Every finding on record at Siena Hospice LLC

Upon patient record review, 11 of 14 (Patients #1, 2, 3, 4, 5, 6, 8, 10, 11, 13, 14) did not have evidence in the patient record that the comprehensive assessment takes into consideration the imminence of death. Patient #1) Upon review of patient's medical record, the comprehensive assessment dated 11/7/24 did not contain evidence of documentation of the imminence of death. Patient #2) Upon review of patient's medical record, the comprehensive assessment dated 10/10/24 did not contain evidence of documentation of the imminence of death. Patient #3) Upon review of patient's medical record, the comprehensive assessment dated 3/10/24 did not contain evidence of documentation of the imminence of death. Patient #4) Upon review of patient's medical record, the comprehensive assessment dated 12/25/24 did not contain evidence of documentation of the imminence of death. Patient #5) Upon review of patient's medical record, the comprehensive assessment dated 4/5/24 did not contain evidence of documentation of the imminence of death. Patient #6) Upon review of patient's medical record, the comprehensive assessment dated 1/19/24 did not contain evidence of documentation of the imminence of death. Patient #8) Upon review of patient's medical record, the comprehensive assessment dated 2/6/24 did not contain evidence of documentation of the imminence of death. Patient #10) Upon review of patient's medical record, the comprehensive assessment dated 4/28/24 did not contain evidence of documentation of the imminence of death. Patient #11) Upon review of patient's medical record, the comprehensive assessment dated 6/14/23 did not contain evidence of documentation of the imminence of death.. Patient #13) Upon review of patient's medical record, the comprehensive assessment dated 4/23/24 did not contain evidence of documentation of the imminence of death. Patient #14) Upon review of patient's medical record, the comprehensive assessment dated 11/18/24 did not contain evidence of documentation of the imminence of death.

Upon patient record review, 14 of 14 (Patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. briefs and wipes. Patient #1) The patient's current plan of care dated 7/4/25, there was no evidence that the POC contained any of the medical supplies related to the management of the terminal illness needed for the palliation and management of the patient's end of life care. The patient was using adult briefs and wipes. Patient #2) The patient's current plan of care dated 7/4/25, there was no evidence that the POC contained any of the medical supplies related to the management of the terminal illness needed for the palliation and management of the patient's end of life care. The patient was using adult briefs and wipes. Patient #3) The patient's current plan of care dated 7/4/25, there was no evidence that the POC contained any of the medical supplies related to the management of the terminal illness needed for the palliation and management of the patient's end of life care. The patient was using adult briefs and wipes. Patient #4) The patient's current plan of care dated 7/4/25, there was no evidence that the POC contained any of the medical supplies related to the management of the terminal illness needed for the palliation and management of the patient's end of life care. The patient was using adult briefs and wipes. Patient #5) The patient's current plan of care dated 7/4/25, there was no evidence that the POC contained any of the medical supplies related to the management of the terminal illness needed for the palliation and management of the patient's end of life care. The patient was using adult briefs and wipes. Patient #6) The patient's current plan of care dated 7/4/25, there was no evidence that the POC contained any of the medical supplies related to the management of the terminal illness needed for the palliation and management of the patient's end of life care. The patient was using adult briefs and wipes. Patient #7) The patient's current plan of care dated 7/4/25, there was no evidence that the POC contained any of the medical supplies related to the management of the terminal illness needed for the palliation and management of the patient's end of life care. The patient was using adult briefs and wipes. Patient #8) The patient's current plan of care dated 8/6/24, there was no evidence that the POC contained any of the medical supplies related to the management of the terminal illness needed for the palliation and management of the patient's end of life care. The patient was using adult briefs and wipes. Patient #9) The patient's current plan of care dated 5/13/25 , there was no evidence that the POC contained any of the medical supplies related to the management of the terminal illness needed for the palliation and management of the patient's end of life care. The patient was using adult briefs and wipes. Patient #10) The patient's current plan of care dated 1/21/25, there was no evidence that the POC contained any of the medical supplies related to the management of the terminal illness needed for the palliation and management of the patient's end of life care. The patient was using adult briefs and wipes. Patient #11) The patient's current plan of care dated 7/23/24, there was no evidence that the POC contained any of the medical supplies related to the management of the terminal illness needed for the palliation and management of the patient's end of life care. The patient was using adult briefs and wipes. Patient #12) The patient's current plan of care dated 5/28/24, there was no evidence that the POC contained any of the medical

Upon patient record review, 1 of 14 (Patient #13) 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 #13) The patient bereavement plan of care following death, the action plan/intervention portion was left blank.

Upon patient record review, 14 of 14 (Patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient #1)The aide plan of care dated 4/27/25 contained orders to turn and position patient, encourage fluids as tolerated if not contraindicated, and change bed linens. These tasks did not have a frequency. Patient #2) The aide plan of care dated 5/5/25 contained orders to turn and position patient, encourage fluids as tolerated if not contraindicated, and change bed linens. These tasks did not have a frequency. Patient #3) The aide plan of care dated 3/9/25 contained orders to turn and position patient, encourage fluids as tolerated if not contraindicated, and change bed linens. These tasks did not have a frequency. Patient #4) The aide plan of care dated 6/15/25 contained orders to turn and position patient, encourage fluids as tolerated if not contraindicated, mechanical lift, and change bed linens. These tasks did not have a frequency. Patient #5) The aide plan of care dated 5/25/25 contained orders to turn and position patient, encourage fluids as tolerated if not contraindicated, and change bed linens. These tasks did not have a frequency. Patient #6) The aide plan of care dated 5/4/25 contained orders to turn and position patient, encourage fluids as tolerated if not contraindicated, and change bed linens. These tasks did not have a frequency. Patient #7) The hospice aide plan of care dated 5/12/25 contained orders to turn and position patient, encourage fluids as tolerated if not contraindicated, and change bed linens. These tasks did not have a frequency. Patient #8) The aide plan of care dated 7/28/24 contained orders to encourage fluids as tolerated if not contraindicated, and change bed linens. These tasks did not have a frequency. Patient #9) The aide plan of care dated 7/28/24 contained orders encourage fluids as tolerated if not contraindicated, and change bed linens. These tasks did not have a frequency. Patient #10) The aide plan of care dated 12/17/24 contained orders to encourage fluids as tolerated if not contraindicated, and change bed linens. These tasks did not have a frequency on the POC. Patient #11) The hospice aide plan of care dated 6/3/24 contained orders to turn and position patient, encourage fluids as tolerated if not contraindicated, and change bed linens. These tasks did not have a frequency. Patient #12) The aide plan of care dated 4/26/24 contained orders to turn and position patient, encourage fluids as tolerated if not contraindicated, and change bed linens. These tasks did not have a frequency. Patient #13) The aide plan of care dated 4/29/24 contained orders to turn and position patient, encourage fluids as tolerated if not contraindicated, and change bed linens. These tasks did not have a frequency. Patient #14) The aide plan of care dated 1/13/25 contained orders to turn and position patient, encourage fluids as tolerated if not contraindicated, and change bed linens. These tasks did not have a frequency.

Upon patient record review 3 of 14 (Patients #1, 6, 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) The hospice aide plan of care dated 4/27/25, the task of recording bowel movement was not ordered. Aide recorded bowel movement dates on 6/9, 6/11, 6/13, 6/16, 6/18, 6/20, 6/23, 6/25, and 6/31/25. Patient # 6) The hospice aide plan of care dated 5/4/25, the task of recording bowel movement was not ordered. Aide recorded bowel movement dates on 6/4, 6/6, 6/9, 6/11, 6/13, 6/16, 6/18, 6/20, 6/23, 6/25, 6/27, 6/30, 7/2, 7/4, and 7/7/2025. Patient # 7) The hospice aide plan of care dated 5/12/25, the task of recording bowel movement was not ordered. Aide recorded bowel movement dates on 6/4, 6/6, 6/9, 6/11, 6/13, 6/16, 6/18, 6/20, 6/23, 6/25, 6/28, 6/29, 7/1, 7/2, and 7/3/2025.

Upon contract review, 1 of 6 (W-9 RN) did not have evidence the agreement to furnish any services under arrangement included that the hospice must retain administrative and financial management, and oversight of staff and services for all arranged services, to ensure the provision of quality care. Arranged care/services are supported by written contract/agreement that requires all care/services are: • Authorized by the hospice • Furnished in a safe and effective manner by qualified personnel • Delivered in accordance with the patient's plan of care The agency did not have evidence of executed contract that was given to surveyor during survey.

Upon patient record review, 1 of 5 records (Patient #5) did not have evidence in the patient record of an individualized written plan of care for each patient that included all problems identified in the initial and comprehensive assessments. Patient #5: On admission, RN documented patient had a stage 2 to coccyx and right buttock, however, the plan of care did not have evidence of problem/intervention/goals to reflect altered skin integrity.

Upon patient record review, 1 of 5 (Patient #5) 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 #5: On admission, RN documented patient had a stage 2 to coccyx and right buttock, however, the plan of care did not include orders for the wound care to be provided.

Upon observation of the home visit, 1 of 3 applicable (Patient 1) did not have evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient #1: On home visit, nurse did not follow hand washing policy of agency (#6-006.1-6-006.2 Hand Hygiene under Hand Washing with Soap and Water, bullet #4) that specifies when washing hands with soap and water to dry hands with a disposable towel from the fingers toward the forearm. Nurse was observed using the patient's cloth reusable towel hanging in the bathroom at start and end of visit to dry hands.

Upon personnel record review, 3 of 10 (Personnel #6, #7, #8 ) did not have evidence that a skills competency assessment, specific to each discipline had been conducted for all personnel including volunteers initially during orientation. Personal records #6, #7, and #8: Skills competency assessments for each of these personnel were conducted however, all were assessed by RN versus like discipline (PT, OT, ST).