Every finding on record at Shepherd Hospice Inc

Upon patient record review, 7 of 14 (Patient #1, #2, #4, #5, #6, #7, #9) did not have evidence that the patient has received effective pain management and symptom control from the hospice for conditions related to the terminal illness. Patient #1,2,4,5,6,7,9: The medical record contained documentation that the patient had pain at an unacceptable pain level. The nurse visit for follow-up was made 7 days later for each patient.

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

Upon patient record review 10 of 14 charts reviewed (Patient #1, #2, #3, #4, #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 #1-10: There was no evidence the psychosocial and or spiritual comprehensive assessment was completed at the time of the survey.

Upon patient record review, 10 of 14 records reviewed (Patient #1, #2, #3, #4, #5, #6, #7, #8, #9, #10) 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, #2, #3, #4, #5, #6, #7, #8, #9, #10: These records had multiple medications listed. There was no evidence of a review for duplicate drug therapy and or a review for drug therapy currently associated with laboratory monitoring at the time of admission and or with any new medication orders. Patient #1: There were no indications listed on the medication profile for atorvastatin, benzonatate, metformin, tramadol and trazodone. In addition, during the home visit the following medications were listed on the medication profile but husband indicated patient is not taking: trazodone, melatonin and benzonatate. Also husband confirmed patient was taking OTC Tylenol 500mg po daily prn which was not listed on the medication profile. All COS. Patient #2: There were no indications listed on the medication profile for allopurinol, amlodipine, aspirin, atorvastatin, benazepril, clonidine, colchicine, furosemide, glipizide, Jardiance, kerendia, mintox, potassium chloride and tamsulosin. In addition, during the home visit the following medications were listed on the medication profile: furosemide 40mg po once a day and colchicine 0.6mg po bid. The patients daughter stated he was not taking the lasix daily and was only taking it twice a week and had not taken the colchicine in over two weeks. Also, benzonatate 100mg one tab tid prn cough and loperamide 2mg po QID prn anti diarrheal was prescribed but was not on the medication profile. All COS. Patient #3: There were no indications listed on the medication profile for tramadol, phenazopyridine, ciprofloxacin, celecoxib and or bisacodyl. In addition, during the home visit the following medications were listed on the medication profile: tramadol, phenazopyridine, ciprofloxacin, celecoxib and or isosorbide. The patient confirmed he did not have these medications in the home and was not taking these medications. He was taking docusate sodium 250mg one po daily for constipation and OTC Tylenol 500mg po once per day. All COS.

Upon patient record review, 7 of 14 records reviewed (Patient #2, #3, #5, #7, #8, #9, #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 #2, 3, 5, 7, 8, 9, 10: The initial bereavement risk assessment was not done at the time of the survey.

Upon patient record review, 5 of 14 records reviewed (Patient #2, #4, #7, #8, #10) 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 #2: The patient received an RN Visit on the start of care and no RN visit since the start of care at the time of the survey. Patient #4: The patient was due an RN Visit on 01/21/25, the visit note was not complete at the time of the survey. COS. Patient #7: The patient was due an RN visit Q14 days per order on 02/11/25, there was no RN visit since the start of care and or since this order was written up to the time of survey. Patient #8: There were no RN visits after the start of care on 03/12/24 at the time of the survey. Patient #10: There was an order for a nurse 1 x W on 02/24/24. There was no skilled nurse and or RN visit from 02/24/24 to 03/14/24.

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

Upon patient record review, 7 of 14 charts reviewed (Patient #1, #2, #4, #5, #6, #7, #9) 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 #1: On admission 12/12/24 the nurse documented the patient had a pain level of "8" at the present time and a "6" would be acceptable. The next nurse visit was on 12/19/24, there was no follow up until 7 days later. Patient #2: On admission 12/12/24 the nurse documented the patient had a pain level of "7" at the present time and a "5" would be acceptable. The next nurse visit was on 12/19/24, there was no follow up until 7 days later. Patient #4: On admission 11/14/24 the nurse documented the patient had lower back pain and bilateral leg pain with a pain level of "7" at the present time and a "5" would be acceptable. The next nurse visit was on 11/21/24 and the pain assessment was blank. Patient #5: On admission 11/14/24 the nurse documented the patient had low back and knee pain with a pain level of "7" at the present time and a "3" would be acceptable. The next nurse visit was on 11/21/24, the pain assessment question was answered "yes" there was no pain assessment completed. Patient #6: On admission 11/14/24 the nurse documented the patient had low back pain and numbness and tingling in bilateral extremities with a pain level of "6" at the present time and a "3" would be acceptable. The next nurse visit was on 11/21/24, the answer to pain was marked "yes" there was no pain assessment completed. Patient #7: On admission 11/14/24 the nurse documented the patient had back pain with a pain level of "7" at the present time and a "3" would be acceptable. The next nurse visit was on 11/21/24, there was no pain assessment was blank. Patient #9: On admission 08/03/24 the nurse documented the patient had low back pain with a pain level of "8" at the present time and a "3" would be acceptable. The next nurse visit was on 8/10/24 although it was documented no reportable pain, there was no follow up until 7 days later.

Upon patient record review, 10 of 14 charts reviewed (Patient #1, #2, #3, #4, #5, #6, #7, #8, #9, #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, #2, #3, #4, #5, #6, #7, #8, #9, #10: There were no individualized written plan of care for each patient based off the problems identified in the initial comprehensive and updated comprehensive assessments. The plan did not include patient/family goals and the care did not include palliation and management of the terminal illness and related conditions. Patient #1: There was no individualized written plan for a full code and not having mortuary listed. In addition, no seizure precautions, no pain, no dyspnea with exertion. Patient #2: There was no individualized written plan for a full code, hyper or hypoglycemia, uncontrolled pain and/or what unrelieved cardiac symptoms that should be reported to the hospice nurse. Patient #3: There was no individualized written plan for how the hospice would communicate in the absence of the patients daughter as she could speak English. The only language the patient could speak was Vietnamese. Patient #4: There was no individualized written plan for pain as it was uncontrolled on admission. Patient #5: There was no individualized written plan for pain as it was uncontrolled on admission and no hyper or hypoglycemia plan of care, the patient was on insulin. Patient #6: There was no individualized written plan for pain as it was uncontrolled on admission. Patient #7: There was no individualized written plan for a full code status and not having a mortuary listed. In addition, pain was uncontrolled on admission and there was no individualized written plan. Patient #8: There was no individualized written plan for a full code status and not having a mortuary listed. In addition, there was no written plan for pain although controlled on admission it was still an active problem controlled with baclofen benzonatate.

Upon patient record review, 1 of 14 records reviewed (Patient #3) 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 #3: During the home visit the patient was receiving Ensure, the hospice nurse advised she would get an order for Glucerna since the patient is diabetic. There was no order for the Ensure.

Upon patient record review, 4 of 14 charts reviewed (Patient #1, #2, #5, #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 patient had oxygen, knee brace and a cane. There was no plan of care to include these DME needs. Patient #2: The patient had oxygen and a cane. There was no plan of care to include these DME needs. Patient #5: The patient had oxygen and a walker for an unsteady gait. There was no plan of care to include these DME needs. Patient #10: The patient had oxygen and a cane. There was no plan of care to include these DME needs.

Upon patient record review, 10 of 14 records reviewed (Patient #1-10) did not have evidence that the plan of care included IDG's documentation of the patient's or families level of understanding, involvement and agreement with the plan of care. Patient #1-#10: There was no evidence in the patient record that the plan of care included the patient or families level of understanding, involvement and agreement with the plan of care.

Upon patient record review, 10 of 14 records reviewed (Patient #1, #2, #3, #4, #5, #6, #7, #8, #9, 10) did not have evidence that the IDG in collaboration with the attending physician reviewed, revised and documents the individualized plan as frequently as the patient's condition requires but no less frequently then every 15 calendar days. Patient #1, 2, 3, 4, 5, 6, 7, 8: There was no evidence of an IDG meeting every 15 days since the start of care. Patient #9: There was no evidence of an IDG meeting every 15 days during the second benefit period between 11/01/24-01/29/25 and during the third benefit period between 01/30/25-03/30/25. The IDG dates 8/14/24 and 9/25/24 only had the nurse and MD present, there was no Chaplain or SW. Patient #10: There was no evidence of an IDG meeting every 15 days during the first benefit period from 02/24/24 - 05/23/24.

Upon patient record review, 1 of 14 records reviewed (Patient #9) 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 #9: There was no evidence of a revised plan of care based off the comprehensive assessment once the patients prognosis was extended and no patient's progress towards outcome/goals were documented.

Upon patient record review, 9 of 14 records reviewed (Patient #1, #2, #3, #4, #5, #6, #7, #9, #10) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1: The chaplain made a spiritual care visit on 12/15/24 and 01/12/25. There were no order for these visits. Patient #2: The chaplain made a spiritual care visit on 12/15/24, 01/12/25 and 02/09/25. There were no orders for these visits. Patient #3: The only visits made since the start of care were by the nurse, there are no frequency orders for nursing visits after the initial assessment at the time of the survey. Patient #4: The nurse and chaplain were making visits since the start of care, there were no orders for these visits. Patient #5: The nurse and chaplain were making visits since the start of care, there were no orders for these visits. Patient #6: The social worker made a visit on 03/03/25 and the chaplain made a visit on 02/17/25, there were no orders for these visits. Patient #7: The social worker made a visit on 02/03/25 and the chaplain made visits on 11/18/24, 12/16/24 and 01/13/25, there were no orders for these visits. Patient #9: The chaplain made visits on 11/06/24, 12/04/24, 01/08/25, there was no orders for these visits. Patient #10: The nurse was ordered 1 X W on 02/24/24, there were visits scheduled on 2/24/24, 2/27/24, 03/08/24 and 03/14/24 with no completion of the visit note.

Upon observation, there was no evidence the board of directors/governing body approves the frequency and detail of the data collection. There was no evidence the governing body approves the frequency and detail of the data collection for QAPI.

Upon personnel record review, 1 of 16 (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: There is no initial skills competency assessment completed on the aide by an RN at the time of the survey.

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. The governing body meeting minutes had no evidence of the following in the meeting minutes: decision making, arranging for professional advise, adopting bylaws, establishing or approving written policies and procedures, human resource management, QAPI, Community needs planning, oversight of the management and fiscal affairs of the hospice and annual review of the policies and procedures.

Upon patient record review, 8 of 14 records reviewed (Patient #1, #3, #4, #6, #7, #8, #9, #10) 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: The CTI for the 1st Benefit Period 12/12/24-03/11/25 had no verbal certification from the nurse documented, no narrative was completed by the physician and there was no physician signature at the time of the survey. Patient #3: The CTI for the 1st Benefit Period 12/12/24 - 03/11/25 had no verbal certification from the nurse documented, no narrative was completed by the physician and there was no physician signature at the time of the survey. Patient #4: The CTI for the 1st Benefit Period 11/14/24-02/11/25 had no verbal certification from the nurse documented, no narrative was completed by the physician and there was no physician signature at the time of the survey. Patient #6: The CTI for the 1st Benefit Period 11/14/24-02/11/25 had no verbal certification from the nurse documented, no narrative was completed by the physician and there was no physician signature at the time of the survey. Patient #7: The CTI for the 1st Benefit Period 11/14/24-02/11/25 had no verbal certification from the nurse documented, no narrative was completed by the physician and there was no physician signature at the time of the survey. Patient #8: The CTI for the 1st Benefit Period 03/12/24-06/24 had no verbal certification from the nurse documented, no narrative was completed by the physician and there was no physician signature at the time of the survey. Patient #9: The CTI for the 1st Benefit Period 08/03/24-10/31/24 had no verbal certification from the nurse documented, no narrative was completed by the physician and there was no physician signature at the time of the survey Patient #10: The CTI for the 1st Benefit Period 02/24/24-05/23/24 had no verbal certification from the nurse documented, no narrative was completed by the physician and there was no physician signature at the time of the survey.

Upon patient record review, 5 of 14 records reviewed (Patient #4, #6, #7, #9, #10) 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 #4: The recertification period for the 2nd benefit period 02/12/24-05/12/25 had no written documentation by the medical director that it is anticipated the patients life expectancy is 6 months or less, the narrative was blank. Patient #6: The recertification for the 2nd benefit period 02/12/25-05/12/25 had no written documentation by the medical director that it is anticipated the patients life expectancy is 6 month or less, the narrative was blank. Patient #7: The recertification period for the 2nd benefit period 02/12/25-05/12/25 had no written documentation by the medical director that it is anticipated life expectancy is 6 months or less, the narrative was blank. Patient #9: The recertification period for the 2nd benefit period 11/01/24-01/29/24 and the 3rd benefit period 01/30/25 -03/30/25 had no written documentation by the medical director that it is anticipated the patients life expectancy is 6 months or less, the narrative was blank. Patient #10: The recertification period for the 2nd benefit period 05/24/24-08/21/24 and the 3rd benefit period 08/22/24-10/20/24 had no written documentation by the medical director that it is anticipated the patients life expectancy is 6 months or less, the narrative was blank.

Upon patient record review, 8 of 14 charts reviewed (Patient #2, #3, #4, #5, #6, #7, #9) in the state of California only 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 #2: There was no evidence the patient chose to receive a copy of non covered services, this was left blank on the notice of election form. During the home visit the patient daughter confirmed she was not asked if they wanted a copy of non covered services. In addition, the record indicated the patient signed and dated a blank notice of Medicare non coverage on the start of care. Patient #3: There was no evidence the patient chose to receive a copy of non covered services, this was left blank on the notice of election form. During the home visit the patient confirmed he was not asked if he wanted a copy of non covered services. In addition, the patient signed a notice of election for hospice. There was no staff signature on the notice of election. Patient #4, 5: There was no evidence the patient chose to receive a copy of non covered services, this was left blank on the notice of election form. In addition, the record indicated the patient signed and dated a blank notice of Medicare non coverage on the start of care. Patient #6: There was no evidence the patient chose to receive a copy of non covered services, this was left blank on the notice of election form. Patient #7, 9: There was no evidence the patient chose to receive a copy of non covered services, this was left blank on the notice of election form. In addition, the patient signed a notice of election for hospice. There was no staff signature on the notice of election. Patient #8: The record indicated the patient signed and dated a blank notice of Medicare non coverage on the start of care.

Upon patient record review, 1 of 14 records reviewed (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. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient #1: The record indicated a nurse visit on 01/15/25 documented coordination with facility staff, this patient is at home and there is no applicability to coordinate with facility staff. This was documented in error.

Upon patient record review, 2 of 14 record reviewed (Patient #11, #12) 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 revoked on 04/17/24, there was no evidence of a discharge summary having been sent to the patient's attending physician. Patient #12: The record indicated the patient revoked on 09/16/24, there was no evidence of a discharge summary having been sent to the patient's attending physician.

Upon patient record review, 4 of 14 records reviewed (Patient #11, #12, #13, #14) did not have evidence that the discharge summary includes all required information. Patient #11, #12, #13, #14: There was no evidence of a discharge summary at the time of the survey.

Upon patient record review, 1 of 6 (Patient #2) 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. Patient 2: The narrative portion of the initial comprehensive nursing assessment, dated 10.05.2021, states that the patient takes trazodone 100mg qHS for sleep; however, the trazodone does not appear on the patient's medication profile. (corrected onsite)

Upon patient record review, 3 of 3 applicable (Patient #1, 4, 5) did not have evidence in the patient record that hospice aide assignments and duties include the tasks to be completed and the frequency of those tasks. Patient 1: The HA care plan, dated 09.28.2021, did not specify the frequency of the tasks the aide is to perform. The patient requires a bath via shower chair, shampoo, and nails cleaned. (corrected on site) Patient 4: The HA care plan, dated 07.26.2021, did not specify the frequency of the tasks the aide is to perform. The patient requires a bath via shower chair, shampoo, and teeth brushed. Patient 5: The HA care plan, dated 09.24.2021, did not specify the frequency of the tasks the aide is to perform. The patient requires a bed bath, shampoo, and nails cleaned.