Every finding on record at Toc Inc

Upon observation, there was not documented evidence that the Emergency Preparedness Plan included the establishment of individualized strategies, for addressing those emergency events, which were identified by the conduct of their Hazard Vulnerability Assessment Risk Assessment, as being most likely to occur, and would affect the Hospice's ability to provide care.

Upon patient record review, 1 of 11 (Patients #3) did not contain a current/comprehensive Medication Profile. The patient record reflected that they had Physician-ordered Oxygen. This Oxygen was not included on their Medication Profile.

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 was admitted under the GIP Level of Care on 11/29/2021, and remained/died in the hospital on 12/03/2021. The initial 90 day Plan of Care, forwarded to the Physician for signature/date, had no Nursing interventions included on the POC. The single problem listed on this POC was "Stress", under psychological concerns of family. There was a visit frequency for both Nursing and Social Work disciplines.

Upon patient record review, 2 of 11 (Patients #5 and 6) 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 medications and treatments: Patient #5: A verbal order was obtained on 03/28/22 for, "Sacral Pressure Ulcer. Cleanse with Normal Saline-soaked 4x4's, pat dry, apply Opti-foam sacral dressing. Change every 7 days and and p.r.n., for 14 days." This is not a complete order, as there is not indication for such p.r.n. dressing changes. A verbal order was obtained on 04/11/22 for, "Cleanse coccyx wound with dermal cleanser, blot dry, apply Opti-foam sacral dressing. Change every 7 days and and p.r.n." This is not a complete order, as there is not indication for such p.r.n. dressing change. Patient #6: The 04/22/22 SOC CTI noted, "Patient has Foley Catheter in place." A verbal order was also obtained on 04/22/22 which included, "Assess and maintain Foley Catheter. Complete as needed Foley Catheter changes when indicated. " This is not a complete treatment order.

Upon patient record review, 3 of 11 (Patients #2, 4 and 5) did not contain evidence that the IDG had ensured that all care and services were provided in accordance with the Plan of Care: Patient #2: The admitting RN documented, "Wound to coccyx. Applied Opti-foam sacral dressing for padding." There was no Physician order located for such dressing intervention. Patient #4 A verbal order was obtained on 04/04/22 for, "Three superficial skin tears to: 1) Right elbow; 2) Right shoulder; and 3) Right knee. Cleanse with soap/water, and leave open to air. SN to observe these sites 2x weekly." None of the next SN visits dated 04/04, 04/06 or 04/12/22 documented any reference of the assessment of these 3 sites of concern. Patient #5: On the 04/11/22 visit the nurse documented having provided wound care to the left hip and left buttocks. There was no Physician order for such wound care interventions. A verbal order was obtained on 04/11/22 for, "Cleanse coccyx wound with dermal cleanser, blot dry, apply Opti-foam sacral dressing. Change every 7 days and and p.r.n." There was no documented evidence that this new wound care order was initiated at the next subsequent nursing visits, to include 04/11 nor 04/13/22. A verbal order was obtained on 03/17/22 for, "SN to complete catheter maintenance care every visit." There was no evidence of the nurse having provided such catheter care on any of the 03/21, 03/23, or 03/25/22 visits.

Upon patient record review 1 of 10 applicable applicable (Patient #2) did not contain evidence that the Hospice Aide had provided services that were: • Ordered by the interdisciplinary group • Included in the plan of care The Aide POC dated 05/03/22 did not assign the task of obtaining Vitals. These were obtained by the Aide during the Surveyor-attended home visit on 05/03/22.

Upon personnel record review, 2 of 5 applicable (Personnel #4 and 6) did not contain evidence that a Skills Competency Assessment, specific to each discipline, had been conducted for all personnel, including Volunteers, initially during orientation, prior to independent patient care/services: Personnel #4: DOH was 06/12/20. There was no documented evidence of an initial Skills Competency Assessment having been conducted prior to her provision of independent patient care/services. Personnel #6: DOH was 10/08/19. There were a couple of MSW Skills Competency checklists in his file, but they were not dated, in order to ascertain whether an initial Skills Competency had been conducted prior to his provision of independent patient care/services.

Upon patient record review, 1 of 11 (Patient #5) did not evidence that all entries were clear and complete. A verbal order was obtained on 03/28/22 for, "Sacral Pressure Ulcer. Cleanse with Normal Saline-soaked 4x4's, pat dry, apply Opti-foam sacral dressing. Change every 7 days and and p.r.n., for 14 days." On the 04/04/22 SN visit the nurse documented only the following, "Opti-foam sacral dressing", without delineating the entire wound care which had been provided on that date.

Upon patient record review, 1 of 1 applicable (Patient #9) live discharged patient (Revocation) did not contain a Discharge Summary which included all CMS-required information, as follows: • 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

Upon patient record review, 11 of 11 (Patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, and 11) did not contain evidence that the Interdisciplinary Group, as part of the review of the Plan of Care, had determined the ability of the patient and/or in-home caregiver to safely administer drugs and biologicals to the patient in his or her home.

Upon patient record review, 11 of 11 (Patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, and 11) did not contain evidence that the Hospice's written policies and procedures for managing the disposal of controlled drugs was provided, nor discussed/documented, with these patients.

Upon inpatient contract review, 1 of 1 (dba Horizons Care Center/GIP/RIP) did not contain a provision that the inpatient provider shall have established patient care policies consistent with those of the Hospice.

Upon inpatient contract review, 1 of 1 (dba Horizons Care Center/GIP/RIP) did not contain a provision that the Hospice patient's inpatient clinical record must include: 1) A record of all inpatient services furnished and events regarding care that occurred at the Facility; 2) That a copy of the Discharge Summary shall be provided to the Hospice at the time of discharge from the Facility; and 3) That a copy of the inpatient clinical record is available to the Hospice at the time of discharge from Facility.