Every finding on record at Sunrise Hospice, Inc.

Upon patient record review, 2 of 5 records (Patient #2,#3) 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: Patient 2: The medication profile does not contain the Oxygen that the patient is on per the plan of care. Patient 3: The medication profile contains: Nystatin external powder with directives to apply powder topically to breasts, skin folds until resolves. There is no evidence of a frequency. Calmoseptine with directive of apply topically to buttocks as needed. There is no evidence of a frequency.

Upon patient record review, 1 of 5 (Patient #4) 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 4: RN made visits on 3-22-22 and 3-29-22 and has evidence of patient's blood pressure being elevated 175/77. Pt is on Lasix and Carvedilol. Nurse instructs caregiver to assess blood pressure in afternoon and call agency if still elevated. There is no care plan for cardiovascular disease initiated.

Upon patient record review, 2 of 5 (Patient #2,#3) 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: The plan of care contains: Jevity continuous at 60cc/hour per pump with directive of flush peg tube with 125cc every 4 hours. There is no order as to what to flush the peg tube with. Patient 3: The plan of care contains: Nystatin external powder with directives to apply powder topically to breasts, skin folds until resolves. There is no evidence of a frequency. Calmoseptine with directive of apply topically to buttocks as needed. There is no evidence of a frequency.

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

Upon patient record review 1 of 11 (Patient # 1) did not have evidence that the hospice Registered Nurse completed an initial assessment within 48 hours after the election of hospice care in accordance with §418.24. Patient #1-The patient elected the hospice benefit on 12/13/21. The first nursing visit is documented 12/16/21.

Upon patient record review 5 of 11 (Patient #1, #3, #7, #8, #9) 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, #3, #7, #8, #9 -The records do not contain a complete initial nursing assessment upon start of care to identify the patients physical needs. On each of the records routine visit notes were completed instead of RN initial assessment visits. The records did not include documentation of the patients diagnosis at admission, non verbal pain indicators, PPS levels, target pain goals, functional limitations/Activities of daily living, caregiver assistance, a complete psychological assessment, sleep rest patterns, spiritual/religious screening, complete integumentary status assessments including wound evaluations if applicable, NYHA Functional Classification for patients with Heart Disease, a complete nutrition food consumption assessment, nutrition fluid and intake screening, a complete fall risk assessment and/or an evaluation of equipment needs. Patient #1-The patient was admitted 12/16/21 and the initial nursing visit note documents the patient has two small pressure ulcers to the heels. A complete wound assessment is not documented as a part of the assessment. Patient #3- The patient was admitted 01/05/22 and a psychosocial assessment did not occur until the Social Worker visited on 01/12/22. A psychosocial assessment was not performed by the Chaplain or RN as part of the comprehensive assessment. Patient #7-The patient was admitted on 09/21/21and a psychosocial assessment did not occur until the Social Worker visited on 10/21/21. A psychosocial assessment was not performed by the Chaplain or RN as part of the comprehensive assessment. Patient #8-The patient was admitted on 08/20/21and a spiritual assessment did not occur until the Chaplain visited on 08/30/21. A spiritual assessment was not performed by the Social Worker or RN as part of the comprehensive assessment. Patient #9- The patient was admitted on 08/26/21. The patient refused Chaplain services and a spiritual assessment was not performed by the RN or Social Worker.

Upon patient record review, 2 of 11 (Patient #1, #2) 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. Patient #1-The patient was admitted on 12/16/21 and the medication profile states the patient is not on any medications. The record documents the patient is on several medications including Tylenol, Miralax, and Trazadone noted in the admission nursing visit documentation. Patient #2- The medication profile includes Miralax 17 gm powder daily for constipation. A diluent is not included in the profile.

Upon patient record review, 3 of 11 (Patient #7, #8, #9 ) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component completed within the 5 days 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. Patient #7- The patient was admitted on 09/21/21 and a bereavement risk assessment is not on record. Patient #8-The patient was admitted on 08/20/21 and a bereavement risk assessment was not performed prior to the patients death on 08/30/31. Patient #9 The patient was admitted on 08/26/21 and a bereavement risk assessment is not on record.

Upon patient record review, 8 of 9 applicable (Patient #1,#2, #3,#4, #6, #7, #9, #10) did not have evidence in the patient record that the comprehensive assessment is updated by the IDG and includes reassessment of the patient's response to care and progress towards desired outcomes. Staff complete a visit note each visit but there is not evidence of an updated assessments. Review of IDG documentation does not reveal an update to the comprehensive assessment completed by the IDG.

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

Upon patient record review, 1 of 11 applicable (Patient #1) 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- The patient was admitted on 12/16/21 with constipation and the need for wound care according to the initial nurses note. The plan of care does not include any interventions or goals.

Upon patient record review, 2 of 11 applicable (Patient #1, #7) did not have evidence the plan of care 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. Patient #1-The 12/16/21 plan of care does not include frequencies for nursing, spiritual care or social work services. The 12/16/21 plan of care does not include the scope of nursing services to be provided. No nursing interventions are listed on the plan of care. Patient #7- The 09/21/21 plan of care does not include frequencies for nursing, social worker, spiritual care or aide services.

Upon patient record review, 5 of 11 applicable (Patient #1, #2, #3, #7, #9) 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 specific orders for all medications and treatments. Patient #1- The plan of care only includes the patients diagnosis. The patient was admitted 12/16/21 with severe calorie malnutrition and lower extremity wounds and constipation. The 12/15/21 plan of care does not include medications and treatments. Patient #2- The 01/25/22 plan of care reads SN to instruct the caregiver on management of skin tear using recommended dressing changes. Provide education on wound care as ordered. The plan of care is not specific for the location of wounds and the actual wound care to be provided. On 12/30/21 and 01/03/22 the Chaplain documents performing interventions via telehealth. The plan of care was not updated with telehealth orders. Patient #3- The 01/05/22 plan of care does not include medications. The patient was admitted with kidney failure and has a med profile on record. Patient #7-The patient was admitted on 09/21/21 with a Foley and tube feedings. The plan of care does not address management of the Foley catheter. The plan of care orders include teach patient regarding care of Peg tube. The management of the PEG and tube feedings are not specific on the plan of care. On 09/26/21 an order was written which reads: Acetic acid irrigation .25 % 15 ml irrigate/instill 15 ml of acetic acid mixed with 15 ml NS one time daily and as indicated for pain. The orders are not specific for what is to be irrigated. Patient #9- The patient was admitted on 08/26/21 with a suprapubic catheter. The plan of care orders on 08/26/21 read: change suprapubic catheter as ordered. The orders are not specific for suprapubic catheter changes and maintenance.

Upon patient record review, 4 of 11 applicable (Patient #1, #7, #8, #9) 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-The 12/15/21 plan of care does not include equipment and supply needs . The patient is receiving wound care supplies. Patient #7-the 09/21/21 plan of care dos not include equipment or supply needs. The agency is responsible for management of the Foley and PEG tube. Patient #8- The 08/22/21 plan of care does not include equipment or supply needs. The patient was admitted with Oxygen and a hospital bed was to be ordered according to the initial nursing documentation. Patient #9- The 08/26/21 plan of care does not include equipment or supply needs. The patient had equipment needs as the record indicates at discharge the transferring hospice was made aware of the patient's equipment needs

Upon patient record review, 6 of 9 applicable (Patient #3, #4, #6, #7, #9, #10) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient #3- The revised plans of care on record between 01/11/22 and 02/02/22 do not note the patient's progress towards outcome/goals from the plan of care. On 1/11, 1/19 and 2/2 the updated plans of care only document "done" instead of the actual progress towards the nursing goals. Patient #4- The revised plans of care between 12/10/19 and 01/27/22 identify nursing problems and goals for fall risks, altered bowel elimination, impaired nutritional status and impaired skin integrity. Each of the revised plans of care do not note the patient's progress towards outcome/goals from the plan of care. The updates only document goals appropriate continue with plan of care. Patient #6- The revised plans of care 01/06/22-02/09/22 identify nursing problems and goal for fall risks, and alteration in comfort. Each of the revised plans of care do not note the patient's progress towards outcome/goals from the plan of care. The updates only document goals appropriate and interventions done. Patient #7- The plan of care revisions between 09/21/21 and 11/11/21 identify nursing problems and goals for inadequate nutrition , anxiety, fall risk, altered gu elimination, and risk for infection. Each of the revised plans of care do not note the patient's progress towards outcome/goals from the plan of care. Patient #9-The revised plans of care between 09/20/21 and 11/02/21 identify nursing problems and goals for impaired urinary function, decreased cardiac output, fall risk, and impaired skin integrity. Each of the revised plans of care do not note the patient's progress towards outcome/goals from the plan of care. The revisions only document goals appropriate continue with plan of care. Patient #10- The revised plans of care between 11/19/21 and 01/28/22 identify nursing problems and goals for fall risk and cognitive impairment. Each of the revised plans of care do not note the patient's progress towards outcome/goals from the plan of care. The revisions only document goals appropriate continue with plan of care.

Upon patient record review, 1 of 11 (Patient # 10) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #10-The Social Worker is ordered to visit the patient once a month effective 11/19/21. One Social Worker visit is on record 11/22/21. There are no visits on record for December 2021 or January 2022 and no documentation regarding the missed visits.

Upon patient record review, 2 of 8 applicable (Patient #3, #9) did not evidence documentation in the patient record that a hospice aide provides services that are ordered by the IDG and included in the plan of care. Patient #3- The Aide is ordered to provide personal care twice weekly effective 1/11/21. The week 1/11-1/15/22 , 1/16/22-1/22/22 and 01/30/22-02/05/22 no aide visits are documented. There is no documentation on record regarding the missed visits. Patient #9- An Aide is not ordered to visit the patient and an Aide care plan is not on record. The Aide has visits documented 11/1/22, 11/03/22, 11/06/22 and 11/08/22 which are blank and signed by the Aide (unclear).

Upon personnel record review, 1 of 11 applicable (Personnel # 7) 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 #7-The personnel file does not include a competency assessment.

Upon contract review, 1 of 2 applicable contracts (GA) did not have evidence of contracts to differentiate the role of Medical Director and Alternate Medical Director. The agency has two signed contracts for Medical Director. GA is the Alternate Medical Director.

Upon patient record review, 7 of 11 (Patient #1, #2, #3, #4, #6, #7, #8) 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. Patient # 1, #2, #3, #4, #6, #7, #8-The records do not contain a certificate of terminal illness completed by the medical director.

Upon patient record review, 2 of 2 applicable (Patient #4, #11) 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 #4-The patient was recertified 01/13/22 for the 14th benefit period and a recertification CTI is not on record. Patient #11- Patient #11-The last CTI on record was written on 04/08/21. The patient is still currently on service.

Upon patient record review, 1 of 1 applicable (Patient #9) 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 #9- The patient was transferred to another hospice on 11/08/21 and a transfer summary is not on record.