Every finding on record at Studio City Hospice Inc

Upon patient record review, 2 of 5 (Patient #1 & #3) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient #1, & #3 MSW frequency listed as "one time then prn", SC frequency listed as "one time then prn"

Upon patient record review, 1 of 14 (Patient 3) did not have evidence that if a patient has been adjudged incompetent under state law by a court of proper jurisdiction, the rights of the patient are exercised by the person appointed to act on the patient's behalf. Patient 3: The hospice medical record did not contain evidence of the court appointed Conservatorship status that was present in the SNF record. Consents were executed by son of patient, who was not the Conservator for this patient.

Upon patient record review, 13 of 14 (Patient #1,2,3,4,5,6,7,8,9,11,12,13,14) did not have evidence in the patient's imminence of death. Patients: 1,2,3,4,5,6,7,8,9,11,12,13,14 did not contain evidence that admitting RN completed the imminence of death portion of the comprehensive assessment.

Upon patient record review, 4 of 14 (Patient 1,2,9,10) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient 1: The medical record contains a narrative by the nurse on 05/08/23 mentioning the patient using oxygen. There is no oxygen on the medication profile. Patient 2: SNF medication list reviewed by surveyor revealed a current MD order for Lovenox 40mg/0.4ml SQ daily written on 5/22/23, this was not included on the hospice medication profile. The hospice medication profile also had an order by hospice medical director on 7/21/23 to decrease the Lisinopril dose to 20mg orally every day. No evidence that this order has been implemented in SNF. No order on file in SNF record. Patient 9: The POC contains Oxygen in the DME list. There is no evidence of the Oxygen listed on the medication profile. Patient 10: medication profile included Clearlax 17gm/1 scoop orally prn daily for constipation, does not include diluent. The medication profile contains oxygen as follows: Oxygen 2-5 liter/min via NC or mask prn shortness of breath. And oxygen may be increased to 6-10liters/min if sats fall below 90%. Medication profile is incomplete as no parameters for administration are included. The record also contains a communication note "Trimethoprim/sulfamethoxazole and Cipro were ordered" There is no evidence of these medication being on the medication profile.

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

Upon patient record review, 10 of 14 (Patient 1,2,3,4,5,6,7,8,9,10) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient 1,2,3, 5: Frequency orders incomplete for MSW upon admission. Written as "MSW 1x then prn". Patient 4: Frequency orders incomplete for MSW upon admission. Written as " MSW 1x then prn". Patient 6: Frequency orders incomplete for MSW upon admission. Written as " MSW 1x then prn". Patient 7: Frequency orders incomplete for MSW and SC upon admission. Written as "MSW 1x then prn" and "SC 1x then prn". Also includes "NP 1 as needed" Patient 8: Frequency orders incomplete for MSW and SC upon admission. Written as "MSW 1x then prn" and "SC 1x then prn" Patient 9: The POC contains an order for MSW to continue to provide support to family. No evidence of a frequency. Patient 10: Frequency orders incomplete for MSW upon admission. Written as "MSW 1x then prn".

Upon patient record review, 5 of 14 (Patient 8,9,10,12,14) 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 medications and treatments. Patient 8: The POC has Oxygen listed on the DME supply list. There is no evidence of an order for Oxygen. Patient 9: The POC contains Oxygen in the DME list. There is no order for the Oxygen on the POC. Patient 10: The POC contains an order for clear lax 17gm daily with no diluent. The record contains a communication note Trimethoprim/sulfamethoxazole and Cipro were ordered. There is no evidence of these medication being on the POC. Patient 12: The POC contains an order to change G tube dressing daily with no evidence of details of the order. The POC contains an order to change the foley catheter with no directives or frequency. Patient 14: The POC 07/30/22 contains an order to change the PICC line dressing every 7 days and prn. There are no directives with the order.

Upon patient record review, 1 of 14 (Patient 12) 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 12: The medical record contains a note on 10/03/22 patient has an enteral pump. This pump is not listed on the POC.

Upon client record review, 9 of 14 (Patient 2,3,5,7,8,9,10,12,14) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 2 The medical record contains a Psychosocial assessment visit on 06/19/23 from 9-10am. The note is blank. No evidence the visit was completed per orders of 1x eval. Patient 3: The medical record contains evidence of a LVN visit on 07/12/23 from 10:30-11:00 AM. There is no evidence of documentation in the note, the note is blank. Unable to determine visit frequency compliance. Patient 5: The SN documented on 06/28/23 “SN administered Amlodipine Besylate 10mg”. There is no evidence of an order for Amlodipine Besylate. Patient 7: The POC 05/01/23 contains an order for SN 1x a week and 1 prn. There is no evidence the nurse completed a visit the weeks of 06/18/23-06/24/23 and 06/25/23-07/01/23. There is no evidence of a refusal for the visit and no missed visit documentation. The medical record contains an SN visit on 07/12/23. The visit note is left blank. Per agency policy PC.C15 Clinical Records all disciplines must submit their completed documentation within 7 days, no evidence of visits frequency compliance. Patient 8: The POC 04/23/23 contains an order for SN 1x a week and 1 PRN. There is evidence the patient was seen by SN twice in the same weeks on 04/23/23 and 04/29/23, 05/21/23 and 05/24/23, 06/04/23 and 06/09/23, 07/02/23 and 07/07/23, 07/16/23 and 07/19/23. There is no evidence these visits were PRN and no evidence of an order to increase the visits. Patient 9: The nurse documented on 03/17/23 “Wound cleansed with NS”. The order on POC is for the wound to be washed with sterile wound cleanse. Patient 10: The medical record contains documentation by the nurse that patient has a foley and is being suctioned for mucus plugs on 04/28/23. There is no evidence of an order for a foley or suctioning. Patient 12: The POC contains an order for SN 1x a week there is evidence pt was seen 10/03/22 and 10/06/22 with no evidence of a PRN or order for an extra visit. The medical record contains a note by the nurse 10/03/22 “pt still on Nutren 3.0 at 70ml/hr per enteral pump. There is no evidence of an order for this enteral feeding. Patient 14: The POC contains an order for Morphine 20mg/ml give 0.25ml every 2 hours prn. There is evidence the nurse on 07/31/22 gave 0.25ml of Morphine at 0600 and 0700. The POC contains an order for Ativan 0.5mg every 6 hours prn. There is evidence the nurse on 07/31/22 gave Ativan 0.5mg at 0500 and 0900. There is no evidence of an order to increase the frequency of either Morphine or the Ativan.

Upon patient record review 1 of 14 (Patient #2) did not have evidence that the IDG ensures that the care and services provided are based on all assessments of the patient and family needs. Patient 2: The medical record contains a communication note by the RN on 06/19/23: “Email from facility wanting CHHA”. There has not been an aide ordered for the patient as of this date.

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 medical record contains evidence the pt expired on 08/18/22 the first sympathy letter was sent 09/18/22. Per agency Bereavement Policy 4-006.1, the first bereavement letter is to be sent within the first 2 weeks of death.

Upon patient record review 2 of 14 (Patient 4,9) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient 4: The POC contains an order for aide 2 x a week. There is no evidence the aide visited the pt. No evidence of refusal. Patient 9: The POC 04/14/22 contains an order for aide 2x a week. There is no evidence the aide made a visit. On 04/21/22 there is a note to cancel aide visits by the nurse, no order. There is evidence the aide began visiting the patient on 10/22/22 weekly until 12/12/22. There is no evidence of an order for the correct frequency for aide visits until 12/10/22.

Upon observation, there was no evidence the hospice is directed by a Board of Directors/governing body/Administrator which assumes full legal authority and responsibility for the operation of the hospice. The agency has billed for the patients and submitted certification of terminal illness with several lacking signatures and narrative notes, several patients lacking face to face visits.

Condition of Participation: Medical Director.

Upon patient record review, 12 of 14 (Patient 1,2,3,5,6,7,8,9,10,11,12,14) did not have evidence that the medical director or physician designee provides written certification that it is anticipated that the patient's life expectancy is 6 months or less if the illness runs its normal course. The physician must consider the following when making this determination: • The primary terminal condition • Related diagnosis • Current subjective and objective medical findings • Current medication and treatment orders • Information about the medical management of any of the patient's conditions unrelated to the terminal illness Patient 1: The medical record contains a CTI 10/15/22 to be completed by the medical director that is not signed. Per agency Policy 4-022.1 “The signed and dated certification must be present prior to billing for each certification period”. Patient 2: The medical record contains a CTI 06/14/23 with narrative by the medical director “Based on referring physician’s assessment, patient is appropriate for hospice and has a prognosis of 6 months or less”. There is no evidence of any further documentation by the medical director. Patient 3: The medical record does not contain evidence of a CTI for admission 05/22/23 from the Medical director. The Medical director is the attending. Patient 5: The medical record contains a CTI by the medical director on 05/17/23. The physician documents “Based on referring physician’s assessment patient is appropriate for hospice and has a prognosis of 6 months or less”. There is no evidence of any further documentation by the medical director. Patient 6: The CTI narrative 05/24/23 by medical director is does not contain a signature by the medical director and the agency has billed for this. Patient 7: CTI dated 5/1/23 by the Medical Director is not signed and the agency has billed for this. Patient 8: The Medical record contains a CTI on 07/22/21 with no narrative completed by the Medical director. Patient 9: The medical record contains a CTI on 07/13/23 that says “see attached” in the narrative section and there is no evidence of an attachment. Patient 10: The medical record contains a CTI by the medical director with no signature on 03/07/23. Patient 11: The medical record contains a CTI on 04/04/23 by the medical director with no narrative. Patient 12: The medical record contains a CTI 09/28/22 by the Medical director with no narrative. Patient 14: The CTI medical director completed on 07/30/22 does not contain a narrative.

Upon patient record review, 1 of 14 (Patient #9) did not have evidence that before the recertification period for each patient, the medical director or physician designee must review the patient's clinical information and provide written documentation that it is anticipated that the patient's life expectancy is 6 months or less. Patient 9: The medical record contains a CTI on 07/13/23 that says “see attached” in the narrative section and there is no evidence of an attachment.

Condition of Participation: Clinical Records.

Upon record review, 5 of 14 (Patient 1,2,9,12,13) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient 1: The medical record contains Election of Benefits the form completed by the RN 10/15/22 : “I (name of representative) request to be admitted to Comprehensive Hospice”. The form should have the patient’s name in that space. The consents are signed by the patient's representative 10/16/22 and the SOC was 10/15/22. Patient 2: The medical record contains Election of Benefits the form completed by the RN 6/14/23: “I (name of representative) request to be admitted to Comprehensive Hospice”. The form should have the patient’s name in that space. The consents are signed by the representative 6/16/23 and the SOC was 06/14/23. Patient 9: The medical record contains an Election of Benefits that does not contain the election date. Patient 12: The Election of Benefits dated 09/28/23 does not contains specific identifiers of the chosen attending physician in the allotted place. Patient 13: The medical record contains an Election of Benefits with a place for the attending physician’s specific identifiers and this is left blank.

Upon patient record review, 5 of 14 (Patient 2,8,11,12,14) did not have evidence that each patient record contains Physician certification and recertification of terminal illness. Patient 2: The medical record contains a CTI 06/14/23 that is not signed by the attending physician. Patient 8: The medical record contains a CTI on 04/23/23 that is not signed by the attending physician. Patient 11: The medical record contains a CTI on 04/04/23 with no signature by the attending physician. Patient 12: The medical record contains a CTI on 09/28/22 that is not signed by the attending physician. Patient 14: The medical record contains a CTI 07/30/22 that is not signed by the attending physician.

Upon patient client record review, 1 of 14 (Patient 3) did not have evidence that each patient record contains Advance Directives. Patient 3: The patient was admitted to hospice on 5/22/23 with an Advanced Directive in place. Form has not been uploaded to hospice EMR. Advance Directive was found in SNF record only.

Upon patient client record review, 14 of 14 (Patient 1-14) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient 1,2,3,4,5,6,7,8,9,10,11,12,13,14: The medical record did not have appropriately authenticated signatures on consent paperwork that identifies discipline of staff who completed these documents. Patient 2: The medical record contains documentation on 07/21/23 by the MSW “all CR’s in place”. There is no evidence CR’s is an approved abbreviation. Patient 5: The medication profile 05/31/23 and order contains Lisinopril with an indication of “HPN”. There is no evidence of HPN being an approved abbreviation. Patient 6: The medication profile 05/24/23 and order contains Hydralazine and Nifedipine with an indication of “HPN”. There is no evidence of HPN being an approved abbreviation. Patient 7: The medication profile 05/01/23 and order contains Lisinopril with an indication of “HPN”. There is no evidence of HPN being an approved abbreviation. Patient 9: The medical record contains documentation by the nurse “Wound care treatment done at surgical site left breast” on 03/10/23 and 03/15/23. There is no evidence of the details of the wound care provided. Patient 10: The SN documented on 04/27/23 "PROM to all ext" There is no evidence ext is an approved abbreviation. Patient 11: The medical record contains documentation by the nurse on 04/20/23, 04/18/23 and 04/06/23 “Wound care done per order”. There is no evidence of the details of the wound care provided.

Upon client record review, 2 of 14 (Patient 11,12) did not have evidence that the discharge summary includes all required information. Patient 11: There is no evidence of the following documentation being included in the discharge summary: A summary of the patient's stay, including treatments, symptoms and pain management, The patient's current plan of care, patient's latest physician orders, any other documentation that will assist in post-discharge continuity of care or that is requested by the attending physician or receiving facility. Patient 12: The medical record contains a discharge summary that does not include the following elements: A summary of the patient's stay, including treatments, symptoms and pain management,the patient's current plan of care, the patient's latest physician orders,any other documentation that will assist in post-discharge continuity of care or that is requested by the attending physician or receiving facility.

Upon client record review, 3 of 14 (Patient 2,9,10) did not have evidence that the hospice plan of care identifies the care and services that are needed and specifically identify which provider (nursing facility or hospice) is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care. Patient 2: The POC contains an order for wound care to the scapula and left shoulder with no directive of who will perform the wound care. Patient is SNF resident. Patient 9: The POC 04/21/22 contains wound care orders that do not state who will perform the wound care. Patient 10: The POC contains wound care orders to the right buttocks but does not state who is to perform the wound care.

Upon observation, there was no evidence the hospice provides orientation to personnel of a SNF/NF or ICF/IID regarding the policies and procedures of the provision of care/service including all required content. Waterman Post Acute had no evidence of orientation provided to the SNF by the hospice.