Every finding on record at Savior Hospice Care Inc

Upon patient record review, 2 of 5 (Patient #2, 4) 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 Patient 2: The medication list entry for triamcinolone 0.1% cream indicates apply a small amount topically bid, but fails to provide the location specified in the related order. (corrected onsite) Patient 4: The medication list entry for polyethylene gylcol 3350 powder 1 packet po daily fails to include the reconstitution instructions for this powdered medication. (corrected onsite)

Upon patient record review, 1 of 5 (Patient #4) 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 4: On 03.13.2024, the plan of care was established indicating that a chaplain will see the patient 1 x monthly; this discipline order frequency was followed through August 2024. On 09.09.2024, the previous order was discontinued and replaced with a new order for the chaplain to see the patient only on an as needed basis.

Upon patient record review, 1 of 5 (Patient #3) 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 3: On admission for hospice services, the patient was noted to have a stage II pressure wound to the L gluteal area; a care plan was established that included interventions of applying calmoseptine and turning & repositioning the patient q 2 hours. During the updated comprehensive assessment by the RN on 09.09.2024, the RN noted that the wound was resolved. However, the care plan has not been updated to date reflecting the discontinuation of interventions and resolution of this problem. (corrected onsite)

Upon client record review, 1 of 5 (Patient #4) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 4: The plan of care indicates that a SN will see the patient 2 x weekly. However, during the weeks of 07.28.2024, 08.11.2024, and 08.25.2024 the patient was seen 3 x each week by a skilled nurse.

Upon patient record review, 1 of 14 (Patient #11) did not have evidence that the hospice informed and provided written information to the patient concerning its policies on advance directives, including a description of applicable state law. Patient #11: There were no legals signed to include advance directives.

Upon patient record review, 1 of 14 (Patient #11) did not have evidence that the hospice obtained the patient's or representative's signature confirming that they received a copy of the Patient's Rights and Responsibilities. Patient #11: There were no legals signed to include patient rights and responsibilities.

Upon patient record review, 13 of 14 records reviewed (Patient #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #13, #14) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient #1: The record indicated a place in the legal documents for the patient to chose an attending physician. There was no evidence the patient chose an attending physician, it was left blank. Patient #2: The record indicated a place in the legal documents for the patient to chose an attending physician. There was no evidence the patient chose an attending physician, it was left blank. Patient #3, 4: The record indicated a place in the legal documents for the patient to chose an attending physician. There was no evidence the patient chose an attending physician, it was left blank. COS. Patient #5: The record indicated a place in the legal documents for the patient to chose an attending physician. There was no evidence the patient chose an attending physician, it was left blank. Patient # 6: The record indicated a place in the legal documents for the patient to chose an attending physician. There was no evidence the patient chose an attending physician, it was left blank. Patient # 7: The record indicated a place in the legal documents for the patient to chose an attending physician. There was no evidence the patient chose an attending physician, it was left blank. Patient # 8: The record indicated a place in the legal documents for the patient to chose an attending physician. There was no evidence the patient chose an attending physician, it was left blank. Patient # 9: The record indicated a place in the legal documents for the patient to chose an attending physician. There was no evidence the patient chose an attending physician, it was left blank. Patient # 10: The record indicated a place in the legal documents for the patient to chose an attending physician. There was no evidence the patient chose an attending physician, it was left blank. Patient #11: The record indicated a place in the legal documents for the patient to chose an attending physician. There was no evidence the patient chose an attending physician, it was left blank. Patient # 13 : The record indicated a place in the legal documents for the patient to chose an attending physician. There was no evidence the patient chose an attending physician, it was left blank. Patient #14: The record indicated a place in the legal documents for the patient to chose an attending physician. There was no evidence the patient chose an attending physician, it was left blank.

Upon patient record review, 1 of 14 (Patient #11) did not have evidence of the appropriate documentation for release of confidential information. Patient #11: There were no legals signed to include confidentiality.

Upon patient record review, 1 of 14 (Patient #11) did not have evidence that the patient received information about the services covered under the hospice benefit. Patient #11: There were no legals signed to include services covered under the hospice benefit.

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

Upon patient record review 9 of 14 records reviewed (Patient #1, #2, #3, #5, #6, #7, #8, #9, #10) 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: The record indicated the patient was admitted on 10/05/23. There was no evidence of the comprehensive assessment to include assessing the spiritual needs that were related to the terminal illness. Patient #2: The record indicated the patient was admitted on 08/11/23. There was no evidence of the comprehensive assessment to include assessing the spiritual needs that were related to the terminal illness. Patient #3: The record indicated the patient was admitted on 03/13/24. There was no evidence of the comprehensive assessment to include assessing the spiritual needs that were related to the terminal illness. Patient #5: The record indicated the patient was admitted on 07/15/23. There was no evidence of the comprehensive assessment to include assessing the spiritual needs that were related to the terminal illness. Patient #6: The record indicated the patient was admitted on 11/16/23. There was no evidence of the comprehensive assessment to include assessing the spiritual needs that were related to the terminal illness. Patient #7: The record indicated the patient was admitted on 03/01/24. There was no evidence of the comprehensive assessment to include assessing the spiritual needs that were related to the terminal illness. Patient #8: The record indicated the patient was admitted on 02/04/24. There was no evidence of the comprehensive assessment to include assessing the spiritual needs that were related to the terminal illness. Patient #9: The record indicated the patient was admitted on 01/15/24. There was no evidence of the comprehensive assessment to include assessing the spiritual needs that were related to the terminal illness. Patient #10: The record indicated the patient was admitted on 01/12/24. There was no evidence of the comprehensive assessment to include assessing the spiritual needs that were related to the terminal illness.

Upon patient record review, 1 of 14 records reviewed (Patient #1) 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: The Medication Administration Record indicated Acetaminophen 325mg 2 tabs BID for pain and also Acetaminophen 650mg 1 suppository rectally Q4hours prn was listed. There is not an entry to include a maximum dose of 4000 mg daily of Acetaminophen. COS.

Upon patient record review, 7 of 14 record reviewed (Patient #1, #2, #3, #6, #7, #8, #10) 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: The record indicated the patient was admitted on 10/05/23. There was no evidence of a bereavement risk assessment at the time of the survey. Patient #2: The record indicated the patient was admitted on 08/11/23. There was no evidence of a bereavement risk assessment at the time of the survey. Patient #3: The record indicated the patient was admitted on 03/13/24. There was no evidence of a bereavement risk assessment at the time of the survey. Patient #6: The record indicated the patient was admitted on 11/16/23. There was no evidence of a bereavement risk assessment at the time of the survey. Patient #7: The record indicated the patient was admitted on 03/01/24. There was no evidence of a bereavement risk assessment at the time of the survey. Patient #8: The record indicated the patient was admitted on 02/04/24. There was no evidence of a bereavement risk assessment at the time of the survey. Patient #10: The record indicated the patient was admitted on 01/12/24. There was no evidence of a bereavement risk assessment at the time of the survey.

Upon patient record review, 1 of 14 (Patient #12) did not have evidence in the patient record that the written plan of care is developed by the IDG, in consultation with the patient's attending physician. Patient #12: The record indicated the patient chose an attending that was not the hospice medical director. There was no evidence the patient attending physician was contacted or involved in the patients care.

Upon patient record review, 1 of 14 record reviewed (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.

Upon patient record review, 1 of 14 records reviewed (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 medications and treatments. Patient #1: The Physician Order indicated Acetaminophen 325mg 2 tabs BID for pain and also Acetaminophen 650mg 1 suppository rectally Q4hours prn was listed. There is not an order entry to include a maximum dose of 4000 mg daily of Acetaminophen. COS.

Upon patient record review, 4 of 14 records reviewed (Patient #1, 2, 5, 11) 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 #1: The record indicated the patient had pain issues based on the assessment and also had a cognitive disorder. There was no evidence of an individualized written plan of care that reflected the patient/family goals and interventions based on the problem identified. There was no updates to the plan of care, measurable pain goals, and progress toward goals. COS. Patient #2: The record indicated a fall on 01/25/24. There plan of care was not revised based on the updated comprehensive assessment to include progress toward the outcome/goals. Patient #5: The record indicated the patient previously had a Cardiac Care Plan for End Stage Heart Symptoms, this care plan was resolved on 6/27/24. The nursing assessment on 6/28/24 indicated crackles to the base of the lungs bilaterally, skin was pale and patient had a non productive cough. The plan of care was not updated to include problems/goals/interventions related to the cardiac care plan. COS. Patient #11: The record indicated the patient was discharged for cause. There was no care plan that individualized any interventions and or goals for care or the planning of the discharge for cause.

Upon client record review, 4 of 14 records reviewed (Patient #3, #5, #6, #10) 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 record indicated the Chaplain made a visit on 6/6/24 and 7/1/24, the Social Worker made a visit on 6/14/24 and 7/1/24. There was no frequency order for these visits. Patient #5: The record indicated an order on 6/14/24 for SC 1 XM. There was no evidence of Chaplain visit in June 2024. Patient #6: The record indicated a BC visit was ordered on 6/11/24 1XM. There was no evidence of a BC visit made. Patient #10: The record indicated an order on 7/9/24 for SN 3 XW. There was no evidence of a 3rd nurse visit between 7/9/24 to 07/16/24.

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. According to the Medicare Claims Processing Manual, Chapter 11; hospice services must be reasonable and necessary for the palliation or management of the terminal illness and related conditions. The individual must elect hospice care and a certification that the individual is terminally ill must be completed by the patient’s attending physician (if there is one), and the Medical Director (or the physician member of the Interdisciplinary Group (IDG). Nurse practitioners or physician assistants serving as the attending physician may not certify or re-certify the terminal illness. It was evidenced that multiple CTI's were being authenticated by NP's and not by the hospice medical director, patient rights were not being honored by not allowing patients to select their attending physician, comprehensive assessments were not being completed on every new admission, and individualized plans of care were not being revised and updated for each hospice patient.

Condition of Participation: Medical Director.

Upon patient record review, 9 of 14 (Patient #3,4,5,6,7,8,9,11,14) 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 #3, 4, 5, 6 , 7, 8, 9, 11, 14 : The medical record does not contain an appropriately completed initial certification of terminal illness. There was no oral or written certification of the terminal illness. The medical director did not complete and or sign the initial CTI instead an NP signed.

Upon patient record review, 8 of 14 records reviewed (Patient #1, #2, #5, #6, #8, #9, #10, #12) 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: The medical record does not contain an appropriately completed recertification of terminal illness for the 9th Benefit Period (10/05/23 to 12/03/23). The medical director did not complete and or sign the CTI. Patient #2: The medical record does not contain an appropriately completed recertification of terminal illness for the 4th Benefit Period (08/11/23 to 11/08/23). The medical director did not complete and or sign the CTI. Patient #5: The medical record does not contain an appropriately completed recertification of terminal illness for the following benefit periods. Benefit Period 2 (10/13/23 to 01/10/24). Benefit Period 3 (01/11/24 to 03/10/24). Benefit Period 4 (03/11/24 to 05/09/24). The medical director did not complete and or sign the CTIs. Patient #6: The medical record does not contain an appropriately completed recertification of terminal illness for the 2nd Benefit Period (2/14/24 to 05/13/25). The medical director did not complete and or sign the CTI. Patient #8: The medical record does not contain an appropriately completed recertification of terminal illness for the 2nd Benefit Period (05/04/24 to 08/01/24). The medical director did not complete and or sign the CTI. Patient #9: The medical record does not contain an appropriately completed recertification of terminal illness for the 2nd Benefit Period (04/14/24 to 07/12/24). The medical director did not complete and or sign the CTI. Patient #10: The medical record does not contain an appropriately completed recertification of terminal illness for the 2nd Benefit Period (01/12/24 to 04/10/24) and or the 3rd Benefit Period (04/11/24 to 06/09/24). The medical director did not complete and or sign the CTI. Patient #12: The medical record does not contain an appropriately completed recertification of terminal illness for the 2nd Benefit Period (5/3/23 to 7/31/23), 3rd Benefit Period (08/01/23 to 09/29/23) and or the 4th Benefit Period (09/30/23 to 11/28/23). The medical director did not complete and or sign the CTI.

Condition of Participation: Clinical Records.

Upon patient client record review, 9 of 14 records reviewed (Patient #1, #2, #3, #4, #5, #6, #7, #10, #11) 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, 5: The Hospice Medicare election statement does not clearly identify the patients choice for the attending physician nor does it clearly indicate the patient chooses the hospice Medical Director as their attending. The line to write in the attending physicians name was left blank. In addition the patient/family was not informed they have the right to request a list of non covered services. Patient #2, 3, 4, 6, 7, 10: The Hospice Medicare election statement does not clearly identify the patients choice for the attending physician nor does it clearly indicate the patient chooses the hospice Medical Director as their attending. The line to write in the attending physician name was left blank. Patient #11: There were no legals signed to include no notice of election for hospice services.

Upon patient client record review, 1 of 14 (Patient #12) did not have evidence that each patient record contains Physician certification and recertification of terminal illness. Patient #12: The medical record does not contain an appropriately completed initial certification of terminal illness. The physician did not sign the initial certification. In addition, the medical director did not complete and or sign the CTI.

Upon patient client record review, 1 of 14 records reviewed (Patient #11) did not evidence that each patient record contains physician orders. Patient #11: The record indicated the patient was discharged for cause. There was no evidence of an MD order for the discharge.

Upon client 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 Patient #11: The record indicated the patient was discharge for cause. There was no evidence the hospice discharge summary included treatments, symptoms and plan of care was sent to the patients attending physician.

Upon client record review, 1 of 14 records reviewed (Patient #11) did not have evidence that the discharge summary includes all required information. Patient #11: The record indicated the patient was discharge for cause. There was no evidence the hospice discharge summary included treatments, symptoms and plan of care was sent to the patients attending physician.