI on 3/11/22. Patient #5: no signature or narrative for CTI on 3/10/21. Patient #6: no signature or narrative for CTI on 6/24/20. Patient #8: no signature or narrative for CTI on 2/6/22.

Upon patient record review, 1 of 2 applicable (Patient #1) 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 #1: no signature for CTI on 8/5/21 recertification.

Upon patient client record review, 1 of 8 (Patient #8) 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 #8: No attending physician was identified on consent form.

Upon patient client record review, 3 of 8 (Patient #3, 5, 8) did not evidence that each patient record contains physician orders. Patient #3, 5, 8, no discharge order documented in chart.

Upon patient client record review, 3 of 8 (Patient #1, 2, 5) 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: Medicare payment responsibility left blank. Consent was signed by someone other than patient without documenting reason patient can not sign or name and signature of legal authorized representative. Patient #2: Medicare payment responsibility left blank. Patient #5: Medicare payment responsibility left blank.

Upon observation, there was no evidence the organization follows their policies and procedures to maintain the the patient's clinical record in confidential manner. Patient #3, Patient has discharged due to patient death on 8/17/21 in wrong chart. Patient #5, Revocation paperwork documented on 3/5/21, placed in wrong chart.

Upon client record review, 2 of 3 applicable (Patient #3,8) did not have evidence that the discharge summary includes all required information. Patient #3 and 8, discharge summary was incomplete, did not explain patient stay, symptoms and pain management.

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.

Upon personnel record review, 1 of 1 applicable (Personnel #9) 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.

Upon personnel record review, 1 of 1 applicable (Personnel #8) did not have evidence all Physical Therapy Services are provided by a qualified licensed Physical Therapist (PT) in accordance with the state's Physical Therapy Practice Act and the hospice's policies and procedures and/or job descriptions.

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.

Upon personnel record review 3 of 10 (Personnel 8, 9, 10) did not have employee files to verify COVID. DPS called contracting agencies who stated they would not provide the requested documents.