Every finding on record at Senior Solutions Inc

Based on interview and record review, the agency failed to conduct and document the required disaster exercises to test their emergency preparedness plan. Findings include: --- During an interview on 12/17/24 at 3:52 p.m., staff member C stated the agency had done a "Snowmageddon" winter weather tabletop exercise on 11/25/24. Staff member C stated he took over redoing the emergency preparedness program and could not find documentation of a second required emergency exercise in the last two years. Staff member C stated there had not been any actual emergency since he started at the agency to utilize as a second exercise. Staff member C stated they had some exercises in the planning stage but they had not occurred yet. Review of the agency emergency preparedness binder showed a sign in sheet and printout of a "Snowmageddon" winter weather exercise on 11/25/24. There were no other exercises completed in the disaster binder.

Based on interview and record review, the agency failed to estimate the cost savings of each position occupied by volunteers for the amount of time specified by each volunteer. This deficient practice had the potential to affect all patients receiving volunteer services. Findings include: --- Review of the agencys policy and procedure titled, Volunteer Services, with a revision date of 5/2023, showed: ";... The Volunteer Coordinator will track the use of volunteers, the cost savings achieved, and that the hours of volunteer services will exceed 5% of the total patient care hours of paid and contracted hospice personnel. The Volunteer Coordinator will provide an annual report to the Governing Body to demonstrate the cost savings of volunteer activities..." During an interview on 12/17/24 at 3:45 p.m., staff member C stated he did not have documentation which showed the estimated savings of each position occupied by a volunteer for the number of hours of time volunteered. He stated he would start completing that documentation going forward. Review of the agencys HER Administration Report, titled Volunteer Cost Savings Report, did not reflect the volunteer cost savings data was collected and calculated from 4/1/24 through 12/18/24. During an interview on 12/18/24 at 11:00 a.m., staff member B stated the facility did not have documentation for the estimated cost saving report since April of 2024, when the previous Volunteer Coordinator left. She stated is was an expectation that this data would be collected and calculated going forward.

Based on interview and record review, the agency failed to ensure they computed the level of activity provided by volunteers, that at a minimum, equals five percent of the total patient care hours of all paid hospice employees. This deficient practice had the potential to affect all patients receiving volunteer services. Findings include: --- Review of the agencys policy and procedure titled, Volunteer Services, with a revision date of 5/2023, showed, ";... The Volunteer Coordinator will track the use of volunteers, the cost savings achieved, and that the hours of volunteer services will exceed 5% of the total patient care hours of paid and contracted hospice personnel..." During an interview on 12/17/24 at 3:45 p.m., staff member C stated he did not have documentation which showed the calculated level of activity by volunteers. Review of the agencys HER Administration Report, titled Volunteer Cost Savings Report, did not reflect the level of activity was collected and calculated to show, at a minimum, equals five percent of the total patient care hours of all paid hospice employees, from 4/1/24 through 12/18/24. During an interview on 12/18/24 at 11:00 a.m., staff member B stated the facility did not have documentation for the level of activity by volunteers to reflect the calculated percentage of volunteer hours to patient care hours. She stated it was an expectation that this data would be collected and calculated going forward.

Based on interview and record review, the agency failed to ensure a provider order was obtained prior to a patients discharge after the patient elected revocation of services (NOTR); failed to ensure the patient reviewed and signed a revocation of election of hospice care statement; and failed to ensure a discharge summary was completed and sent to the patients attending physician for 1 (#6) of 14 sampled patients. This deficient practice had the potential to affect any patient with an elected revocation of services aftercare. Findings include: --- A review of the agencys policy and procedure titled, Revocation of Hospice Benefit, with a revision date of 5/2023, showed: ";... 3. The Case Manager will notify the attending physician and interdisciplinary group about the revocation and reason. A discharge summary will be sent to the attending physician. 4. A revocation of election of hospice care statement will be signed by the patient and will document the date, time, and reason for revocation. A copy will be sent to billing and will be retained in the clinical record. The organization will submit the NOTR to the Medicare contractor (MAC) within 5 calendar days of the date on the notice..." Review of patient #6s EHR, on 12/18/24, failed to show a signed revocation form, physician orders for discharge, and a discharge summary were completed at the time of the patients revocation of services on 10/8/24. Review of patient #6s General Visit Note, dated 7/9/24, showed, ";Call received from [patient #6s] son [Son Name] stating that patient is doing better and wants to revoke hospice benefit and seek treatment. Discussed with patient and family that narcotic medication will have to be disposed of and also discussed how hospice services work and that [patient #6] will lose his first benefit period as he is revoking. Understanding was stated by family and patient... Revocation form was signed, and patient has follow up with his primary care provider [Name of primary care provider] this afternoon." A request was submitted to the agency on 12/18/24 at 10:50 a.m., for documentation of patient #6s signed revocation form, physician order for discharge, and the discharge summary. This documentation was not provided by the end of the survey. During an interview on 10/18/24 at 11:00 a.m., staff member b stated she was not able to find the signed revocation of services form, the physician order for discharge, or the discharge summary for patient #6. She stated it was the expectation that these were completed and documented at the time a patient revokes their services.

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, 6 of 14 (Personnel #1,#4,#5,#6,#8,#11) did not have evidence Emergency Preparedness training including: • Demonstrate staff knowledge of emergency procedures • Provide emergency preparedness training at least every two years • 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 Personnel 1,4,5,6,8,11: There was no evidence of emergency preparedness training after initial orientation.

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

Condition of Participation: Patient’s Rights. L500

Upon patient record review, 4 of 14 (Patients #6,#7,#9,#10) 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. Patients 6,7,9,10: There was no evidence the agency provided its policies on advance directives upon transfer from another hospice agency.

Upon patient record review, 4 of 14 (Patients #6,#7,#9,#10) 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. Patients 6,7,9,10: There was no evidence the agency provided Patient Rights and Responsibilities upon transfer from another hospice agency.

Upon patient record review, 4 of 14 (Patients #6,#7,#9,#10) did not have evidence that the patient chooses a health care provider, including an attending physician. Patients 6,7,9,10: There was no evidence the agency provided the patients a choice for an attending physician upon transfer from another hospice agency.

Upon patient record review, 4 of 14 (Patients #6,#7,#9,#10) did not have evidence of the appropriate documentation for release of confidential information. Patients 6,7,9,10: There was no evidence the agency received documentation for the release of confidential information upon transfer from another hospice agency.

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

Upon patient record review 2 of 14 (Patients #4,#6) 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 4: The medical record contained an initial spiritual assessment completed 10/31/23, with a start of care 10/16/23. Patient 6: The medical record contained initial spiritual and psychosocial assessments completed 1/29/24, with a start of care 1/23/24.

Upon patient record review 1 of 14 (Patient #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 10: There was no evidence of a comprehensive psychosocial assessment.

Upon patient record review, 9 of 14 (Patients #1,#2,#3,#4,#5,#6,#7,#8,#10) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications. Patient 1: The medication profile contained oxygen with no delivery method. Corrected on site. Patient 2: The medication profile contained oxygen with no delivery method, and miralax oral powder with no instructions for a diluent. Corrected on site. Patient 3: The medication profile contained lidocaine topical cream with no area defined for administration, and oxygen with no delivery method. Corrected on site. Patient 4: The medication profile contained nystatin and clotrimazole topical prescriptions with no area defined for administration, and oxygen with no delivery method. Corrected on site. Patient 5: The medication profile contained oxygen with no delivery method, and miralax oral powder with no instructions for a diluent. The profile also contained trazadone listed twice with differing doses and no instructions to differentiate if both were to be taken at different times or if one was as needed. Corrected on site. Patient 6: The medical record contained nursing documentation upon admission identifying patient was oxygen dependent. There was no evidence of the medication profile containing oxygen. The medication profile contained Miralax oral powder with no instructions for a diluent, and voltaren topical gel with no defined area for administration. Corrected on site. Patient 7: The medication profile contained oxygen with no delivery method, and miralax oral powder with no instructions for a diluent. The profile also contained four hydromorphone listings. Corrected on site. Patient 8: The medication profile contained miralax oral powder with no instructions for a diluent. Corrected on site. Patient 10: The medication profile contained metamucil oral powder with no instructions for a diluent, oxygen with no delivery method, and nystatin topical cream with no area defined for administration. Corrected on site.

Upon patient record review, 3 of 14 (Patients #5,#6,#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 5: The medical record contained an initial bereavement assessment completed 9/28/23, with a start of care 9/21/23. Patient 6: The medical record contained an initial bereavement assessment completed 1/29/24, with a start of care 1/23/24. Patient 10: There was no evidence of a bereavement assessment.

Upon patient record review, 6 of 14 (Patients #3,#4,#5,#6,#10,#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 3: There was no evidence of an RN assessment since 9/11/23. Patient 4: There was no evidence of an RN assessment between 1/9/24 and 2/7/24. Patient 5: There was no evidence of an RN assessment between 1/18/24 and 2/8/24. Patient 6: There was no evidence of an RN assessment between 1/23/24 and 2/14/24. Patient 10: There was no evidence of an RN assessment since admission 1/22/24. Patient 14: There was only one RN assessment upon admission 4/7/23. Patient discharged for extended prognosis 9/14/23.

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

Upon patient record review, 6 of 14 (Patients #3,#4,#5,#6,#10,#14) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient 3: There was no evidence of an RN assessment since 9/11/23 and no wound assessments and measurements 1/30/24 to current. The agency's wound policy requires wound measurements and assessments to be completed weekly. Patient 4: There was no evidence of an RN assessment between 1/9/24 and 2/7/24. Patient 5: There was no evidence of an RN assessment between 1/18/24 and 2/8/24. Patient 6: There was no evidence of an RN assessment between 1/23/24 and 2/14/23. Patient 10: There was no evidence of an RN assessment since admission 1/22/24. Patient 14: There was no evidence of an RN assessment after admission 4/7/23 through discharge for extended prognosis 9/14/23.

Upon patient record review, 7 of 14 (Patients #1,#2,#3,#4,#6,#7,#10) 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: The medical record contained nursing documentation upon admission identifying patient was dyspneic, unable to ambulate and receiving social work visits. There was no evidence of problems, goals, and interventions related to respiratory dysfunction, immobility, and psychosocial needs. Corrected on site. Patient 2: The medical record contained nursing documentation upon admission identifying patient was admitted for primary diagnosis of COPD and receiving social work visits. There was no evidence of problems, goals, and interventions related to respiratory dysfunction and psychosocial needs. Corrected on site. Patient 3: The medical record contained nursing documentation 1/30/24 identifying patient issue with dysphagia. There was no evidence of problems, goals, and interventions related to dysphagia. Corrected on site. Patient 4: The medical record identified patient primary diagnosis of Alzheimer's disease. There was no evidence of problems, goals, and interventions related to neurological dysfunction. Corrected on site. Patient 6: The medical record contained nursing documentation upon admission identifying oxygen dependence and social work visits. There was no evidence of problems, goals, and interventions related to respiratory dysfunction and psychosocial needs. Corrected on site. Patient 7: The medical record contained nursing documentation upon admission identifying oxygen dependence. There was no evidence of problems, goals, and interventions related to respiratory dysfunction. Corrected on site. Patient 10: The medical record contained nursing documentation upon admission identifying oxygen dependence, social work, and spiritual care visits. There was no evidence of problems, goals, and interventions related to respiratory dysfunction, psychosocial and spiritual needs. Corrected on site.

Upon patient record review, 9 of 14 (Patients #1,#2,#3,#4,#5,#6,#7,#8,#10) 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 medical record contained an order for oxygen with no delivery method. Corrected on site. Patient 2: The medical record contained orders for oxygen with no delivery method, and miralax oral powder with no instructions for a diluent. The record also contained nursing documentation 1/29/24 identifying patient had indwelling catheter. There was no evidence of an for catheter type, size, change frequency, and maintenance. Corrected on site. Patient 3: The medical record contained orders for lidocaine topical cream with no area defined for administration, and oxygen with no delivery method. Corrected on site. Patient 4: The medical record contained orders for nystatin and clotrimazole topical creams with no areas defined for administration, and oxygen with no delivery method. Corrected on site. Patient 5: The medical record contained orders for oxygen with no delivery method, and miralax oral powder with no instructions for a diluent. Corrected on site. Patient 6: The medical record contained nursing documentation upon admission identifying patient use of oxygen. There was no evidence of an order for oxygen. The record also contained orders for miralax oral powder with no instructions for a diluent, and voltaren topical gel with no area defined for administration. Corrected on site. Patient 7: The medical record contained orders for oxygen with no delivery method, and miralax no instructions for a diluent. Corrected on site. Patient 8: The medical record contained an order for miralax oral powder with no instructions for a diluent. Corrected on site. Patient 10: The medical record contained orders for metamucil oral powder with no instructions for a diluent, oxygen with no delivery method, and nystatin topical cream with no area defined for administration. Corrected on site.

Upon patient record review, 7 of 14 (Patients #1,#2,#3,#4,#5,#6,#10) 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 medical record contained nursing documentation upon admission identifying patient use of oxygen and a walker. There was no evidence of orders for the oxygen equipment and walker included in the plan of care. Corrected on site. Patient 2: The medical record contained nursing documentation 1/29/24 identifying patient use of a wheelchair, hospital bed, and hoyer lift. There was no evidence of orders for the wheelchair, bed, and lift included in the plan of care. Corrected on site. Patient 3: The medical record contained nursing documentation 1/30/24 identifying patient use of a wheelchair, shower chair, and oxygen. There was no evidence of orders for the wheelchair, shower chair, and oxygen equipment included in the plan of care. Corrected on site. Patient 4: The medical record contained nursing documentation upon admission identifying patient use of a walker. There was no evidence of an order for the oxygen equipment included in the plan of care. Corrected on site. Patient 5: The medical record contained nursing documentation upon admission identifying patient use of a walker. There was no evidence of an order for the oxygen equipment included in the plan of care. Corrected on site. Patient 6: The medical record contained nursing documentation upon admission identifying patient use of a wheelchair, shower chair, sit to stand lift, and oxygen. There was no evidence of orders for the wheelchair, shower chair, sit to stand lift, and oxygen equipment included in the plan of care. Corrected on site. Patient 10: The medical record contained nursing documentation upon admission identifying patient use of a walker. There was no evidence of an order for the oxygen equipment included in the plan of care. Corrected on site.

Upon client record review, 5 of 14 (Patients #2,#4,#5,#6,#7) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 2: The medical record contained a nursing frequency ordered for RN twice weekly. The medical record contained an LVN visit 1/21/24 outside ordered frequency only allowing RN visits. Patient 4: The medical record contained a nursing frequency ordered for RN once weekly. The medical record contained an LVN visits 1/17/24, 1/24/24, and 1/31/24 outside ordered frequency only allowing RN visits. Patient 5: The medical record contained a nursing frequency ordered for RN twice weekly. The medical record contained an LVN visit 1/4/24, 1/11/24, 1/25/24, and 1/31/24 outside ordered frequency only allowing RN visits. Patient 6: The medical record contained a nursing frequency ordered for LPN once weekly. The medical record contained RN visits 1/23/24 and 2/14/24 outside ordered frequency only allowing LVN visits. The record also contained a documented visit by the social worker 1/19/24 prior to admission to hospice services on 1/23/24. Patient 7: The medical record contained social worker visits 1/3/24, 1/8/24, and 1/16/24, an RN visit 12/31/23 and advising on medication administration via phone 1/5/24 prior to admission to hospice services 1/23/24.

Condition of Participation: Infection Control.

Upon observation, there was no evidence the organization develops, implements, and maintains an effective, on-going, organization wide Quality Assessment and Performance Improvement (QAPI) program.

Upon observation, there was no evidence the program shows measurable improvement in indicators related to improved palliative outcomes and hospice services.

Upon observation, there was no evidence the hospice measures, analyzes, and tracks quality indicators, including adverse patient events and other aspects of performance that enable the hospice to assess processes of care, hospice services, and operations.

Upon observation, there was no evidence the QAPI program uses quality indicator data, including patient care and other relevant data in the design of its program. The hospice must use the data collected to: • Monitor the effectiveness and safety of services and quality of care • Identify opportunities and priorities for improvement

Upon observation, there was no evidence QAPI activities focus on high risk ,high volume, or problem prone areas.

Upon observation, there was no evidence Quality Assessment and Performance Improvement activities focus on high risk, high volume or problem-prone areas by considering incidence, prevalence, and the severity of problems.

Upon observation, there was no evidence Quality Assessment and Performance Improvement activities focus on high risk, high volume or problem-prone areas by understanding how they affect palliative outcomes, patient safety and quality of care.

Upon observation, there was no evidence the hospice investigates all adverse events, incidents, accidents, variances or unusual occurrences that involve patient care and develops a plan of correction to prevent the same or similar event from occurring again.

Upon observation, there was no evidence a written plan of correction is developed in response to any QAPI activity that does not meet an acceptable threshold.

Upon observation, there was no evidence the number and scope of distinct QAPI projects conducted annually is based on the needs of the hospice's population and internal organizational needs and must reflect the scope, complexity, and past performance of the hospice's services and operations.

Upon observation, there was no evidence the hospice documents what QAPI projects are being conducted, the reasons for conducting these projects, and the measurable progress achieved on these projects.

Upon observation, there was no evidence of involvement of the governing body and organizational leaders in the Quality Assessment/Performance Improvement (QAPI) program.

Upon observation, there was no evidence the hospice's governing body is responsible for ensuring that the hospice-wide Quality Assessment and Performance Improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness.

Upon observation, there was no evidence the hospice ensures the implementation of a hospice wide Quality Assessment/Performance Improvement (QAPI) program by the designation of a person responsible for coordinating QAPI activities.

Upon observation, there was no evidence in QAPI reports that the hospice maintains a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the hospice's Quality Assessment and Performance Improvement program.

Upon observation, there was no evidence in the QAPI reports that the hospice maintains a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases.

Upon observation, there was no evidence licensed professionals participate in the hospice's QAPI program.

Upon patient record review, 1 of 14 (Patient #11) 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 11: The patient's son was listed on the bereavement list as receiving services. There was no evidence of a bereavement care plan and tasks completed. Agency confirmed the son declined bereavement, however the EMR did not contain any documentation of refusal.

Condition of Participation: Hospice Aide and Homemaker Services. L607

Upon personnel record review, 1 of 14 (Personnel #6) did not have evidence in the personnel file that the hospice aide had received at least l2 hours of in-service training during each 12-month period. In-service training may occur while an aide is furnishing care to a patient.

Upon patient record review, 3 of 14 (Patients #3,#6,#9) did not have evidence in the patient record that hospice aide assignments and duties are individualized to patient needs. Patient 3: The medical record contained an order for a Hoyer lift to assist with transfers. The aide care plan did not contain transfer instructions. Corrected on site. Patient 6: The medical record contained nursing documentation upon admission identifying patient was a transfer with sit to stand. The aide care plan did not contain transfer instructions. Corrected on site. Patient 9: Upon home visit observation, the patient required assist of 1-2 for transfers. The aide care plan did not contain transfer instructions. Corrected on site.

Upon patient record review 2 of 14 (Patients #8,#9) 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 8: Upon interview with nursing and the patient's spouse during home visits, the patient was reported to be receiving sponge baths due to limited size and safety for a shower in the home. The aide care plan contained a bathing task for showers. Patient 9: Upon observation during home visit, the aide explained they were going to toilet the patient. The aide care plan did not contain a task for toileting.

Upon observation, there was no evidence the hospice maintains, documents and provides volunteer orientation and training that is consistent with hospice industry standards.

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 as evidenced by the lack of infection control program, QAPI program and alternate medical director.

Upon personnel record review, 3 of 14 (Personnel #4,#10,#11) did not have evidence the hospice employees and contract employees have received orientation on the hospice philosophy. Personnel 4,10,11: There was no evidence of orientation to the hospice philosophy.

Upon personnel record review, 3 of 14 (Personnel #4,#10,#11) did not have evidence that the hospice employees have received orientation on their specific job requirements. Personnel 4,10,11: There was no evidence of orientation in the personnel files.

Upon personnel record review, 4 of 14 (Personnel #4,#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. Personnel 4,8,9,10: There was no evidence of initial skills competency assessments.

Condition of Participation: Medical Director.

Upon contract review, 1 of 4 (Alternate MD contract) did not have evidence of a contract to fulfill the role of alternate medical director for the agency. The alternate MD also acts as the primary MD for another company location.

Upon patient record review, 3 of 14 (Patients #3,#8,#9) 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 3: The medical record contained a CTI for benefit period 6 starting 2/12/24 signed on 2/12/24 with no evidence of a verbal order to recertify received. The formatted information regarding completion of face to faces and providing information to the certifying physician was empty on the CTIs for benefit periods 3-6. Patient 8: The formatted information regarding completion of face to faces and providing information to the certifying physician was empty on the CTIs for benefit periods 3-10. Patient 9: The formatted information regarding completion of face to faces and providing information to the certifying physician was empty on the CTIs for benefit periods 3-5.

Upon patient client record review, 5 of 14 (Patients #1,#2,#3,#4,#8) 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 1,2,3,4,8: The medical record contained incomplete election forms with no reason beneficiary unable to sign, and incomplete consent forms lacking patient representative's relationship to the patient.

Upon client record review, 4 of 14 (Patients #6,#7,#9,#10) did not have evidence that the written policies and procedures for managing controlled drugs was provided and discussed. Patient 6,7,9,10: There was no evidence the agency provided policies regarding controlled substances upon transfer from another hospice agency.

Upon observation, there was no evidence that when the hospice provides durable medical equipment under contract, then the DMEPOS provider is accredited by a CMS approved accreditation organization.

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 14 (Personnel #4) did not have evidence that personnel credentialing activities are conducted to verify qualifications of all credentialed/licensed personnel in the positions they hold at the time of hire, at Reaccreditation or in accordance with specific state practice act requirements. Personnel 4: There was no evidence of current NP licensure, the license verification expired 12/31/21.

Upon personnel record review, 1 of 14 (Personnel #10) 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 10: There was no evidence of a criminal background check obtained.