Every finding on record at Tri City Hospice, Inc

Upon client record review, 5 of 5 (Patients #1,2,3,4,5) did not have evidence that the IDG in collaboration with the attending physician reviewed, revised and documents the individualized plan as frequently as the patient's condition requires but no less frequently then every 15 calendar days. Patients #1,2,3,4: The IDG notes did not validate Attending Physician/Medical Director or MSW involvement with signatures on the IDG’s for 6/27/25 and 7/17/25. Corrected on site team members signed IDG late on 7/17/25. Patient #5: The IDG note did not validate Attending Physician/Medical Director, RN, MSW or SC involvement with signatures on the IDG for 6/27/25. Corrected on site team members signed IDG late on 7/17/25.

Upon observation, there was no evidence that during the initial assessment visit in advance of furnishing care, the hospice provided the patient and/or family with verbal (meaning spoken) and written notice of the Patient's Rights and Responsibilities in a language and manner that the patient understands. Patient #14: Consents and acknowledgements signed with illegible signature, and "self" written in as signer's relationship to patient. The patient's primary diagnosis is Alzheimer's Disease

Upon patient record review, 1 of 14 (Patient #14) 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 #14: Consents and acknowledgements are signed with illegible signature, with "self" written in as signer's relationship to patient. The patient's primary diagnosis is Alzheimer's Disease

Upon patient record review, 1 of 14 (Patient #14) 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 #14: Consents and acknowledgements signed with illegible signature, and "self" written in as signer's relationship to patient. The patient's primary diagnosis is Alzheimer's Disease

Upon observation, there was no evidence the patient has the right to voice grievances/complaints regarding treatment or care that is (or fails to be) furnished and lack of respect of property by anyone who is furnishing care/service on behalf of the hospice. Patient #14: Consents and acknowledgements signed with illegible signature, and "self" written in as signer's relationship to patient. The patient's primary diagnosis is Alzheimer's Disease

Upon patient record review, 1 of 14 (Patient #14) did not have evidence that if a state court has not adjudged a patient incompetent, any legal representative designated by the patient in accordance with state law may exercise the patient's rights to the extent allowed by state law. Patient #14: Consents and acknowledgements signed with illegible signature, and "self" written in as signer's relationship to patient. The patient's primary diagnosis is Alzheimer's Disease.

Upon client record review, 1 of 14 (Patient #14) did not have evidence that the plan of care included IDG's documentation of the patient's or families level of understanding, involvement and agreement with the plan of care. Patient #14: Consents and acknowledgements signed with illegible signature, and "self" written in as signer's relationship to patient. The patient's primary diagnosis is Alzheimer's Disease

Upon patient record review, 1 of 14 (Patient #14) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient #14: Consents, election of hospice including choice of physician has illegible signature, and "self" written in as signer's relationship to patient. The patient's primary diagnosis is Alzheimer's Disease

Upon patient record review, 14 of 14 (Patient #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14) did not have evidence of the appropriate documentation for release of confidential information. Patients #1-14: Agency failed to maintain confidentiality of patient record as evidenced by persons accessing record and documenting visits who are not verified employees of the agency, at the time of survey. Patient #1: 5/18/24 Visit documented by ET, LVN Patient #2: Initial assessment 4/10/25 by DK, RN Patient #3: Initial assessment 4/8/25 by DK, RN Patient #4: Initial assessment 4/4/25 by DK, RN Patient #5: Initial assessment 4/3/25 by DA, RN Patient #6: Initial assessment 3/15/25 by SK, RN Patient #7: Initial assessment 3/12/25 by DK, RN Patient #8: Initial assessment 1/1/25 by DK, RN Patient #9: Initial assessment 10/28/24 by DA, RN Patient #10: Initial assessment 5/16/25 by DA, RN. Hospice Aide visits including 5/22 and 5/26/25 by PJR, HA Patient #11: Initial assessment 3/2/25 by DK, RN Patient #12: Initial assessment 4/4/25 by NM, RN Patient #14 Initial assessment 9/24 by DA, RN. Also, Consents signed with illegible signature, with "self" written in as signer's relationship to patient. The patient's primary diagnosis is Alzheimer's Disease

Upon patient record review, 1 of 14 (Patient #14) did not have evidence that the patient received information about the services covered under the hospice benefit. Patient #14: Consents and acknowledgements signed with illegible signature, and "self" written in as signer's relationship to patient. The patient's primary diagnosis is Alzheimer's Disease

Upon patient record review, 1 of 14 (Patient #14) 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 #14: Consents and acknowledgements signed with illegible signature, and "self" written in as signer's relationship to patient. The patient's primary diagnosis is Alzheimer's Disease

Upon observation, there was no evidence all licensed professional services provided directly or under arrangement are authorized, delivered and supervised only by health care professionals who meet the appropriate qualifications specified in CFR 418.114 and who practice under the hospice's policies and procedures. Agency is providing licensed services by multiple staff, with no evidence of employment (including license, screening, training, competence, supervision).

Upon observation, there was no evidence the hospice is in compliance with accepted professional standards and principles for all core services which includes nursing services, medical social services and counseling services. The Hospice Agency is providing core services by staff other than direct employees.

Upon personnel record review, 1 of 12 (Personnel #4 ) 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 #4: Shampoo competency does not specific all 3 types of sink, tub, bed.

Condition of Participation: Organization and administration of services. The hospice must organize, manage, and administer its resources to provide the hospice care and services to patients, caregivers and families necessary for the palliation and management of the terminal illness and related conditions.

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 Directors/governing body does not exercise responsibility for the operation of the hospice, as evidenced by as evidence by administrator interview, survey response, persons accessing records/documenting visits, not clearly and/or appropriately employed by the agency, and core services are not being provided by employees. Personnel #2: Executive Director/Administrator Designee job qualifications include A Bachelor's degree in Business administration, masters Degree in health care or related field preferred. 3-5 years experience in health care management. Resume reference anticipated nursing school graduation May 2023. License issued August 2023. Resume on file shows current position to be initial leadership role, with no prior leadership experience.

Upon personnel record review, 1 of 12 (Personnel #6) 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 #6: Agency identified as bereavement coordinator and personnel agrees during interview, but there is no competency on file

Upon patient client record review, 1 of 14 (Patient #14) 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 #14: Consents, including election of hospice benefit, signed with illegible signature, with "self" written in as signer's relationship to patient. The patient's primary diagnosis is Alzheimer's Disease

Upon patient client record review, 1 of 14 (Patient #1) did not have evidence that each patient record contains Physician certification and recertification of terminal illness. Patient #1: Patient chose attending physician, but there is no CTI for 1st 90 day period

Upon observation, there was no evidence a copy is provided of the hospice written policies and procedures on the management and disposal of controlled drugs to the patient or patient representative and family. Patient #14: Consents, election, and acknowledgements signed with illegible signature, with "self" written in as signer's relationship to patient. The patient's primary diagnosis is Alzheimer's Disease

Upon client record review, 1 of 14 (Patient #14) did not have evidence that the written policies and procedures for managing controlled drugs was provided and discussed. Patient #14: Consents signed with illegible signature, with "self" written in as signer's relationship to patient. The patient's primary diagnosis is Alzheimer's Disease

Upon observation, there was no evidence the organizational chart matches the hospice's information submitted to CMS and/or State licensing agencies for ownership and management personnel. The Administrator/DPCS Designee hire date is 3/1/24. There is no evidence that change was reported to CDPH.