Every finding on record at Sos Hospice, Inc.

Observed in Document Review. During review of the survey findings related to the Emergency Management Plan it was noted the organization had not conducted an annual testing of its emergency operations plan for the last two years or since the last survey. This was discussed and validated with Leadership.

Observed in Document Review. Leadership shared they had planned on educating the employees on the emergency plan the day the surveyor arrived and had not completed any emergency management training at least once every two years. This was discussed and validated with the Administrator and Director of Patient Care Services.

Observed in Record Review. In 1 of 3 patient records reviewed, During RR# 1's patient record review it was noted the organization had not ensured it respected, protected, and promoted the patients' rights. For example: review of RR# 1's patient record revealed no documentation that the hospice obtained the signature of the patient or representative to confirm that the patient or representative has received a copy of the notice of rights and responsibilities. This was reviewed, discussed, and validated with the Director of Patient Care Services.

Observed in Record Review. In 3 of 3 patient records reviewed, During RR# 1, RR# 2, and RR# 3's patient records review it was noted the organization had not ensured it respected the patients' right to elect hospice care, in accordance with Medicare hospice regulations. For example: review of RR# 1, RR# 2, and RR# 3's patient records revealed signed Hospice Election of Benefit forms with the election date blank. This was reviewed, discussed, and validated with the Director of Patient Care Services. Observed in Record Review. In 1 of 1 patient records reviewed discharged for extended prognosis, During RRD/C# 1's patient record review it was noted the organization had not ensured it provided a Notice of Medicare Non-Coverage to the patient or patient representative 2 days prior to patient discharge for extended prognosis per regulations. This was reviewed with the Director of Patient Care Services and validated.

Observed in Record Review. In 3 of 3 patient records reviewed, During RR# 1, RR# 's patient records review it was noted the organization had not ensured it respected the patients' right to participate in decisions about their care, treatment, or services. For example review of the patients' records revealed no documentation regarding of the different hospice levels of care covered under the hospice benefit. This was reviewed, discussed, and validated with the Administrator and Director of Patient Care Services.

Observed in Record Review. In 3 of 3 patient records reviewed, During RR# 1, RR# 2, and RR# 3's records review it was noted the organization had not ensured it assessed it's patients. For example: review of RR# 1, RR# 2, and RR# 3's patient record revealed documentation a patient volunteer was offered to the patient representative and the volunteer was declined. However, review of the Volunteer program and Volunteer HR file revealed the organization did not have a patient volunteer to offer patient's, as the one volunteer that was hired was note trained, oriented, or had a competency assessment related to being a patient volunteer. This was discussed and validated with the Administrator and Director of Patient Care Services.

Observed in Record Review. In 1 of 3 patient records reviewed, During RR# 2's patient record review it was noted the organization had not ensured a comprehensive assessment was completed no later than 5 calendar days after the election of hospice care. For example: review of RR# 2's patient record revealed RR# 2's start of care was approximately 13 days prior to the surveyor review of the record. Further review of RR# 2's patient record revealed no documentation of an initial psychosocial assessment. This was reviewed, discussed, and validated with the Director of Patient Care Services.

Observed in Document Review. During interview with the Director of Patient Care Services and review of the audit tracking form revealed the organization had not re-educated staff on hand hygiene, completed supervisory visits, or evaluated the staff competence with hand hygiene. This was discussed and validated with the Administrator and Director of Patient Care Services.

Observed in Document Review. During review of the Volunteer program binder it was noted the organization had not ensured there was documentation of recruitment of new volunteers. The Volunteer program binder had recruitment for 2024 with monthly documented recruitment of volunteers from Volunteer Match.com dated in the future to include: 1/20/2024; 2/10/2024; 3/17/2024; 4/14/2024; 5/12/2024; 6/8/24; 7/10/2024; 8/13/2024; 9/10/2024; 10/11/2024; 11/6/2024; and 12/18/2024 with a picture of the website behind each documented recruitment form. However, there was no documentation of Volunteer recruitment since the last survey. This was discussed and validated with the Director of Patient Care Services.

Observed in Document Review. Governance did not provide for the resources needed to maintain safe, quality care, treatment or services as evidenced by no written agreement/contract to meet the needs of patient in the need of general inpatient (GIP) and caregivers in need of respite levels of care. This was discussed and validated with the Director of Patient Care Services and Administrator. Observed in Record Review. There was no evidence that the governing body and leadership had established requirements to support patient care treatment and services as evidenced by Condition Level Deficiencies 418.116; 418.108; 418.100; 418.60; 418.113; 418.104; 418.52; 418.78; and 418.54. Observed in Document Review. Governance did not provide for the resources needed to maintain safe, quality care, treatment, or services as evidenced by: Leadership was aware there were no oriented and trained active patient volunteers and there had not been a patient care volunteer for over two years, and the organization was in the process of completing the training and orientation for an active patient volunteer. The organization's volunteer completed administrative volunteer duties only since hire. This was discussed and validated with the Administrator and Director of Patient Care Services.

Observed in HR File Review. In 3 of 3 newly hire HR files reviewed, During review of new employees since the last survey, HR# 1, HR# 2, and HR# 5's HR files it was noted the organization had not ensured it had assessed the initial competency of the newly hires Volunteer, Director of Patient Care Services, and Bereavement Coordinator/Volunteer Coordinator as part of the orientation. For example: review of the HR files revealed no initial competency documentation. This was reviewed, discussed, and validated with the Administrator and Director of Patient Care Services.

Observed in Record Review. In 3 of 3 patient records reviewed, During RR# 1, RR# 2, and RR# 3's patient records review it was noted the organization had not ensured it maintained complete and accurate patient records. For example: review of RR# 1's Hospice Consent form revealed the patient representative and no documentation of RR# 1's patient name or medical record number on any of the 4/4 pages to indicate the Hospice Consent was for RR# 1. Review of RR# 2's patient record revealed a Hospice Consent form with the name of RR# 2's patient representative and no documentation of RR# 2's patient name or medical record number on any of the 4/4 pages to indicate the Hospice Consent was for RR# 2. Review of RR# 3 patient record revealed the patient representative name on the Hospice Consent and no documentation of the RR# 3's name or medical record number on any of the 4/4 pages to indicate the Hospice Consent was for RR# 3. This was reviewed, discussed, and validated with the Administrator and Director of Patient Care Services..

Observed in Record Review. In 1 of 3 patient records reviewed, During RR# 2's patient record review it was noted the organization had not ensured it maintained the security and integrity of the health information. For example: review of RR# 2's patient record revealed a faxed copy of a signed POLST with hand written Medical Record number in black ink on the POLST. This was discussed and validated with the Administrator and Director of Patient Care Services.

Observed in Document Review. During contract review it was noted the organization failed to make arrangements to provide short term inpatient/general inpatient (GIP) and respite levels of care. For example: Review of the Contract binder revealed no contract for short term inpatient/GIP or respite levels of care. The Medical Director shared during an interview that the organization was waiting for the corporate approval from the Skilled Nursing Facilities as he had patients in the facilities and agreed to a contract/agreement with the organization. This was discussed, and validated with the Administrator and Director of Patient Care Services.

Observed in Record Review. In 2 of 2 patient records reviewed on service for greater than 5 days, During RR# 2 and RR# 3's patient records reviewed with a request for list of hospice non-covered items, it was noted the organization had not implemented a process for managing when a patient requested notice of non-covered items. The Director of Patient Care Services shared the organization had not implemented a process in place to ensure patients received the list of hospice non-covered items when requested.

Observed in Emergency Management Session. During review of the Emergency Management Plan it was noted the organization had not maintained a list of needed contacts it would need in the event of a disaster scenario that included: patient's physicians. This was reviewed, discussed and validated with Leadership.

Observed in Emergency Management Session. During the Environment of Care and Emergency Management Sessions it was noted the organization had not conducted an annual testing of its emergency operations plan for the last two years. This was discussed and validated with Leadership.

Observed in HR File Review. In 10 of 12 HR files reviewed, During Volunteer HR, HR# 1, HR# 2, HR# 3, HR# 4, HR# 6, HR# 7, HR# 8, HR# 9, and HR# 10's HR file it was noted the organization had not ensured it provided emergency management education and training at least every two years. Review of the HR file revealed no documentation at least once every two years. This was discussed and validated with leadership

Observed in Record Review. In 14 of 14 patient records reviewed, During the patients' records review and Admission Packet it was noted the organization had not ensured it respected, protected, and promoted the patients' rights. For example: review of the patients' records revealed no documentation that the hospice obtained the signature of the patient or representative to confirm that the patient or representative has received a copy of the notice of rights and responsibilities. This was reviewed, discussed, and validated with the Administrator/DPCS designee.

Observed in Record Review. In 1 of 1 patient records reviewed with discharge for extended prognosis, During RR# 2's patient record review it was noted the organization had not ensured it provided a Notice of Medicare Non-Coverage to the patient or patient representative two days prior to discharge per regulations. For example: review of RR# 2's patient record revealed a revocation form dated the same day of discharge. Further review of the revocation form revealed documentation under other, discharge due to extended prognosis. This was discussed, and validated with the Administrator/DPCS designee. Observed in Record Review. In 4 of 4 patient records reviewed with request for a list of hospice non-covered items, During RRHV# 1, RRHV# 2, RR# 6, and RR# 7's patient records review it was noted the organization had not ensured it respected the patients' right o participate in decisions about their care, treatment, or services. For example: review of RRHV# 1, RRHV# 2, RR# 6, and RR# 7's patient records revealed a request to receive a list of hospice non-covered items at the start of care. Further review of the patients' records revealed no documentation that the patients had received the list of hospice non-covered items. This was reviewed, discussed, and validated with the Administrator/DPCS designee and validated. Observed in Record Review. In 3 of 14 patient records reviewed, During RR# 1, RR# 3, and RRD/C# 2's patient records review it was noted the organization had not ensured it respected the patients' right to elect hospice care, in accordance with Medicare hospice regulations. For example: review of RR# 1, RR# 3, and RRD/C# 2's patient records revealed signed Hospice Election of Benefit forms with the election date blank. This was reviewed, discussed, and validated with the Administrator/DPCS designee.

Observed in Record Review. In 14 of 14 patient records reviewed, During the patients' records review and Admission Packet it was noted the organization had not ensured it respected the patients' right to participate in decisions about their care, treatment, or services. For example review of the Admission packet and patients' records revealed no documentation regarding of the different hospice levels of care covered under the hospice benefit. This was reviewed, discussed, and validated with the Administrator/DPCS designee.

Observed in Record Review. In 9 of 14 patient records reviewed, During RRHV# 1, RRHV# 2, RRHV# 3, RR# 1, RR# 2, RR# 3, RR# 4, RR# 5, RR# 6, RRD/C# 1, RRD/C# 2's patient record review it was noted the organization had not assessed the need for a volunteer. For example: review of the patient's plan of care revealed the volunteer was declined. However, the Volunteer Coordinator shared there were no patient volunteers and had not had a patient volunteer in over two years, and that leadership had not directed the Volunteer Coordinator to recruit patient volunteers, as there was no need for the patients because they were all in facilities. The Administrator/DPCS designee shared the clinicians determine if the patient needs a volunteer and the patients and their family members were not asked if they need a volunteer. This was discussed and validated with the Administrator/DPCS designee.

Observed in Record Review. In 2 of 14 patient records reviewed, During RRHV# 3 and RR# 5's patient records review it was noted the organization had not ensured the comprehensive assessment was completed no later than five calendar days after the election of hospice care. For example: review of RR# 5's patient record revealed the social worker completed the initial psychosocial assessment 10 days after the election of hospice care. Review of RRHV# 3's patient record revealed the social worker completed the initial psychosocial assessment 6 days after the election of hospice care. This was reviewed, discussed, and validated with the Administrator/DPCS designee.

Observed in Record Review. In 5 of 14 patient records reviewed, During RRHV# 1, RRHV# 3, RR# 6, BR# 1, and BR# 2's patient records review it was noted the organization had not ensured it assessed it's patients. For example: review of RRHV# 1, RRHV# 3, and RR# 6's patient record revealed no documentation of an initial bereavement assessment. This was discussed and validated with the Administrator/DPCS designee.

Observed in Record Review. In 3 of 14 patient records reviewed, During RRHV# 1, RRHV# 2, and RRHV# 3's patient record review it was noted the organization had not ensured the plan of care was based on the patient's goals and time frames, settings, and services required to meet those goals. For example: during the home observation of RRHV# 1 and RRHV# 2 it was noted the patients had full side rails. Review of RRHV# 1 and RRHV# 3's plan of cares revealed no goals for the use of side rails. During RRHV# 2's home observation it was noted RRHV# 2 had full side rails. Review of RRHV# 2's plan of care revealed the goal patient will demonstrate appropriate use of side rails for bed mobility to assist with turning and repositioning. However, RRHV# 2 had two contracted upper extremities, unable to follow commands, and the terminal diagnosis of Alzheimer's and unable to use the side rails for mobility. This was reviewed, discussed, and validated with the Administrator/DPCS designee.

Observed in Record Review. In 2 of 4 patient records reviewed with wounds, During HV# 1 and RR# 4's patient record review it was noted the organization had not ensured the plan of care included all the treatments necessary to meet the patients' needs. For example: Review of RRHV# 1's patient record revealed documentation that a wound consultant was providing wound care once a week. Review of RRHV# 1 plan of care revealed no documentation regarding wound care from an external organization. Review of RR# 4's patient record revealed documentation that a wound consultant was providing wound care once a week. Review of RR# 4's plan of care revealed no documentation regarding wound care from an external organization. This was reviewed, discussed, and validated with the Administrator/DPCS designee.

Observed in Record Review. In 2 of 14 patient records reviewed, During RRHV# 1 and RRHV# 3's patient record review it was noted the organization had not ensured it included all the services needed for the palliation and management of the terminal illness and related conditions. For example: during RRHV# 1 and RRHV# 3's home observation both patients were bed bound and observed with full side rails on the bed. Review of RRHV# 1 and RRHV# 3's plan of care revealed no documentation of side rails as an intervention. This was discussed with the Administrator/DPCS designee and validated.

Observed in Patient Home. In 3 of 3 home visits conducted, During RRHV# 1, RRHV# 2, and RRHV# 3's home observation it was noted the organization had not ensured it provided care, treatment, or services according to the patient's individualized plan of care. For example: review of RRHV# 1's plan of care revealed documentation that RRHV# 1 had a pressure ulcer to the right hip and the intervention to complete a skin assessment at every SN visit. During RRHV# 1's home observation the licensed vocational nurse (LVN) was observed assessing the skin of the buttock and peri-anal area. However, the skin of the back, head, and feet were not assessed according to the plan of care. Review of RRHV# 2's plan of care revealed an intervention to assess the skin of RRHV# 2 due to risk of skin break down. During RRHV# 2's home observation the LVN was observed assessing the legs, feet, peri-anal area, buttock and the left side of RRHV# 2's back. However, the LVN did not assess the right side of the back or RRHV# 2's head. Review of RRHV# 3's plan of care revealed an intervention to assess RRHV# 3's skin. During RRHV# 3's home observation the LVN was observed assessing the feet, legs, peri-ana area, and buttock. However, the LVN did not assess RRHV# 3's back or head. This was discussed, and validated with the LVN/Owner.

Observed in Leadership Session. During the Leadership and Data Use Management session it was noted the organization had not ensured it evaluated the quality assessment and performance improvement program annually. This was discussed with leadership and validated.

Observed in Patient Home. In 3 of 3 home visits conducted, During RRHV# 1, RRHV# 2, and RRHV# 3's home observation it was noted the organization had not ensured it implemented the infection prevention and control activities it had planned and that staff followed the organization's policy Hand Hygiene that included performing hand hygiene after removing gloves and before putting on gloves. For example: during RRHV# 1's home observation the licensed vocational nurse (LVN) was observed applying hand sanitizer to both hands and rubbed the hands together and then used a paper towel to remove the excess hand sanitizer. In addition, the LVN was observed removing gloves multiple times during patient care with no hand hygiene completed before putting on new gloves. During RRHV# 1's wound care the LVN cleaned the pressure ulcer to the right hip and with the same pair of gloves applied the dressing to the wound. During RRHV# 2's home observation the LVN was observed removing gloves multiple times during patient care with no hand hygiene completed before putting on new gloves. During RRHV# 3's home observation the LVN was observed removing gloves multiple times during patient care with no hand hygiene completed before putting on new gloves. This was observed, discussed, and validated with the LVN/Owner.

Observed in Patient Home. In 2 of 3 home visits conducted, During RRHV# 1's home observation it was noted the organization had not ensured it provided patient/caregiver education based on the patient/caregiver needs an abilities. For example: during RRHV# 1's home observation the LVN had the assistance of two caregivers from the Assisted Living Facility (ALF) while cleaning the peri-anal area due to a bowel movement. One care giver was observed cleaning the peri-area with gloves and then walking over to the dresser to open a draw looking for an ointment. In addition, once the caregiver was done assisting the care giver removed the gloves and put the dirty gloves in the shirt pocket and did not perform hand hygiene during any of the care. During RRHV# 2's home observation the caregivers assisted the LVN in cleaning the peri-anal area due to a bowel movement. One caregiver applied ointment to the peri-area removed gloves and put them in the pocket and continues with visit with no hand hygiene. The LVN did not re-educate regarding infection control during the home observations to the caregivers. This was discussed and validated with the LVN/Owner

Observed in Record Review. In 2 of 2 bereavement records reviwed, During review of BR# 1 and BR# 2's bereavement record it was noted the organization had not ensured it planned the patient's care. For example: review of BR# 1's bereavement record revealed BR# 1's was to begin the bereavement program approximately 10 months prior to the surveyor review of the record. Review of BR# 1's bereavement record revealed no initial bereavement risk assessment, no post death risk assessment and no bereavement plan of care. Review of the Bereavement Program revealed multiple mailings listed as over-due, as they had not been sent. Review of BR# 2's bereavement record revealed BR# 2 was to begin the bereavement program approximately five months prior to the surveyor review of the record. Review of BR# 2's bereavement record revealed no initial bereavement risk assessment, no post death risk assessment and no bereavement plan of care. Review of the Bereavement Program revealed multiple mailings listed as over-due, as they had not been sent. This was discussed with the Bereavement Coordinator that shared he/she/they did not always have access to the patient records and was unable to include the patients in the bereavement program. This was discussed, and validated with the LVN/Owner and Administrator/DPCS designee.

Observed in HR File Review. In 1 of 2 HR files reviewed with hospice aide., During HR# 12's HR file review it was noted the organization had not ensured staff were competent to perform their responsibilities. For example: review of HR# 12's HR file revealed HR# 12 had been hired approximately 17 months prior to the surveyor review of the record and no documentation of an initial competence evaluation. This was discussed and validated with Leadership. Observed in HR File Review. In 1 of 2 HR files reviewed for hospice aide, During HR# 12's HR file review it was noted the organization had not ensured staff were competent to perform their responsibilities. For example: review of HR# 12's HR file revealed HR# 12 was hired approximately 17 months prior to the surveyor review of the record. Further review of HR# 12's HR file revealed no documentation of an initial home health aide competency evaluation. This was discussed and validated with Leadership.

Observed in Record Review. In 2 of 14 patient records reviewed, During RRHV# 1 and RR# 4's patient record review it was noted the organization had not ensured the RN prepared complete written care instructions for the hospice aide. For example: review of RRHV# 1 patient record revealed RRHV# 1 had a wound to the right hip with a dressing. Review of RRHV# 1's hospice aide written patient instructions revealed the task of a bed bath and no documentation regarding the dressing. Review of RR# 4's patient record revealed RR# 4 had a wound on the right lower extremity with a dressing. Review of RR# 4's hospice aide written patient instructions revealed the task of a bed bath and no documentation regarding the dressing. This was discussed and validated with the Administrator/DPCS designee.

Observed in HR File Review. In 2 of 2 HR files reviewed with hospice aide, During HR# 2 and HR# 12's HR files review it was noted the organization had not ensured staff were supervised effectively. For example: review of HR# 2's HR file revealed the HHA had been hired approximately three years. However, review of HR# 2's HR file revealed no documentation of an annual on-site RN present supervisory visit. Review of HR# 12's HR file revealed HR# 12 had been hired approximately 17 months prior to the surveyor review of the record. However, review of HR# 12's HR file revealed no documentation of an annual on-site RN present supervisory visit. This was discussed with Leadership and validated.

Observed in Document Review. During review of the Volunteer Program with the Volunteer Coordinator it was noted the organization had not documented recruitment of new volunteers. Further review of the Volunteer Program revealed one volunteer for administration only. During second interview with Volunteer Coordinator the Volunteer Coordinator shared there were no active volunteers. This was reviewed, discussed, and validated with the Volunteer Coordinator and Administrator/DPCS designee.

Observed in Document Review. During review of the Volunteer program and interview with the Volunteer Coordinator it was noted the organization had not ensured it provided services that met the patient needs and demonstrate cost savings. For example,:a review of the Volunteer program records revealed there were no active volunteers. In addition, a review of the volunteer hours revealed the Volunteer Coordinator documented his hours under a former volunteer. Since those volunteer hours on the cost report cannot be used and thus there were no hours worked to meet this requirement. This was discussed, and validated with the LVN/Owner and Administrator/DPCS designee.

Observed in Document Review. During review of the Volunteer program and interview with the Volunteer Coordinator it was noted the organization had not ensured it provided services that meet the patient needs and the required 5% cost savings. The organization had no volunteers and the documentation of hours for the cost report were documented by the Volunteer Coordinator under the name of a former volunteer and did not count toward the required goal. This was discussed, and validated by the LVN/Owner and Administrator/DPCS designee.

Observed in Patient Home. In 1 of 3 home visits conducted, During RRHV# 2's home observation it was noted the organization had not ensured the patient was treated in a dignified and respectful manner that supported the patient's dignity. For example: during RRHV# 2's home observation it was noted RRHV# 2 had a room mate in the same room. During the home observation the LVN was observed completing vital signs and performing peri-care with RRHV# 2's room mate in the room and no privacy curtain. This was observed, discussed, and validated.

Observed in Document Review. Governance did not provide for the resources needed to maintain safe, quality care, treatment, or services as evidenced by: Leadership was aware there were no active volunteers and there had not been a patient care volunteer for over two years and had not addressed this issue. Observed in Document Review. Governance did not provide for the resources needed to maintain safe, quality care, treatment or services as evidenced by no written agreement/contract to meet the needs of patient in the need of general inpatient (GIP) and caregivers in need of respite levels of care. In addition, no written agreement/contract to delineate care, treatment, and services of a patient in an Intermediate Care Facility for Individuals with Intellectual Disabilities that had been on hospice services approximately 376 days prior to the survey. This was discussed with Leadership and validated. Observed in Leadership Session. During the Leadership session it was noted the Governing Body had not appointed an Administrator. For example: the Governing Body shared an administrator appointment had not been done by the Governing Body.

Observed in HR File Review. In 2 of 12 HR files reviewed, During review of HR# 11 and the Volunteer HR file it was noted the organization had not ensured it had assessed the initial competency of the Volunteer as part of the orientation. For example: review of Volunteer HR file revealed no orientation documentation or initial competency documentation. Review of HR# 12's HR file revealed no documentation of an initial competence assessment. This was reviewed, discussed, and validated with the Administrator/DPCS designee.

Observed in Medical Management Session. During the Medical Director interview it was noted the alternate Medical Director had died approximately a month ago and the Medical Director shared a name of a new alternate Medical Director that was not listed on the organizational chart. This was discussed with the Administrator/DPCS designee that shared they did not have a contract for the alternate Medical Director or any other documentation to indicate that an Alternate Medical Director was in place. .

Observed in Record Review. In 6 of 14 patient records reviewed, During RRHV# 1, RR# 1, RR# 3, RR# 4, RR# 6, and D/# 2's patient records review it was noted the organization had not ensured it maintained complete and accurate patient records. For example: review of RRHV# 1's patient record revealed two Hospice Consent forms with the name of RRHV# 1's patient representative and no documentation of RRHV# 1's patient name or medical record number on any of the 4/4 pages to indicate the Hospice Consent was for RRHV# 1. In addition, the two Hospice Consent forms had different dates. One of the Hospice Consent form had signatures and dates approximately 16 days after the start of care. The second Hospice Consent form had signatures and a date approximately 30 days after the start of care with a line through the date and corrected to the start of care date. Further review of RRHV# 1's patient record revealed two Medicare Election of Benefits; one dated approximately 16 days after the start of care and the second one dated approximately 30 days after the start of care with a line through the date and corrected to the start of care date. Review of RR# 1's patient record revealed a Hospice Consent form with the name of RR# 1's patient representative and no documentation of RR# 1's patient name or medical record number on any of the 4/4 pages to indicate the Hospice Consent was for RR# 1. Review of RR# 3, RR# 4, RR# 6, and D/C# 2's patient records revealed the patient representative name on the Hospice Consents and no documentation of the patients' names or medical record number on any of the 4/4 pages to indicate the Hospice Consent was for any of the patients. This was reviewed, discussed, and validated with the Administrator/DPCS designee.

Observed in Patient Home. In 1 of 3 home visits conducted, During RRHV# 1's home observation it was noted the organization had not ensured the patient record contained information that reflected the patient's care treatment, or services. For example: during RRHV# 1's home observation the Licensed Vocational Nurse (LVN) was observed completing a medication reconciliation. During the medication reconciliation it was noted the Assisted Living Facility's (ALF) medication administration record had documentation ondansetron as needed for nausea and vomiting. However, review of the hospice medication profile revealed no documentation of ondanestron. This was observed, reviewed, discussed, and validated with the LVN/Owner.

Observed in Record Review. In 6 of 14 patient records reviewed, During RRHV# 1, RRHV# 2, RRHV# 3, RR# 3, RR#,5, and RR# 6's patient record review it was noted the organization had not ensured all entries into the patient record were authenticated. For example: Review RRHV# 1's patient record revealed 25 unsigned skilled nurse (SN) visit notes with dates from four days to 287 days prior to the surveyor review of the record. In addition, the RN recertification, dated 89 days prior to the surveyor review of the record, was not signed. Review of RRHV# 2's patient record revealed six SN visit notes not signed dated from four days to 96 days prior to the surveyor review of the record. Review of RRHV# 3's patient record revealed two RN recertification comprehensive assessment not signed dated from 22 days to 140 days prior to the surveyor review of the record. Review of RR# 3's patient record revealed a social worker note not signed and dated 47 days prior to the surveyor review of the record. Review of RR# 5's patient record revealed 2 unsigned SN visit notes dated seven to 12 days prior to the surveyor review of the record. Review of RR# 6's patient record revealed a Chaplain initial assessment dated 14 days prior to the surveyor review of the record with no signature. This was discussed, and validated with the Administrator/DPCS designee.

Observed in Record Review. In 1 of 14 patient records reviewed, During RR# 6's patient record review it was noted the organization had not ensured it maintained the security and integrity of the health information. For example: review of RR# 6's patient record revealed a signed consent form for hospice services with white-out on the line for the Medicare number and new numbers written on the white-out. Further review of RR# 6's patient record revealed a faxed copy of a signed POLST with hand written name, date, and date of birth in black ink on the POLST.

Observed in Patient Home. In 2 of 2 home visits conducted with oxygen, During RRHV# 1 and RRHV# 3's home observations it was noted the organization had not ensured it identified risks associated with home oxygen therapy such as home fires. For example: during RRHV# 1's home observation the portable oxygen task was stored in RRHV# 1's assisted living facility (ALF) room closet along with the oxygen concentrator and other storage items. Education had not been provided during visit to reinforce the safety of tank storage. During RRHV# 3's home observation the portable oxygen tank was stored in a small closet with clothing over the top of the portable oxygen tank. Education had not been provided during visit to reinforce the safety of tank storage. This was observed, discussed, and validated with the LVN/Owner. Observed in Record Review. In 3 of 14 patient records reviewed, During RRHV# 1, RRHV# 2, and RRHV# 3's patient record review it was noted the organization had not ensured the caregivers were instructed on the safe use of side rails as a restraint according to the organization's policy Appropriate use of Restraints and supplies Policy No. 2-082.1 that included as part of the comprehensive assessment, each patient will be assessed regarding devices being used within the home as restraints. The clinician will, through interview and observation, determine the patient and family/caregiver have level of understanding in the appropriate use of the restraint. And documentation of instruction in the clinical record will include: information taught; patient and family/caregiver understanding; return demonstration; response to teaching. For example: RRHV# 1's home observation revealed RRHV# 1 was bed bound with 2 full bed rails. Review of RRHV# 3's patient record revealed RRHV# 1 had a terminal diagnosis of Alzheimer's and had bilateral leg contractions. Further review of RRHV# 1's patient record revealed no documentation of information taught, patient/caregiver understanding; return demonstration; or response to teaching. RRHV# 2's home observation revealed RRHV# 2 was bed bound with bilateral upper extremity contractions, and had 2 full bed rails. Review of RRHV# 2's patient record revealed 2 full bed rails for patient mobility. Further review of RRHV# 2's patient record revealed RRHV# 2 had a terminal diagnosis of dementia and unable to follow directions. Further review of the RRHV# 2's record revealed no documentation of information taught, patient/caregiver understanding; return demonstration; or response to teaching. RRHV# 3's home observation revealed RRHV# 3 was bed bound with contractions in bilateral upper extremities and 1 full bed rail with the bed up against the wall. Review of RRHV# 3's patient record revealed no documentation of information taught, patient/caregiver understanding; return demonstration; or response to teaching. This was discussed and validated with the Administrator/DPCS designee

Observed in Document Review. During contract review it was noted the organization failed to make arrangements to provide short term inpatient/general inpatient (GIP) and respite levels of care. For example: Review of the Contract binder revealed no contract for short term inpatient/GIP or respite levels of care. The Medical Director shared during an interview that when patients had symptoms that could not be controlled in the home the patient would revoke and be sent to the hospital as the hospice did not have a location for short term inpatient care. Discussion with LVN/Owner and Administrator/DPCS designee shared there was a contract and produced a contract signed by the former owner and an illegible signature with a title of Administrator under the signature and no printed name. In addition, the contract exhibits were blank that included how much the hospice would pay for services. Further review of the contract revealed a State License and Certificate of Insurance expired in 2021. Discussion with LVN/Owner, Administrator/DPCS designee and the Medical Director revealed the Medical Director would increase the level of hospice care to continuous care and if needed request placement for GIP from LVN/Owner and Administrator/DPCS designee. Interviewed Administrator of the contracted Skilled Nursing Facility (SNF) for GIP/Respite that was unfamiliar with the hospice organization and requested a photo of the Administrator signature, as he/she/they had been the administrator five years prior to the execution of the contract. The Administrator for the SNF reviewed the photo and stated it was not her signature and she did not have a copy of the contract in the facility. Review of the last 12 month patient discharge report revealed approximately 11 of the 40 discharges due to hospitalization/revocation. This was reviewed, discussed, and validated with the LVN/Owner.

Observed in Document Review. During RRHV# 3's home observation it was noted the organization had not ensured it provided care, treatment, or services through contractual agreement. For example: during the home observation it was noted that RRHV# 3 had been on hospice services for approximately 376 days and was a resident of an Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID). Review of the contract binder revealed no documentation of a contract/agreement with the ICF/IID. The LVN/Owner shared the organization's did not have a contract/agreement for the provision of hospice services at the ICF/IID. This was reviewed, discussed, and validated with the LVN/Owner.

Observed in Patient Home. In 1 of 1 home visits conducted in an ICF/IID, During RRHV# 3's home observation it was noted the organization had not ensured it coordinated the patient's care, treatment, or services based on the patient's needs. For example: during RRHV# 3's home observation it was noted RRHV# 3 was a resident of an Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID). Review of RRHV# 3's hospice binder at the ICF/IID revealed a hospice plan of care dated eight days prior to the surveyor home visit that had been faxed to the organization the same day as the surveyor's home visit. Further review of RRHV# 3's hospice binder revealed three hospice plans of care dated approximately four months, 10 months, and 11 months prior to the surveyor home visit. This was reviewed, discussed, and validated with the LVN/Owner.

Observed in Document Review. During contract review it was noted the organization had not ensured a contract was in place for RRHV# 3 that resided in an Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID). LVN/Owner shared she was not aware a contract was required that would include coordination with the ICF/IID regarding staff orientation and training for staff members providing hospice care to the patients in hospice.

Observed in HR File Review. In 5 of 12 HR files reviewed, During review of the Volunteer HR file, HR# 6, HR# 7, HR# 8, and HR# 12's HR files it was noted the organization had not conducted a criminal background check. For example: the Volunteer had started volunteering approximately nine months prior to the surveyor review of the HR file. HR# 6, HR# 7, and HR# 8 were contracted therapy staff and HR# 12 was a HHA that had been hired approximately 17 months prior to the surveyor review of the record. However, review of the Volunteer HR file, HR# 6, HR# 7, HR# 8, and HR# 12's HR file revealed no criminal background check. This was reviewed, discussed, and validated with the Administrator/DPCS designee.

Observed in Record Review. In 4 of 4 patient records reviewed, During RRHV# 1, RRHV# 2, RR# 6, and RR#7's patient records reviewed with a request for list of hospice non-covered items, it was noted the organization did not have a process for managing when a patient requested notice of non-covered items. The Administrator/DPCS designee shared the organization did not have a process in place to ensure patients received the list of hospice non-covered items when requested.

Observed in Patient Home. In 2 of 3 home visits conducted, During RRHV# 1 and RRHV# 2's home observation it was noted the organization had not ensured it managed the safety and security risks. For example: during RRHV# 1's home observation in a memory/dementia care Assisted Living Facility (ALF), RRHV# 1's personal caregiver was observed opening RRHV# 1's room door with a key. The LVN shared the doors were always locked, as there were multiple wandering residents. During RRHV# 1's home observation the ALF's staff member left the room and when the staff member returned was unable to open the door due to not having a key. RRHV# 2's home observation was in the same ALF with the room door locked at all times and only able to open from inside the room unless you had a key. During both home observations no education was provided to the ALF staff regarding the risk of someone not having a key to open the door or an evaluation of whom had keys readily available. This was discussed and validated with the LVN/Owner

Observed in Record Review. In 4 of 4 patient records reviewed, the organization failed to ensure that the initial comprehensive assessment was completed within 5 calendar days of the patient's admission. For example, in RR#1 it was noted that there was no documentation of an initial bereavement assessment, social work assessment or spiritual counselor assessment. In RR#2 the initial social work assessment was completed 27 days after admission and the bereavement assessment completed by the spiritual counselor was incomplete. It stated good family support, but did not include the identity of any bereaved. In RR#3 the initial social work assessment was completed 13 days after admission. In RR#4 there was no documentation of an initial bereavement assessment. This was discussed with the CEO, DPCS Designee, staff RN and QAPI Manager.

Observed in Record Review. In 3 of 4 patient records reviewed, the organization failed to ensure that the individualized written plan of care reflected the patient and family goals and interventions based on the problems identified in the assessments. For example, in RR#2, RR#3, and RR#4 there were no current goals, all the goals were Resolved. This was discussed with the CEO, QAPI Manager, staff RN and DPCS designee.

Observed in Record Review. In 2 of 4 patient records reviewed, the organization failed to ensure that the care and services were provided in accordance with the plan of care. For example, in RR#3 it was noted that the HHA was to provide 2 visits a week and during 1 week in March provided 3 visits. There was no mention in IDG, change in POC or supplemental order. In RR#4 it was noted that the spiritual counselor was to see the patient 1 time a month, however for 2 of the 5 months of service there were no documented visits by the spiritual counselor or documentation of refusal of visit. This was discussed with the CEO. QAPI Manger, staff RN and DPCS designee.

Observed in Record Review. In 2 of 4 patient records reviewed, that included aide care, the organization failed to ensure that the quality of care and services provided by the hospice aide was assessed by the RN no less frequently than every 14 days. For example, in RR#4 there was noted to be a 22 day gap in the RN aide supervisory visits in the months of March and April. In RR#2 a aide supervisory visit was incomplete, the RN had written that the family was happy with the care, however had not completed the listed areas of supervision such as, Do aide services meet patient's need?. This was discussed with the CEO. DPCS Designee, QAPI Manager and staff RN.

Observed in Leadership Session. During Leadership session it was discovered that the leaders had not created and implemented a process for managing behaviors that undermine a culture of safety. This was discussed with the CEO, DPCS Designee, QAPI Manager and staff RN.

Observed in Record Review. In 4 of 4 patient records reviewed, the organization failed to ensure that the record reflected the patient's care, treatment, and/or services. For example, in RR#2 all of the LVN notes (10 of 14 skilled nurse notes) were incomplete, most contained a time in and out and some other documentation, however they were all indicated as a Draft note and were not complete and signed. Also, in RR#3, 15 of 20 skilled nurse notes and RR#4, 2 of 47 skilled nurse notes were incomplete, most contained a time in and out and some other documentation, however they were all indicated as a Draft note and were not complete and signed. In RR#1 there was no visit documentation for 9 days for SN and HHA visits, no notes. The DPCS designee stated that the visits had been done, but not documented yet. The organization's policy required that notes are completed and submitted within 5 days. This was discussed with the CEO, DPSC designee, staff RN and QAPI manager.

Observed in Record Review. In 2 of 4 patient records reviewed, The organization failed to ensure that the initial comprehensive assess was completed within 5 calendar days of the patient's admission. For example: Upon review of RR#4 it was noted that the initial MSW assessment was not completed until 13 days after admission. On RR#3 the MSW assessment was done 8 days after admission. These observations were reviewed with the CEO, DPCS, and the RN Supervisor.

Observed in Record Review. In 4 of 4 patient records reviewed, the organization failed to ensure that the individualized written plan of care reflected the patient and family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessment. For example: in review of RR#1, and RR#2, the patient was receiving services from the Chaplain and the MSW however there were no care plans to address psychosocial, or the patient's spirituals needs. For RR#3 and RR#4 the MSW is seeing the patient monthly yet there is no care plan to address psychosocial needs. These observations were reviewed with the CEO, DPCS, and RN Supervisor.

Observed in Record Review. In 2 of 4 patient records reviewed, the organization failed to ensure that the care and services were provided in accordance with the plan of care. For example: upon review of RR#2 it was noted that the MSW was seeing the patient one time each certification period, yet there had been no order set for MSW frequency beyond the initial assessment order. In RR#4 the MSW was seeing the patient monthly however there was no frequency order beyond the initial assessment order. For the chaplain in RR#4, the initial assessment noted the patient was to be visited each certification period, however there is no frequency established beyond the initial assessment order. This observation was reviewed with the CEO, and RN Supervisor.

Observed in Data Session. During the data management session it was noted that the hospice failed to develop, implement, and maintain an effective, ongoing, and data-driven QAPI program that reflected the complexity of its organization and services, as the organization failed to incorporate performance improvement activities to demonstrate improvement in hospice performance. The QAPI program did not address clinical record reviews. Clinical record reviews could have identified areas of risk relevant to the quality and safety of care provided. The QAPI program also did not review the organization's culture of safety. This observation was reviewed with the CEO, DPCS, QAPI Coordinator, and RN Supervisor.

Observed in Record Review. In 1 of 4 patient records reviewed, the organization failed to ensure that the quality of care and services provided by the hospice aide was assessed by the RN no less frequently than every 14 days. For example: in review of RR#3 there was noted to be a 15 day gap in the RN aide supervisory visits in the months of February, April and again in June. These observations were reviewed with the CEO, DPCS, and the RN Supervisor.

Observed in Leadership Session. The governing body/leadership did not ensure that the following Conditions of Participation were met as determined through observations, documentation, and staff interviews:  - §418.100 and 418.58

Observed in Record Review. In 1 of 4 patient records reviewed, the organization failed to ensure that the record reflected the patient's care, treatment, and/or services. For example: on review of RR#1 all LVN notes in the record were incomplete, most contained a time in and time out with little other documentation. This observation was reviewed with the CEO, DPCS, and the RN Supervisor.