Every finding on record at Sun Care Hospice Inc.

Upon patient record review, 1 of 5 (Patient #4) did not contain evidence that the Plan of Care included all services necessary for the palliation and management of the terminal illness and related conditions, including the following: A detailed statement of both the scope and frequency of services necessary to meet the specific patient and family need: Patient #4: The most recent IDG Meeting dated 11/08/24 listed, "Initial SW assessment and as needed once per month." A discipline's ordered visit frequency cannot include a p.r.n. visit frequency, without a baseline frequency to support it.

Upon observation, there was not evidence that the annual report documented 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.

Upon Inpatient contract review, 1 of 1 (Hampden Hills) did not contain evidence that a copy of the Discharge Summary shall be provided to the Hospice at the time of a patient's discharge from the inpatient facility.

Upon patient record review, 3 of 15 (Patient #3,7,15) 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 #3 has oxygen use in place with no evidence of the oxygen order on the medication profile. Patient #7 has Triamcinolone cream ordered on the medication profile, however no evidence of indication of where to apply cream. Patient #15 has Calmoseptine ordered on the medication profile, however no evidence of indication of where to apply cream.

Upon patient record review, 1 of 15 (Patient #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.

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

Upon observation, there was no evidence the hospice has an interdisciplinary group (IDG) or groups composed of individuals who work together to meet the physical, medical, psychosocial, emotional, and spiritual needs of the hospice patients and families facing terminal illness and bereavement. Interdisciplinary group members must provide the care and services offered by the hospice, and the group, in its entirety, must supervise the care and services. The agency does not employ a medical social worker or pastoral or other counselor to participate in IDG and for patient/family needs.

Upon patient record review, 3 of 15 (Patient #3,7,15) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #3 has oxygen use in place with no evidence of the oxygen order. Patient #7 has Triamcinolone cream ordered, however no evidence of indication of where to apply cream. Patient #15 has Calmoseptine ordered, however no evidence of indication of where to apply cream.

Upon client record review, 11 of 15 (Patient #3,4,6,7,8,9,10,11,12,13,15) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #3 on 8/27/27 and 8/29/24 SN note states "wound care completed as area cleansed, meta-honey applied and 4x4 dressing applied" on 9/5/24 SN note states "Dressing change included removing previous dressing, cleaning wound and peri-skin with wound cleanser, apply the covering with ABD and securing with Kerlix, then apply the elastic compress stocking and secure with self adhering wrap", on 9/10/24 SN note states "Wound care completed per orders, patient tolerated well", on 9/13/24 SN note states "Wound care completed per orders", no evidence of wound care orders in place. Patient #4: Order for MSW for initial visit not performed. Patient #6 on 9/19/24 orders in place for "Volunteer as needed", no evidence of a volunteer for the agency. Patient #7: Order for MSW for initial visit not performed. Patient #8: Order for MSW for initial visit not performed. Patient #9 Order for MSW for initial visit not performed and on 4/3/24 orders in place for MSW visits 1/month, no evidence of MSW visits made. Patient #10 Order for MSW for initial visit not performed and on 4/2/24 orders in place for MSW visits 1/month, no evidence of MSW visits made. Patient #11 Order for MSW for initial visit not performed and on 6/5/24 orders in place for MSW visits 1/month, no evidence of MSW visits made. Patient #12 Order for MSW for initial visit not performed and on 7/18/24 orders in place for MSW visits 1/month, no evidence of MSW visits made. Patient #13 Order for MSW for initial visit not performed and on 4/5/24 orders in place for LVN 1/week, evidence of visits made only on 5/13/24 and 5/17/24. On 4/5/24 orders in place for RN initial visits and Q14 days with a new order in place on 5/17/24 stating RN visit 1 and PRN, evidence of RN visits made on 5/22/24, 5/29/24, 6/4/24, 6/12/24 and 6/28/24. Patient #15 Order for MSW for initial visit not performed and on 8/16/24 orders in place for SN 2x/week and 3 PRN and orders in place for RN Q14 days with visits made by an RN only on 8/20/24, 8/29/24 and 8/30/24, no evidence of SN visits per orders.

Upon observation, there was no evidence the hospice is in compliance with accepted professional standards and principles for all core services which includes medical social services and counseling services. The agency does not have evidence of medical social services or counseling employee(s).

Upon observation, there was no evidence the hospice provides medical social services as a core service.

Upon personnel record review, 1 of 19 (Personnel #13) did not have evidence that all bereavement services are provided by a qualified counselor in accordance with applicable laws and regulations, professional practice standards, the hospice's policies and procedures and/or job descriptions which includes experience or education in grief or loss counseling. No evidence of counselor.

Upon observation, there was no evidence the hospice is in compliance with accepted professional standards and principles for all non-core services which includes volunteers, physical therapy, occupational therapy and speech-language pathology.

Upon patient record review 1 of 15 (Patient #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 #14 on 4/1/24 orders in place for aide2x/week with an active care plan on 4/9/24, no evidence of any aide visits made.

Upon personnel record review, the agency did not have evidence the of an individual who supervises volunteers is qualified by meeting the hospice's policies and procedures and/or job description criteria and is a designated hospice employee as agency did not have evidence of Volunteer Coordinator.

Upon observation, there was no evidence volunteers are used in day to day administrative and/or direct patient care roles. The agency did not have volunteers

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.

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. The Board of Director/governing body did not ensure the appointed administrator (Personnel #9) was qualified per agency policy and job description. The job description for the Administrator approved by the governing body states the following: "A healthcare professional with 2 years health related experience, knowledge and ability to effectively admin the hospice services" and there is no evidence the Administrator meeting the requirements on the job application or resume in the personnel file. In addition, did not ensure appropriate care and services available to patients/families as there was no evidence of core disciplines such as medical social services and pastoral or counseling services, short-term inpatient/respite, medical supplies (including drugs and biologicals) and medical appliance, along with non-core services of PT/OT/SLP, or volunteer, volunteer coordinator.

Upon observation, there was no evidence the hospice is primarily engaged in providing the following care and services: • Medical social services • Counseling services, including spiritual counseling, dietary counseling and bereavement counseling • Volunteer • Physical therapy, occupational therapy, speech-language pathology services • Short-term inpatient care • Medical supplies (including drugs and biologicals) and medical appliance

Upon personnel record review, 8 of 19 (Personnel #2,3,4,5,6,7,8,9) did not have evidence that a skills competency assessment, specific to each discipline had been conducted for all personnel including volunteers initially during orientation.

Upon patient client record review, 3 of 15 (Patient #3,7,8) did not have evidence that each patient record contains Advance Directives. All patients had DNR however, this was not signed by the physician.

Upon client record review, 1 of 15 (Patient #13) did not have evidence that the discharge summary includes all required information.

Condition of Participation: Personnel Qualifications.

Upon personnel record review, 1 of 19 (Personnel #15 ) did not have evidence that personnel credentialing activities are conducted to verify qualifications of all credentialed/licensed personnel in the positions they hold at the time of hire, at renewal or in accordance with specific state practice act requirements. No evidence of social worker for license verification.

Upon personnel record review, 1 of 19 (Personnel #19) 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. No evidence of SLP file.

Upon personnel record review, 1 of 19 (Personnel #18) 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. No evidence of OT file.

Upon personnel record review, 1 of 19 (Personnel #17) did not have evidence all Physical Therapy Services are provided by a qualified licensed Physical Therapist (PT) in accordance with the state's Physical Therapy Practice Act and the hospice's policies and procedures and/or job descriptions. No evidence of PT file

Upon personnel record review, 3 of 19 (Personnel #17,18,19) 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. Agency does not employ nor contract for PT/OT/SLP

Upon personnel record review, 5 of 19 (Personnel #12,13,14,15,16) did not have evidence of criminal background checks being obtained in accordance with state requirements. In the absence of state requirements, criminal background checks are obtained within three months of the date of employment for all states that the individual has lived or worked in the past 3 years. Agency does not employ social work, counseling, volunteer, or volunteer coordinator.