Every finding on record at Sun Rise Hospice

Upon patient record review, 5 of 14 (Patient #8, #9, #10, #12 and #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. #8-There was no documentation of an initial bereavement assessment completed within the record. #9-There was no documentation of an initial bereavement assessment completed within the record. #10-There was no documentation of an initial bereavement assessment completed within the record. #12-There was no documentation of an initial bereavement assessment completed within the record. #13-There was no documentation of an initial bereavement assessment completed within the record.

Upon observation, there was no evidence the Emergency Plan communication plan must includes a primary and alternate means for communicating with hospice's employees and Federal, state, tribal, regional, and local emergency management agencies.

Upon personnel record review, 7 of 13 (Personnel #2, #5, #9, #10, #11, #12, #13) 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 #2, #9, #10, #11, #12, #13: The agency did not provide surveyor access to the personnel record. Personnel #5: The personnel record did not have evidence that the hospice employees received Emergency Preparedness training.

Condition of Participation: Patient’s Rights. L500

Upon patient record review, 1 of 6 (Patient #6) did not have evidence that the hospice informed and provided written information to the patient concerning its policies on advance directives, including a description of applicable state law. Patient #6: The agency did not provide access to the requested medical record to surveyor.

Upon patient record review, 1 of 6 (Patient #6) did not have evidence that the hospice obtained the patient's or representative's signature confirming that they received a copy of the Patient's Rights and Responsibilities. Patient #6: The agency did not provide access to the requested medical record to surveyor.

Upon patient record review, 1 of 6(Patient #6) did not have evidence that the patient has received effective pain management and symptom control from the hospice for conditions related to the terminal illness. Patient #6: The agency did not provide access to the requested medical record to surveyor timely.

Upon patient record review, 6 of 6 (Patient #1, #2, #3, #4, #5, #6) did not have evidence that the patient chooses a health care provider, including an attending physician. Patients #1,#2,#3,#4,#5: The medical record did not contain evidence the patient was given the option to choose a health care provider or attending physician. Patient #6: The agency did not provide access to the requested medical record to surveyor.

Upon patient record review, 1 of 6 (Patient #6) did not have evidence of the appropriate documentation for release of confidential information. Patient #6: The agency did not provide access to the requested medical record to surveyor.

Upon patient record review, 1 of 6 (Patient #6) did not have evidence that the patient received information about the services covered under the hospice benefit. Patient #6: The agency did not provide access to the requested medical record to surveyor.

Upon patient record review, 1 of 6 (Patient #6) did not have evidence that the patient received information about the scope of services that the hospice will provide and specific limitations on those services. Patient #6: The agency did not provide access to the requested medical record to surveyor.

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

Upon patient record review 1 of 6 (Patient #6) did not have evidence in the patient record that the hospice conducted and documented in writing a patient-specific comprehensive assessment that identifies the patient's need for hospice care and services, and the patient's need for physical, psychosocial, emotional, and spiritual care. This assessment includes all areas of hospice care related to the palliation and management of the terminal illness and related conditions. Patient #6: The agency did not provide access to the requested medical record to surveyor timely.

Upon patient record review 6 of 6 (Patient #1, #2, #3, #4, #5, #6) 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, 4, 5: The patient record did not contain evidence the physical, psychosocial, emotional and spiritual needs were identified as part of the comprehensive assessment. Patient #2, 3: The patient record did not contain evidence the emotional needs were identified as part of the comprehensive assessment. Patient #3: The patient record did not contain evidence the emotional needs were identified as part of the comprehensive assessment. Patient #6: The agency did not provide access to the requested medical record to surveyor timely.

Upon patient record review, 2 of 6 (Patient #5, #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 #5:The medication profile included Oxygen 2LPM NC. RN assessment on 7/30/22 documented Oxygen at 4.5 LPM NC. No evidence of Oxygen 4.5 LPM NC on medication profile. Patient #6: The agency did not provide access to the requested medical record to surveyor timely.

Upon patient record review, 6 of 6 (Patient #1, #2, #3, #4, #5, #6) 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, 4, 5: The patient record did not contain evidence of an initial bereavement risk assessment. Patient #6: The agency did not provide access to the requested medical record to surveyor timely.

Upon patient record review, 2 of 6 (Patient #2 and 6) 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 #2: The patient was admitted by the RN on 2/4/23. All visits on record 2/4/23-3/13/23 were performed by the LVN. The RN did not visit the patient to update the comprehensive assessment. Patient #6: The agency did not provide access to the requested medical record to surveyor timely.

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

Upon patient record review, 1 of 6 (Patient #6) did not have evidence in the patient record that the written plan of care is developed by the IDG, in consultation with the patient's attending physician. Patient #6: The agency did not provide access to the requested medical record to surveyor timely.

Upon patient record review, 2 of 6 (Patient #5, #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 #5: The record indicated that the patient had oxygen at 4.5 L/min via nasal cannula. There was no evidence of an order for oxygen at 4.5 L/min via nasal cannula. Patient #6: The agency did not provide access to the requested medical record to surveyor timely.

Upon patient record review, 2 of 6 (Patient #3, #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 equipment and supply needs. Patient #3: The plan of care dated 2/4/23 does not include all equipment needs. According to the nurses initial assessment on 2/4/23 the patient needs a walker and wheelchair. Patient #6: The agency did not provide access to the requested medical record to surveyor timely.

Upon client record review, 3 of 6 (Patient #4, #5, #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: Plan of care dated 8/12/22 included social work visit frequency of 1x evaluation. No social work visits made and no evidence of refusal of visits. orders for MSW no visit made Patient #5: Plan of care dated 7/30/22 included social work, bereavement, and spiritual visit frequency of 1x evaluations per caregiver request. No social work, bereavement, or spiritual visits made and no evidence of refusal of visits. Patient #6: The agency did not provide access to the requested medical record to surveyor timely.

Condition of Participation: Quality Assessment and Performance Improvement.

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. QAPI was not provided to the surveyor to review any items for compliance with 418.58.

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.

Upon observation, there was no evidence in the QAPI reports that the hospice maintains a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases.

Upon patient record review, 3 of 6 (Patient #4, #5, #6) did not have evidence that Social work services are based on the patient's psychosocial assessment and the patient/family's needs and acceptance of these services. Patient #4: The initial plan of care dated 8/12/22 contains an order for psychosocial assessment. The RN visit on 8/12/22 documents the family requests support from the Social Worker for mortuary assistance. The patient record did not contain evidence of a psychosocial assessment the by the Social Worker. The Social worker’s services are not provided in accordance with the plan of care. Patient #5: The initial plan of care dated 7/30/22 contains an order for psychosocial assessment. The family requested support from the medical social worker. The patient record did not contain evidence of a psychosocial assessment the by the Social worker. The Social worker’s services are not provided in accordance with the plan of care. Patient #6: The agency did not provide access to the requested medical record to surveyor timely.

Upon patient record review, 1 of 6 (Patient #4) 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 delivered Patient #4: The medical record did not contain evidence that bereavement services were available to the family or the development of a bereavement plan of care to meet the needs of the bereaved,

Condition of Participation: Furnishing of Non-core Services.

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. The surveyor was not able to review the volunteer program or personnel files for the volunteer coordinator or volunteer as these were not provided to the surveyor to be reviewed.

Condition of Participation: Hospice Aide and Homemaker Services. L607

Upon personnel record review, 1 of 13 (Personnel #13) did not have evidence that Hospice Aide Services are provided by a qualified individual in accordance with the appropriate state's regulations, the hospice's policies and procedures and/or job descriptions and the ACHC Glossary of Personnel Qualifications as defined by the Medicare Conditions of Participation. Personnel #13: The agency did not provide surveyor access to the personnel record timely.

Upon personnel record review, 1 of 13 (Personnel #13) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) ·Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff. ·Reading and recording temperature, pulse, and respiration ·Safe transfer techniques and ambulation. ·Normal range of motion and positioning ·Appropriate and safe techniques in personal hygiene and grooming that include-- ·(A) Bed bath ·(B) Sponge, tub, and shower bath ·(C) Shampoo, sink, tub, and bed ·(D) Nail and skin care ·(E) Oral hygiene ·(F) Toileting and elimination The other subject areas in this section may be evaluated through written examination, oral examination or after observation of a Hospice Aide with a patient. Personnel #13: The agency did not provide surveyor access to the personnel record.

Upon personnel record review, 1 of 13 (Personnel #2) did not have evidence that the RN who supervises classroom and practical training possesses a minimum of 2 years nursing experience, at least 1 year of which must be in home care. Personnel #2: The agency did not provide surveyor access to the personnel record timely.

Conditions of Participation - Volunteers. L641

Upon personnel record review, 1 of 13 (Personnel #11) did not have evidence the 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. Personnel #11: The agency did not provide surveyor access to the personnel record timely.

Upon observation, there was no evidence the hospice maintains, documents and provides volunteer orientation and training that is consistent with hospice industry standards.

Upon observation, there was no evidence volunteers are used in day to day administrative and/or direct patient care roles.

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

Condition of Participation: Organization and Administration of Services.

Upon observation, there was no evidence BOD/governing body minutes reflect the involvement in the hospice's management and administration of its resources to provide hospice services to patients and families. The agency did not provide QAPI reports to the surveyor upon request during the survey. The governing body minutes did not include review of the agency's QAPI program or performance improvement plans for years 2021 and 2022.

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 oversight provided to the hospice agency as evidence by several personnel without evidence of background checks, no evidence of competencies, no access to personnel records, no access to patient records timely, no access to ensure non-core services such as the volunteer program, no evidence of QAPI program to review, no evidence of governing body to review, no evidence of personnel file provided for DCPS/Alternate Administrator, and no evidence of RN to speak with during the survey. Upon personnel record review, 1 of 13 (Personnel #2) did not have evidence the alternate administrator's personnel record verifies that: • The employee has appropriate education and experience requirements • There is a signed job description for this role • The employee has been orientated to this role Personnel #2: The agency did not provide surveyor with access to the requested personnel record for the alternate administrator.

Upon personnel record review, 7 of 13 (Personnel #2, #3, #9, #10, #11, #12, #13) did not have evidence the hospice employees and contract employees have received orientation on the hospice philosophy. Personnel #2, #9, #10, #11, #12, #13: The agency did not provide surveyor access to the personnel record. Personnel #3: The personnel record did not have evidence that the hospice employees received orientation on the hospice philosophy.

Upon personnel record review, 7 of 13 (Personnel #2, #3, #5, #10, #11, #12, #13) did not have evidence that the hospice employees have received orientation on their specific job requirements. Personnel #2, #10, #11, #12, #13: The agency did not provide surveyor access to the personnel record. Personnel #3, #5: The personnel record did not have evidence that the hospice employees received orientation on their specific job requirements.

Upon personnel record review, 10 of 13 (Personnel #2, #3, #4, #5, #6, #9, #10 #11 #12, #13) did not have evidence that a skills competency assessment, specific to each discipline had been conducted for all personnel including volunteers initially during orientation. Personnel #2, #9, #10, #11, #12, #13: The agency did not provide surveyor access to the personnel record. Personnel #3, #4, #5, #6: The personnel record did not contain evidence of a skills competency assessment.

Upon patient record review, 1 of 6 (Patient #6) 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 #6: The agency did not provide access to the requested medical record to surveyor timely.

Condition of Participation: Clinical Records.

Upon patient client record review, 1 of 6 (Patient #6) did not have evidence that each patient record contains:(this references that the documentation is part of the patient record. Citing the inaccuracy of a component of the record is cited under other standards) • Initial plan of care • Updated plan of care • Initial assessments • Comprehensive assessments • Updated comprehensive assessments • Signed and dated clinical and progress notes Patient #6: The agency did not provide access to the requested medical record to surveyor timely.

Upon patient client record review, 3 of 6 (Patient #1, #5, #6) 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 did not contain a signed election statement is not on file. Patient #5: The medical record does not contain a signature by a hospice employee on the election of hospice. Patient #6: The agency did not provide access to the requested medical record to surveyor timely.

Upon patient client record review, 1 of 6 (Patient #6) did not have evidence that each patient record contains Attending Physician certification and recertification of terminal illness. Patient #6: The agency did not provide access to the requested medical record to surveyor timely.

Upon patient client record review, 4 of 6 (Patient #2, #3, #4, #5) 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 #2: The medical record did not contain appropriately authenticated documentation. The updates to the plan of care did not contain signatures from the medical director or any member of the interdisciplinary team. Patient #3: The medical record did not contain appropriately authenticated documentation. The aide notes were not signed by the clinician. The updates to the plan of care did not contain signatures from the medical director or any member of the interdisciplinary team. Patient #4: The medical record did not contain appropriately authenticated documentation. The updates to the plan of care did not contain signatures from the medical director or any member of the interdisciplinary team. Patient #5: The medical record did not contain appropriately authenticated documentation. The initial plan of care and updates to the plan of care did not contain signatures from the medical director or any member of the interdisciplinary team.

Upon client record review, 3 of 6 (Patient #3, #5, #6) 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 #3: There is no evidence in the medical record a discharge summary was sent to the patient’s attending physician when the patient discharged on 3/6/23. Patient #5: There is no evidence in the medical record a discharge summary was sent to the patient’s attending physician when the patient revoked services on 8/8/22. Patient #6: The agency did not provide access to the requested medical record to surveyor timely.

Upon observation, there was no evidence the patient record, whether hard copy or in electronic form, is made readily available on request by an appropriate authority.

Upon observation, there was no evidence that when the hospice provides durable medical equipment under contract, then the DMEPOS provider is accredited by a CMS approved accreditation organization.

Condition of Participation: Personnel Qualifications.

Upon personnel record review, 3 of 13 (Personnel #2, #12, #13) 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 Reaccreditation or in accordance with specific state practice act requirements. Personnel #2, #12, #13: The agency did not provide access to the requested personnel record to surveyor.

Upon personnel record review, 1 of 13 (Personnel #9) 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 #9: The agency did not provide surveyor access to the personnel record.

Upon personnel record review, 1 of 13 (Personnel #2) did not have evidence in the personnel files that if no state licensing, certification or registration requirements exist for personnel qualifications for a Registered Nurse or Licensed Practical Nurse. The following requirements must be met for a: • Registered Nurse – A graduate of a school of professional nursing Personnel #2: The agency did not provide access to the requested personnel record to surveyor.

Upon personnel record review, 2 of 13 (Personnel #9, #12) 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. Personnel #9: The agency did not provide access to the requested personnel record to surveyor timely. Personnel #12: The personnel record did not contain evidence of criminal background checks being obtained.

Upon personnel record review, 6 of 13 (Personnel #2, #3, #4, #10, #11, #13) 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. Personnel #2, #10, #11, #13: The agency did not provide access to the requested personnel record to surveyor. Personnel #3, #4: The personnel record did not contain evidence of criminal background checks being obtained.