Every finding on record at Southwest Hospice Inc

Based on record review and interview, the Agency failed to review and update at least annually it’s Emergency Preparedness Training and Testing program for 1 (2023) of 3 years for which documentation was requested. This failure had the potential that Agency employees would not know their role in an emergency and has the potential to place clients at risk of harm. --- Findings include:During the Entrance Conference conducted with the Administrator and the Supervising Nurse on 04/29/2025 at approximately 10:30 AM, Surveyor requested documentation of Emergency Preparedness Planning and Implementation including drills for 2022, 2023 and 2024. Documentation provided by the Supervising Nurse revealed Emergency Preparedness Planning and Implementation for the years of 2022 and 2024. The documentation failed to include evidence that a drill was conducted for the year of 2023. On 04/29/2025 at approximately 4:20 PM, the Supervising Nurse stated that she had located documentation of Emergency Preparedness Drills for 2022 and 2024, however was unable to find documentation for the year of 2023.  The Supervising Nurse stated that she was recently hired as the Supervising Nurse four weeks ago and was unsure if the Agency had conducted a drill in 2023. During the exit conference on 05/02/2025 at 5:00 PM, the findings were discussed with the Administrator. The Administrator stated during 2023, the Former Supervising Nurse was responsible for maintaining documentation of Emergency Preparedness. The Administrator stated the Agency did conduct evaluations of their Emergency Preparedness Plan in 2023, however documentation had been misplaced in the move when the Agency moved from Address A to Address B. No additional information was provided.Review of the Agency’s policy and procedure manual revealed a policy titled “Testing Program for Emergency Operations Plan (EOP),” with a revision date of 02/2021, which read in part, “Hospice will conduct exercises to test the EOP at least biennially. Hospice will do the following: Participate in a full-scale exercise that is community-based or when a community-based exercise is not accessible, an individual, facility-based exercise….Conduct an additional exercise that may include, but is not limited to the following: - A second full-scale exercise that is community-based or individual, facility-based. A tabletop exercise that includes a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages or prepared questions designed to challenge the EOP…Analyze Hospice’s response to and maintain documentation of all drills, tabletop exercises and emergency events.”

Based on record review and interview, the Hospice failed to maintain documentation of cost savings achieved through the use of volunteers for 1 of 2 calendar years requested (2023), for which documentation of cost savings achieved through the use of volunteers was requested.This failure resulted in the Hospice being unable to provide documentation of utilization of volunteers for the calendar year of 2023 and has the potential to result in substandard care in that it is unknown who was occupying a position as a volunteer, and what time they spent occupying those positions. --- Findings included:During the Entrance Conference conducted with the Administrator and the Supervising Nurse on 04/29/2025 at approximately 10:30 AM, Surveyor requested documentation of cost savings achieved through the use of volunteers for the years of 2023 and 2024. On 04/29/2025 at approximately 4:20 PM, the Supervising Nurse stated that she had located documentation of cost savings achieved through the use of volunteers for the year of 2024, however was unable to find documentation for the year of 2023.On 05/02/2025 at approximately 4:50 PM, an interview was conducted with the Administrator. The Administrator stated that Hospice Aide A was the volunteer coordinator and was responsible for maintaining documentation of volunteer utilization during the year of 2023. The Administrator stated Hospice Aide A was no longer employed by the Agency. The Administrator stated that volunteers were utilized during the year of 2023, however the Agency had misplaced the documentation when they moved from Address A to Address B. Review of the Agency’s policy and procedure manual revealed a policy titled “Volunteer Services,” with a revision date of 02/2021, which read in part, “Hospice will document the cost savings achieved through the use of volunteers and will include: Identification of each position occupied by volunteers. The work time spent by volunteer occupying those positions. Estimate of the dollar cost that Hospice would have incurred if paid employees occupied positions identified. Hospice will document and maintain a volunteer staff sufficient to provide administrative and/or direct patient care in an amount that, at a minimum, equals 5% of the total patient care hours of all paid hospice employees and contract staff. Hospice will document a continuing level of volunteer activity. Hospice will maintain records on the use of volunteer for patient care and administrative services, including the type of services and time worked."

Condition of Participation: Emergency Preparedness

Upon observation, there was no evidence of contracts/agreements with other facilities/agencies/hospices to receive patients in the event the hospice cannot provide care to their patients during an emergency. Corrected on site.

Upon observation, there was no evidence the Emergency Plan communication plan must includes a primary and alternate means for communicating with hospice's employees. Corrected on site.

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. No evidence of emergency preparedness training, no drills. A report was written for weather event that occurred last week, and the QAPI RN signed that she had reviewed the EP plan.

Upon personnel record review, 10 of 13 (Personnel #1,#2,#3,#4,#5,#6,#7,#8,#9,#10 ) did not have evidence Emergency Preparedness training including: • Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles • Demonstrate staff knowledge of emergency procedures • Provide emergency preparedness training at least annually • 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,#2,#3,#4,#5,#6,#7,#8,#9,#10: No evidence of Emergency preparedness training.

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

Upon patient record review 9 of 14 (Patient #1,#4,#7,#8,#9,#10,#11,#13,#14) 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 #1: SOC 3/21/2024. no evidence of a spiritual assessment by SC until 5/2/2024 (not enough info in SN SOC assessment). Patient #4: SOC 4/26/2024. no evidence of a spiritual assessment by SC until 10/29/2024 (not enough info in SN SOC assessment). Patient #7: SOC 10/19/2024. no evidence of a spiritual assessment by SC until 10/25/2024 (not enough info in SN SOC assessment). Patient #8: SOC 10/5/2024. no evidence of a spiritual assessment by SC until 10/15/2024 (not enough info in SN SOC assessment). Patient #9: SOC 8/31/2023. no evidence of a spiritual assessment by SC until 9/13/2023 (not enough info in SN SOC assessment). Patient #10: SOC 12/6/2024. no evidence of a spiritual assessment by SC until 12/18/2024 (not enough info in SN SOC assessment). Patient #11: SOC 1/4/2024. no evidence of a spiritual assessment by SC until 1/23/2024 (not enough info in SN SOC assessment). Patient #13: SOC 8/13/2024. no evidence of a spiritual assessment by SC until 8/26/2024 (not enough info in SN SOC assessment). Patient #14: SOC 9/25/2024. no evidence of a spiritual assessment by SC until 10/4/2024 (not enough info in SN SOC assessment)

Upon patient record review 1 of 14 (Patient #2) 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 #2: No evidence of a spiritual assessment (SN Assessment does not have enough information).

Upon patient record review, 2 of 14 (Patient #2, #6) 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 #2: On home visit medication reconciliation found pt. to be taking Aspirin 81mg PO QD, No evidence on Hospice profile for this medication. Corrected on site. Patient #6: Medication profile dated 12/26/2024 included Voltaren gel 1% apply 1GM 3x day for osteo arthritis. There was no evidence of an area to apply. Corrected on site.

Upon patient record review, 9 of 14 (Patient #1,#2,#4,#7,#8,#9,#10,#11,#13) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient #1: SOC 3/21/2024. Bereavement assessment done 5/2/2024. Patient #2: No evidence of a bereavement assessment completed. Patient #4: No evidence of a bereavement assessment completed. Patient #7: SOC 10/19/2024. Bereavement assessment done 10/25/2024. Patient #8: SOC 10/5/2024. Bereavement assessment done 10/15/2024. Patient #9: No evidence of a bereavement assessment completed. Patient #10: No evidence of a bereavement assessment completed. Patient #11: No evidence of a bereavement assessment completed. Patient #13: SOC 8/13/2024. Bereavement assessment done 9/17/2024.

Upon patient record review, 3 of 14 (Patient #1,#12,#13) 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 #1: No evidence of a comprehensive assessment from 6/10/2024-11/14/2024. Patient #12: No evidence of a comprehensive assessment from 2/8/2024-through end of care (no visit for dc date of 2/28/2024). Patient #13: No evidence of a comprehensive assessment from 8/19/2024-9/6/2024.

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

Upon patient record review, 9 of 14 (Patient #1,#3,#4,#7,#8,#10,#11,#12,#13) 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:On SN SOC identified pt. taking Plavix, issues with dysphagia and no funeral planning done. No evidence of POC for problem/interventions/goals for bleeding precautions, dysphagia or funeral planning. Corrected on site. Patient #3:On SN SOC identified pt. had no funeral planning done. No evidence of POC for problem/interventions/goals for funeral planning. Corrected on site. Patient #4:On SN SOC identified pt. had no funeral planning done. No evidence of POC for problem/interventions/goals for funeral planning. Corrected on site. Patient #7: On SN SOC identified pt. has G-tube, No evidence on POC for problem/intervention/goals for G-tube. Corrected on site. Patient #8:On SN SOC identified issues with dysphagia. No evidence of POC for problem/interventions/goals for dysphagia. Corrected on site. Patient #10: ON SN SOC identified history if aspiration and taking Eliquis. No evidence of POC for problem/interventions/goals for dysphagia/aspiration and bleeding precautions. Corrected on site. Patient #11: On SN SOC identified pt. has O2 and Clopidogrel. No evidence of POC for problem/interventions/goals for O2 and bleeding precautions. Patient #12: On SN SOC identified pt on O2, Eliquis, aspiration precautions, elimination problems and need for funeral planning. POC generated only had titles for these items and no problem/interventions/goals were included. Patient #13: On SN SOC identified pt. taking Eliquis. No evidence of POC for problem/interventions/goals for bleeding precautions.

Upon patient record review, 2 of 14 (Patient #2,#6) 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 #2: On home visit medication reconciliation found pt. to be taking Aspirin 81mg PO QD, No evidence of a Hospice order for this medication. Corrected on site. Patient #6: Order dated 12/26/2024 included Voltaren gel 1% apply 1GM 3x day for osteo arthritis. There was no evidence of an area to apply. Corrected on site.

Upon client record review, 10 of 14 (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. Patients #1,#2,#3,#4,#5,#6,#7,#8,#9,#10: IDG occurred on 1/7/2025 and again on 1/23/2025- 16 days apart.

Upon client record review, 9 of 14 (Patient #1,#5,#6,#7,#8,#9,#11,#12,#14) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1: Order for SN visits dated 3/21/2024, no evidence of SN visits from 6/10/2024-11/14/2024. Patient #5: Order for SC dated 11/27/2024 1x month and 3 PRN. No evidence of SC visit month of December 2024. Patient #6: Order for SN dated 12/23/2024 1x week. No evidence of a visit or missed visit week of 1/19/2025. Patient #7: Order for SC dated 10/21/2024 1x month and 3 PRN. No evidence of visits months of November or December 2024. Patient #8: Order for SN dated 12/12/2024 1x week. No evidence of a visit or missed visit week of 1/19/2025. Patient #9: Order for SC dated 12/12/2024 1x month. No evidence of a SC visit for month of December 2024. Patient #11: Order for SN dated 1/10/2024 1x week. No evidence of visits or missed visits weeks of 3/10/2024, 3/24/2024 and 4/7/2024. Patient #12: Order for SN dated 1/22/2024 1x week. No evidence of SN visits for weeks of 1/28/24, 2/11/2024 and 2/25/2024. Patient #14: Pt SOC 9/25/2024. No evidence of order for SN visit frequency until 11/24/24 order of 1x week with 2 PRN. Visits were made weekly from start of care through 11/24/2024. Week of 11/24/2024 SN visited 2x with an additional PRN.

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. There is policy related to plan for QAPI, no audits until 1/24/2025.

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. No evidence of QAPI activities since 2023, first audit of charts occurred 1/24/2025, with a meeting following on 1/27/2025.

Upon observation, there was no evidence the program must use quality indicator data, including patient care, and other relevant data, in the design of the program. No activity with QAPI since 2023 per DON.

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 No evidence of patient monitoring until 1/24/2025.

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

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 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 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 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. Agency is collecting data in logs for pt. and employee infection. No aggregate of same.

Condition of Participation: Hospice Aide and Homemaker Services. L607

Upon patient record review, 6 of 14 (Patient #1,#2,#3,#5,#6,#7) 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: Per SN assessment, patient is on Plavix, has risk of falls, and is at risk of aspiration with dysphagia. No evidence on the aide assignment of fall, bleeding, or aspiration precautions. Corrected on site. Patient #2: Pt has order for O2, no evidence on the aide assignment for O2 precautions. Corrected on site. Patient #3: Pt has order for O2 and Clopidogrel, no evidence on the aide assignment for O2 and bleeding precautions. Corrected on site. Patient #5: Pt has order for O2 and SN assessed for seizure precautions, no evidence on the aide assignment for O2 and seizure precautions. Corrected on site. Patient #6: Pt has order for O2 and Eliquis, no evidence on the aide assignment for O2 and bleeding precautions. Corrected on site. Patient #7: SN identified pt. at risk for falls, no evidence on aide assignment of fall precautions. Corrected on site.

Upon patient record review 8 of 14 (Patient #1,#2,#5,#6,#7,#9,#10,#14) 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:Order 12/23/2024 Aide visit 2x week. Visits were performed 3x week for weeks of 12/29/2024, 1/5/2025 and 1/12/2025. No visits documented for week of 1/19/2025. Patient #2:Order 12/3/2024 aide 2 x week, order 12/8/2024 aide visits 3x week. Last IDG of 1/23/2025 continues to have aide visit frequency at 3x week. there is no evidence of any aide visits since start of care (supervisory visits were done). Patient #5: Order on IDG POC dated 12/12/2024 aide visit frequency 3x week. Week of 12/29/2024 two visits were made with no evidence of a missed visit. Patient #6: Order 12/23/2024 aide visits 3x week. Week of 1/20/2025 one visit made with no evidence of missed visits. Patient #7: Order dated 10/19/2024 aide visits 2x week. Weeks of 12/22/2024 and 1/5/2025 one visit made with no evidence of missed visits. Patient #9: Order dated 9/15/2024 aide visits 2x week. Weeks of 12/15/24, 12/22/24, 1/5/25, 1/12/25 and 1/19/2025 3 visits per week were made. Patient #10: Order dated 12/12/2024 aide visits 3x week. Weeks of 12/15/24 and 12/18/24 2 visits per week were made. No visits were made for weeks of 12/29/24, 1/5/24, 1/12/25, 1/19/25. Patient #14: Order dated 9/25/2024 aide visits 2 x week. No evidence of any aide visits made (supervisory visits made by RN).

Conditions of Participation - Volunteers. L641

Upon observation, there was no evidence the hospice documents and demonstrates viable and ongoing efforts to recruit and retain volunteers.

Upon observation, there was no evidence the hospice documented the cost savings achieved through the use of volunteers. Documentation must include the following: • The identification of each position that is occupied by a volunteer • The work time spent by volunteers occupying those positions • Estimates of the dollar costs that the hospice would have incurred if paid employees occupied the positions identified in paragraph (d)(1) of CFR 418.78 for the amount of time specified in paragraph (d)(2) of CFR 418.78

Upon observation, there was no evidence the annual report documents the use of volunteers providing day to day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract personnel. No reporting of use of volunteers.

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. There was no evidence of oversight of hospice as evidence by: -The last GB minutes presented are dated 12/22/2021, therefore not annual review since this time. -Lack of active QAPI program -Lack of active emergency preparedness program and training for staff -Lack of Administrator oversight for ensuring patient care/needs are being met and hospice agency is meeting Medicare Conditions of Participation

Upon patient client record review, 1 of 14 (Patient #12) did not evidence that each patient record contains physician orders. Patient #12: No evidence of a discharge order for extended prognosis.

Upon patient client record review, 1 of 14 (Patient #10) 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 #10: SN note in record is dated 12/21/2025 (should have been 12/24/2024 per DON).

Upon client record review, 1 of 14 (Patient #11) did not have evidence that if a patient revokes the election of hospice care or is discharged from hospice in accordance with §418.26, the hospice must forward to the patient's attending physician: • A copy of the hospice discharge summary • The patient's clinical record, if requested Patient #11: No evidence discharge summary sent to attending physician.

Upon client record review, 2 of 14 (Patient #11,#12) did not have evidence that the discharge summary includes all required information. Patient #11,#12: No evidence of a discharge summary.

Upon observation, there was no evidence a copy is provided of the hospice written policies and procedures on the management and disposal of controlled drugs to the patient or patient representative and family. Though there is documentation in each patient record that a copy of the hospice written policies and procedures on the management and disposal of controlled drugs to the patient or patient representative and family, there was no evidence the policy was a part of the admission packet and the DON agrees it was not.

Upon personnel record review, 1 of 13 (Personnel # 13) did not have evidence that all Speech Therapy Services are provided by a qualified licensed Speech-Language Pathologist (SLP) or Audiologist in accordance with the state's Speech-Language Pathology Practice Act and the hospice's policies and procedures and/or job descriptions. Personnel #13: No employee file provided.

Upon personnel record review, 1 of 13 (Personnel #12) did not have evidence all Occupational Therapy Services are provided by a qualified licensed Occupational Therapist (OT) in accordance with the state's Occupational Therapy Practice Act and the hospice's policies and procedures and/or job descriptions. Personnel #12: No employee file for OT provided.

Upon personnel record review, 2 of 13 (Personnel #12,#13) did not have evidence the hospice obtained a criminal background check on all contracted individuals who have direct patient care and access to patient records. No HR files available for review.

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

Upon patient record review 9 of 11 (Patient #1, 2, 3, 4, 5, 6, 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, 2, 3, 4, 5, 6, 8, 9, 10-There is no evidence in the patient records that the psychosocial, emotional, and spiritual needs of the patient were assessed.

Upon patient record review, 5 of 11 (Patient #1, 2, 4, 6, 7) 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 Orders in the record for oxygen effective 2/2/22 not listed in the medication profile. Patient #2 Orders in the record for oxygen effective 2/2/22 not listed in the medication profile. Patient #4 Orders in the record for oxygen effective 2/2/22 not listed in the medication profile. Patient #6 Orders in the record for oxygen effective 2/2/22 not listed in the medication profile. Patient #7 Oxygen ordered at the time of admit on 4/27/21, not included in the medication profile.

Upon patient record review,11 of 11 (Patient #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient #1, 2, 3, 5, 6, 7, 8, 9, 10, 11 Upon admit and to date, there is no evidence of an initial bereavement assessment completed. Patient #4 Upon admit, there is no evidence of an initial bereavement assessment completed within 5 days,

Upon patient record review, 1 of 11 (Patient #8) 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 #8 Evidence in the record show the patient had S/S of approaching death effective 12/21/21 with no further assessments and no communication was provided to the IDG. The patient died on 1/1/22.

Upon patient record review, 1 of 11 (Patient #8) 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 #8 There is evidence in the record that the patient showed s/s of approaching death on 12/21/21 with no update to the patient POC or coordination with the IDG members.

Upon patient record review, 5 of 11 (Patient #1, 4, 5, 6, 7) 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 DME on file for oxygen and suction effective 2/2/22, but not included in the patient plan of care. Patient #4 DME orders on file for Nebulizer & OTB table (7/23), oxygen (2/22), and hospital bed (6/22) but not included in the patient POC. Patient #5 DME orders on file for wheelchair (not dated) and shower chair (1/7) but not included in the patient POC. Patient #6 DME orders on file for wheeled walker, bed alarm, oxygen and nebulizer, but not included in the patient POC. Patient #7 DME order on file for bed, OTB table, oxygen, nebulizer and suction, but not included in the patient POC.

Upon client record review, 2 of 11(Patient #4, 6) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #4 The POC does not include orders for SW visits, but the record reflects SW visits made on 7/15, 8/24, 10/21 and 2/19/22. Patient #6 The POC does not include orders for SW visits, but the record reflects a SW visit made on 2/22/22.

Condition of Participation: Core Services.

Upon observation, there was no evidence the hospice is in compliance with accepted professional standards and principles for all core services which includes nursing services, medical social services and counseling services. There was no evidence the agency had a spiritual care provider/chaplain at the time of survey which is a required core service.

Upon patient record review 2 of 3 applicable (Patient #10, 11) 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 #10 The POC orders reflect that the hospice aide services were discontinued on 1/17, but the aide continued to make visits until 2/24. Patient #11 The POC orders reflect that the hospice aide services will be provided 2x/week from 8/23 until discharge, the aide made a total of one visit on 9/7. The patient's last day on service was 12/24/21.

Condition of Participation: Medical Director.

Upon observation, there was no evidence the hospice designates a physician to serve as Medical Director which includes: • When the Medical Director is not available, a physician designated by the hospice assumes the same responsibilities and obligations as the Medical Director. The agency did not have an alternate Medical Director in place at the time of survey.

Upon patient client record review, 2 of 11 (Patient #1, 4) 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 recertification for the benefit period starting 9/6/21 was not signed timely in accordance to the agency policies. Signature was obtained on 2/15/22. The recertification for the benefit period starting 1/4/22 was not completed and signed timely in accordance with the agency policies. Signature obtained on 2/18/22. Patient #4 The CTI for benefit period #1, effective 6/22/21, was not signed timely in accordance with the agency policies. It was signed on 2/21/22. Benefit period #2, effective 9/20/21, was not signed timely in accordance with the agency policies. It was signed on 2/14/22.

Upon client record review, 1 of 1 applicable (Patient # 10) did not have evidence that the hospice forwarded a summary and a copy of the patient record, if requested, to a facility when transferring the patient to that facility. Patient #10 There is no evidence in the record that a transfer summary was completed or shared with the receiving hospice.

Upon client record review, 2 of 2 applicable (Patient #9, #11) did not have evidence that if a patient revokes the election of hospice care or is discharged from hospice in accordance with §418.26, the hospice must forward to the patient's attending physician: • A copy of the hospice discharge summary • The patient's clinical record, if requested Patient #9 There is no evidence in the patient record that a discharge summary was completed and sent to the attending physician at the time of discharge 2/7/22, and to date. Patient #11 There is no evidence in the patient record that a discharge summary was completed and sent to the attending physician at the time of discharge on 12/24/21 and to date.