Every finding on record at Varco Hospice, LLC

Upon observation, there was no evidence the Emergency Preparedness plan: • Is based on and includes a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach • Includes strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care There was no facility-based and no community based risk assessment utilizing an all-hazards approach.

Upon patient record review, 4 of 14 records reviewed (Patient #3, #8, #9, #10) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient #3: There was a check box yes I choose an attending or no I do not wish to chose an attending, this was left blank. It is unclear if they did or did not want to choose an attending physician. Patient #8: There was a check box yes I choose an attending or no I do not wish to chose an attending, this was left blank. It is unclear if they did or did not want to choose an attending physician. Patient #9: There was a check box yes I choose an attending or no I do not wish to chose an attending, this was left blank. It is unclear if they did or did not want to choose an attending physician. Patient #10: There was a check box yes I choose an attending or no I do not wish to chose an attending, this was left blank. It is unclear if they did or did not want to choose an attending physician.

Upon patient record review 4 of 14 records reviewed (Patient #4, #5, #8, #10) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient #4: The record indicated the start of care was on 09/20/23. The psychosocial comprehensive assessment was not completed until 12/08/23. Patient #5: The record indicated the start of care was on 04/09/24. The psychosocial comprehensive assessment was not completed until 04/30/24. Patient #8: The record indicated the start of care was on 01/14/25. The psychosocial comprehensive assessment was not completed until 01/23/25. Patient #10: The record indicated the start of care was on 10/30/24. The psychosocial comprehensive assessment was not completed until 11/07/24.

Upon patient record review, 10 of 14 records reviewed (Patient #1-#10) did not have evidence in the patient record that the comprehensive assessment takes into consideration the imminence of death. Patient #1-#10: The comprehensive assessment for these patients did not take into consideration the imminence of death.

Upon patient record review, 4 of 14 records reviewed (Patient #3, #4, #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 #3: The medication profile had multiple medications listed to include alendronate 70mg one tab by mouth once weekly, oxygen 2-4 LPM via NC or mask as needed for dyspnea, acetaminophen 650mg PR Q4hour prn pain Temp >100.5, promethazine 25mg po Q4hours prn nausea, Ativan 0.5mg po Q2-4hours prn agitation, hyoscyamine Sulfate 0.125mg one tab po Q4hours prn secretions, hydrochlorothiazide 12.5mg 0.5cap po daily for HTN, and lisinopril 5mg po daily for HTN that was not in the home. The patient was taking Simvastatin 20mg po once daily, Amlodipine 5mg po daily, Sertraline 25 mg po daily, Bisoprolol/HCTZ 5/6.25mg po every day and ibuprofen 200mg po one to two tabs every 6 hours as needed, these medications were not on the medications profile. All COS. Patient #4: The profile indicated Oxygen 2L per minute prn dyspnea or low oxygen saturation via NC or mask gradually increase 1/2L @ a time. There was no max dose listed. This was a COPD patient. COS. Also the medication profile indicated Acetaminophen 650mg one suppository Q4hours prn fever and Acetaminophen 500mg one suppository tid pain, the entry does not include a maximum dose of 4g daily. Both COS. Patient #5: The medication profile indicated Novolog 70/30 100units/ml one dose, there was no route of administration. In addition, Jentadueto 2.5-500mg BID in a.m. with special instructions to take 2 in the a.m. this medication was unclear as to when and how much to take. Also, Lidoderm External Patch 5% one patch to affected area, remove Q12 hours, there was no site location listed. All COS. Patient #6: The medication profile indicated ipratropium-albuterol inhalation solution 0.5-2.5 (3)mg/3ml, 1ml Q6hours cough/congestion. There was no delivery method indicated. COS.

Upon patient record review, 5 of 14 records reviewed (Patient #3, #4, #6, #7, #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 #3: The bereavement assessment was not completed at the time of the survey. Patient #4: The record indicated the start of care was 09/20/23. The bereavement assessment was not completed until 10/07/23. Patient #6: The bereavement assessment was not completed at the time of the survey. Patient #7: The record indicated the start of care was on 05/15/23. The bereavement assessment was not completed until 05/25/23. Patient #9: The bereavement assessment was not completed at the time of the survey.

Upon patient record review, 3 of 14 records reviewed (Patient #3, #4, #5) 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 #3: The record indicated the patient was prescribed azithromycin there was no individualized written plan of care for how to manage this infection. In addition, the patient was Spanish speaking, there was no individualized written plan of care for how communication would be done. COS. Patient #4: The assessment confirmed the patients pain score should be less than a "6". There was no individualized measurable goals for pain control. COS. Patient #5: The record indicated the patient was on Insulin, there was no individualized written plan of care to check blood sugars and what to levels to report and who to report the results to. COS.

Upon patient record review, 4 of 14 records reviewed (Patient #3, #4, #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 #4: The orders for Oxygen were 2L per minute prn dyspnea or low oxygen saturation via NC or mask gradually increase by 1/2 L @ a time. There was no max dose listed. This was a COPD patient. Also the orders indicated Acetaminophen 650mg one suppository Q4hours prn fever and Acetaminophen 500mg one suppository TID pain, the order does not include a maximum dose of 4g daily. ALL COS. Patient #5: Orders indicated Novolog 70/30 100 units/ml one dose, there was no amount or route of administration. In addition, orders written for Jentadueto 2.5-500mg BID in a.m. with special instructions to take 2 in the a.m. this medication was unclear as to when and how much to take. Also, orders written for Lidoderm External Patch 5% one patch to affected area, remove Q12 hours, there was no site location listed. All COS. Patient #6: The orders indicated ipratropium-albuterol inhalation solution 0.5-2.5 (3)mg/3ml, 1ml Q6hours cough/congestion. There was no delivery method indicated. COS.

Upon patient record review, 1 of 14 records reviewed (Patient #6) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #6: The record indicated on 9/30/24 the SW would visit 1 x month for 1 Quarter. There was no SW visit in September 2024, October 2024, November 2024 or December 2024.

Upon personnel record review, 1 of 15 records reviewed (Personnel #7) did not have evidence in the personnel file that the hospice aide had received at least l2 hours of in-service training during each 12-month period. In-service training may occur while an aide is furnishing care to a patient. Personnel #7: There were no in service hours as of the day of the survey and or for January 2024 - December 2024.

Upon patient record review 1 of 14 records (Patient #4) 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 • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #4: The record indicated aide visits were ordered 3 X W. Starting on 11/07/23 only 2 visits were made for 3 weeks in a row.

Upon patient record review 1 of 14 records reviewed (Patient #7) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs. Patient #7: The record indicated a hospice aide supervisory was done on 01/16/25, the next supervisory visit due 01/30/25 and was not completed between 1/17/25 and 1/30/25. COS.

Upon patient record review, 3 of 14 records reviewed (Patient #6,8,9) 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 #6: The effective date for the election of hospice was blank. Patient #8: The effective date for the election of hospice was blank. Patient #9: The effective date for the election of hospice was blank.

Upon patient record review, 2 of 14 records reviewed (Patient #3, #9) 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 #3: The record indicated the medical director was listed as an RN during the IDG meeting on 11/25/24. COS. Patient #9: There was a signed blank revocation on file by the hospice staff and the patient, the patient was currently on service. In addition, the bereavement risk assessment was completed on 1/6/25 which was prior to the start of care date on 01/09/25.

Upon patient record review 1 of 11 (Patient #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 #6: Although the Chaplain attempted to conduct a Spiritual on 3/8/2022, he was unable to schedule the assessment time with the family. There was no additional effort by the Chaplain or effort by another Clinician to indicate a Spiritual Assessment had been conducted and incorporated into the comprehensive assessment.

Upon patient record review, 2 of 11 (Patients #1 and #6) did not have evidence in the patient record that the comprehensive assessment included a bereavement component which included 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: There was no documentation to indicate a Bereavement Risk Assessment had been conducted and incorporated into the comprehensive assessment. Patient #6: Although the Chaplain attempted to conduct a Bereavement Assessment on 3/8/2022, he was unable to schedule the assessment time with the family. There was no additional effort by the Chaplain or effort by another Clinician to indicate a Bereavement Risk Assessment had been conducted and incorporated into the comprehensive assessment.

Upon client record review, 1 of 11 (Patient #1) did not have evidence that the IDG in collaboration with the attending physician reviewed, revised and documented the individualized plan as frequently as the patient's condition requires but no less frequently then every 15 calendar days. Patient #1: On 12/13/2021, the IDG met together to update the patient's plan of care. The next meeting was not until 1/10/2022 (Day 28).

Upon client record review, 4 of 11 (Patient #1, 2, 5, and 6) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1: Although the Patient was receiving Social Work visits, the Plan of Care did not include the visit frequency of the Social Worker. Patient #2: Although the Patient was receiving Social Work and Chaplain visits, the Plan of Care did not include the visit frequency of either discipline. Patient #5: Although the Patient was receiving Social Work and Chaplain visits, the Plan of Care did not include the visit frequency of either discipline. Patient #6: Although the patient was receiving Social Work visits, the Plan of Care did not include the visit frequency.

Upon observation, there was no evidence the QAPI program uses quality indicator data, including patient care and other relevant data in the design of its program. The hospice must use the data collected to: • Monitor the effectiveness and safety of services and quality of care • Identify opportunities and priorities for improvement

Upon observation, there was no evidence the board of directors/governing body approves the frequency and detail of the data collection. Based on review of the latest Governing Body meeting minutes, there was no documentation to indicate the Governing Body had approved the current QAPI, including the frequency and detail of the data collection.

Upon observation, there was no evidence the hospice documents what QAPI projects are being conducted, the reasons for conducting these projects, and the measurable progress achieved on these projects.

Upon patient record review, 1 of 2 applicable (Patient #10) did not have evidence that the hospice offered 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 delivery Patient #10: Expired on 5/27/2021. The Bereavement Plan of Care had tasks that included, sending a letter at nine months from the death. The letter was scheduled to be sent on 2/26/2022, and had not yet been sent as of the Survey date.

Upon patient record review 3 of 7 applicable (Patients #2, #5 and #9) did not have documentation in the patient record that a hospice aide provided services that were: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #2: An Aide Care Plan dated 10/7/2021, included directions for the Aide to shampoo the patient's hair 1x week. During the weeks of 1/9/2022 and 1/30/2022, the Aide provided the shampoo service 3x week. Patient #5: An Aide Care Plan dated 11/20/2021, included directions for the Aide to shampoo the patient's hair 1x week. During the week of 12/5/2021, the Aide provided the shampoo service 2x week. Patient #9: The Initial Plan of Care include an Aide frequency of 3 x week. During the week of 11/14/2021, the Patient received Aide services only 2 x week.

Upon client record review, 3 of 3 applicable (Patients #7, #8 and #11) did not have evidence that the discharge summary includes all required information. Patients #7, #8 and #11: Were discharged from Hospice Services. The Discharge Summary did not include a summary of the patient's stay, the current plan of care, and the patient's latest Physician orders.