Every finding on record at United Alliance Hospice Care Inc

Upon patient record review, 3 of 10 (Patient #1, #4, #5) 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 #1: Polyethylene Glycol powder 17 gm had no diluent and oxygen not on medication profile. Corrected on Site Patient #4: Polyethylene Glycol powder 17 gm had no diluent on medication profile. Corrected on Site Patient #5: Oxygen not on medication profile. Corrected on Site

Upon patient record review, 4 of 10 (Patients #2, #3, #4, #9) 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 #2: Bereavement Risk Assessment was not completed within 5 days of Start of Care. Corrected on Site (8/2/24) Patient #3: Bereavement Risk Assessment was not completed within 5 days of Start of Care. Corrected on Site (8/2/24) Patient #4: Bereavement Risk Assessment was not completed within 5 days of Start of Care. Patient SOC 7/13/24. Bereavement Risk Assessment completed on 7/27/24. Patient #9: Bereavement Risk Assessment was not completed within 5 days of Start of Care. Patient SOC 9/26/23. Bereavement Risk Assessment completed on 12/22/23.

Upon patient record review, 7 of 10 (Patients #1, #3, #4, #5, #6, #7, #8) did not have evidence the plan of care must 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 Patients #1, #4, #6: MSW/Chaplain visit frequency were PRN. These frequencies did not include a baseline visit frequency for the MSW/Chaplain. Patient #3: Chaplain visit frequency listed PRN. This frequency did not include a baseline visit frequency for the Chaplain. Patients #5, #7, #8: MSW visit frequency listed PRN. This frequency did not include a baseline visit frequency for the MSW.

Upon patient record review, 3 of 10 (Patients #1, #4, #5) did not have evidence the plan of care (POC) must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #1: Polyethylene Glycol powder 17 gm had no diluent and oxygen not on POC. Corrected on Site Patient #4: Polyethylene Glycol powder 17 gm had no diluent on POC. Corrected on Site Patient #5: Oxygen not on POC. Corrected on Site

Upon patient record review, 5 of 10 (Patients #1, #2, #3, #5, #10) did not have evidence the plan of care (POC) must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient #1: This patient had an oxygen concentrator, rollator, bedside table, bedside commode and wheel chair. These items were not included on the POC. Patients #2 and #10: The record reflected that these patients had a nebulizer treatment. There was no nebulizer machine included on their POC. Corrected on Site. Patient #3: This patient had a cane, walker, bedside table and bedside commode. These items were not included on the POC. Corrected on Site. Patient #5: The record reflected that this patient had an oxygen treatment. There was no oxygen equipment included on the POC. Corrected on Site.

Upon client record review, 1 of 10 (Patient #2) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care (POC). Patient #2: The POC listed MSW visit frequency of, 1X's per month. There were no evidence of MSW visits for July 2024.

Upon patient record review, 1 of 10 (Patient #10) did not have evidence of bereavement plan of care up to 1 year following the death of the patient. Patient #10: Did not have evidence of the kind of bereavement services to be offered and the frequency of service delivery. Corrected on Site.

Upon personnel record review, 1 of 15 (Personnel #10 ) 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.) Personnel #10: Did not have all required observed tasks as follows: ·Safe transfer techniques and ambulation. ·Normal range of motion and positioning ·Appropriate and safe techniques in personal hygiene and grooming that include-- -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.

Upon patient record review 3 of 10 (Patients #3, #4, #10) 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 Patient #3: The POC listed Aide visit frequency of, 2 X's per week (6/20/24). There were no visits the first or second benefit week. Patient #4:The POC listed Aide visit frequency of, 2 X's per week (7/13/24). There was only one visit attempt on 7/21/24 and then discontinued per communication note. Patient #10: The POC listed Aide visit frequency of, 2 X's per week (6/26/24). There were no visits the first benefit week.

Upon patient record review, 3 of 10 (Patients #2, #4, #7) 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: • Related diagnosis • Information about the medical management of any of the patient's conditions unrelated to the terminal illness Patients #2, #4, #7: The CTI included hospice primary diagnosis. The CTI did not include any related or unrelated diagnosis in space provided on form.

Upon patient client record review, 10 of 10 (Patients #1,2,3,4,5,6,7,8,9,10) did not have evidence that each patient record contains: • Signed election statement in accordance with 418.24 Patients #1, #2, #10: The Hospice Medicare Election statement does not provide BFCC-QIO contact information, Notice of Non Coved Items addendum information or Effective Date for hospice services on the form. Patients #3, #6, #7, #8, #9: The Hospice Medicare Election statement does not provide BFCC-QIO contact information or Notice of Non Coved Items addendum information. Patients #4, #5: The Hospice Medicare Election statement does not provide BFCC-QIO contact information or evidence that hospice provide Notice of Non Covered Items form as requested.

Upon SNF/NF contract review, 1 of 4 (Astoria SNF contract) did not have a provision stating that the hospice reports all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by anyone unrelated to the hospice to the SNF/NF administrator within 24 hours of the hospice becoming aware of the alleged violation.