Every finding on record at Vela Hospice Care, Inc.

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 #4. Election Statement identifies effective date of election to be 01/14/24. SOC documented as 1/14/24. Initial RN Comprehensive 1/14/24. All admission forms signed 1/15/24. Education provided and related tags communicated.

Upon patient record review, 1 of 5 (Patient #4) 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 #4. Election Statement identifies effective date of election to be 01/14/24. SOC documented as 1/14/24. Initial RN Comprehensive 1/14/24. All admission forms signed 1/15/24. Education provided and related tags communicated.

Upon patient record review, 1 of 5 (Patient #4) 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 #4. Election Statement identifies effective date of election to be 01/14/24. SOC documented as 1/14/24. Initial RN Comprehensive 1/14/24. All admission forms signed 1/15/24. Education provided and related tags communicated.

Upon patient record review, 1 of 5 (Patient #4) 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 #4. Election Statement identifies effective date of election to be 01/14/24. SOC documented as 1/14/24. Initial RN Comprehensive 1/14/24. All admission forms signed 1/15/24. Education provided and related tags communicated.

Upon patient record review, 1 of 5 (Patient #4) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient #4. Election Statement identifies effective date of election to be 01/14/24. SOC documented as 1/14/24. Initial RN Comprehensive 1/14/24. All admission forms signed 1/15/24. Education provided and related tags communicated.

Upon patient record review, 1 of 5 (Patient #4) did not have evidence of the appropriate documentation for release of confidential information. Patient #4. Election Statement identifies effective date of election to be 01/14/24. SOC documented as 1/14/24. Initial RN Comprehensive 1/14/24. All admission forms signed 1/15/24. Education provided and related tags communicated.

Upon patient record review, 1 of 5 (Patient #4) did not have evidence that the patient received information about the services covered under the hospice benefit. Patient #4. Election Statement identifies effective date of election to be 01/14/24. SOC documented as 1/14/24. Initial RN Comprehensive 1/14/24. All admission forms signed 1/15/24. Education provided and related tags communicated.

Upon patient record review, 1 of 5 (Patient #4) 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 #4. Election Statement identifies effective date of election to be 01/14/24. SOC documented as 1/14/24. Initial RN Comprehensive 1/14/24. All admission forms signed 1/15/24. Education provided and related tags communicated.

Upon patient record review, 1 of 5 (Patient #3) 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: SOC 1/14/24. There were no documented problems, goals and interventions as part of IDG plan of care.

Upon patient record review, 3 of 5 (Patient #1, 2,3) 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 • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient #1, 2: SC frequency as needed. Patient #3 SC 1 as needed

Upon client record review, 1 of 5 (Patient #3) 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. Patient #3: SOC 1/14/24. There were no documented PGI at all by IDG. (IDG meetings 1/15, 1/29, 2/12/24)

Upon patient record review, 1 of 5 (Patient #1) 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: • The primary terminal condition • Related diagnosis • Current subjective and objective medical findings • Current medication and treatment orders • Information about the medical management of any of the patient's conditions unrelated to the terminal illness Patient #1: Initial Certification does not include certification by patient's chosen attending physician.

Upon patient client record review, 1 of 5 (Patient #4) 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 #4. Election Statement identifies effective date of election to be 01/14/24. SOC documented as 1/14/24. Initial RN Comprehensive 1/14/24. All admission forms signed 1/15/24. Education provided and related tags communicated.

Upon client record review, 1 of 5 (Patient #4) did not have evidence that the written policies and procedures for managing controlled drugs was provided and discussed. Patient #4. Election Statement identifies effective date of election to be 01/14/24. SOC documented as 1/14/24. Initial RN Comprehensive 1/14/24. All admission forms signed 1/15/24.

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

Upon patient record review 3 of 14 (Patient #1, 3, 7) did not have evidence that the hospice Registered Nurse must complete an initial assessment within 48 hours after the election of hospice care in accordance with §418.24 Patient 01: The patient was admitted on 11/25/23, the initial comprehensive assessment was started by the RN on 11/26/23 and not completed until 12/7/23. Patient 03: The patient was admitted on 11/12/23, the initial comprehensive assessment was started by the RN on 11/13/23and not completed until 11/15/23. Patient 07: The patient was admitted on 11/24/23, the initial comprehensive assessment was started by the RN on 11/26/23 and not completed until 12/08/23.

Upon patient record review 1 of 14 (Patient #1) 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 01: The patient was admitted on 11/25/23, the spiritual care assessment was completed on 12/6/23.

Upon patient record review 6 of 14 (Patient #1, 2, 3, 4, 8, 14) 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 01: The patient was admitted on 11/25/23, the psychosocial assessment has not been completed to date. Patient 02: The patient was admitted on 11/24/23, the record does not include an initial psychosocial assessment or spiritual care assessment. Patient 03: The patient was admitted on 11/12/23, the record does not include an initial psychosocial assessment or spiritual care assessment. Patient 04: The patient was admitted on 10/15/23, the record does not include an initial psychosocial assessment. Patient 08: The patient was admitted on 11/24/23, the record does not include an initial psychosocial assessment or spiritual care assessment. Patient 14: The patient was admitted on 10/7/22, the record does not include an initial psychosocial assessment.

Upon patient record review, 5 of 14 (Patient #1, 2, 3, 5, 7) 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 01: The medication profile includes Artificial Tears 1.4% Opthalmic solution 1 drop TID for dry eyes, there is no indication for which eye to instill the drops. Patient 02: Upon admit on 11/24/23, the patient record indicates the required use of oxygen, the medication profile does not include oxygen. Patient 03: The medication profile includes Diclofenac Sodium 3% topical gel, apply BID PRN. The application site is not specified. Patient 05: The medication profile includes Latanoprost 0.005% opthalmic solution 1 sol Qday for glaucoma, there is no indication for which eye to instill the medication. The medication profile includes Calmoseptine 20.6% topical ointment apply PRN daily, it does not include an application site. Patient 07: The medication profile includes Voltaren 1% topical gel apply 2 grams to the affected area four times a day, it does not include an application site.

Upon patient record review, 9 of 14 (Patient #1, 2, 3, 4, 5, 6, 8, 10, 13) 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 01: The patient was admitted on 11/25/23, the initial bereavement assessment has not been completed to date. Patient 02: The patient was admitted on 11/24/23, the initial bereavement assessment has not been completed to date. Patient 03: The patient was admitted on 11/12/23, the initial bereavement assessment has not been completed to date. Patient 04: The patient was admitted on 10/28/23, the initial bereavement assessment has not been completed to date. Patient 05: The patient was admitted on 10/15/23, the initial bereavement assessment has not been completed to date. Patient 06: The patient was admitted on 5/25/23, the initial bereavement assessment has not been completed to date. Patient 08: The patient was admitted on 11/24/23, the initial bereavement assessment was not completed, the patient was discharged on 12/17/23. Patient 10: The patient was admitted on 10/17/23, the initial bereavement assessment was not completed, the patient was discharged on 12/6/23. Patient 13: The patient was admitted on 5/10/23, the initial bereavement assessment was not completed, the patient died on 5/28/23.

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

Upon patient record review, 1 of 14 (Patient #1) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient 01: The patient has a venous stasis ulcer to the right shin with redness, eschar and other skin alterations. The RN visit on11/26/23, 11/30/23 and 12/14/23 do not include a wound assessment.

Upon patient record review, 2 of 14 (Patient #5, 7) 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 05: The patient uses Eliquis 2.5mg daily, the plan of care does not include bleeding precautions. Patient 07: The patient utilizes Eliquis 2.5mg twice daily, the plan of care does not include bleeding precautions.

Upon patient record review, 7 of 14 (Patient #1, 2, 3, 4, 5, 6, 7) 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 01: Medication orders on 11/26/23 for Artificial Tears 1.4% Opthalmic solution 1 drop TID for dry eyes, do not include instructions for which eye to instill the drops. In addition, the patient has a venous stasis ulcer to the right shin, the patient record does not include orders for wound care. Patient 02: Upon admit, the patient records indicates the use of oxygen 2L/min PRN. The plan of care does not include orders for oxygen. In addition, during the skilled nursing visit on 11/13/23, the patient was advised by the RN to utilize oxygen 2-5L PRN for shortness of breath, the plan of care does not include orders for the use of oxygen. During the skilled nursing visit on 11/20/23, the RN instructed the patient on the use of Duoneb inhalation therapy every 6 hours PRN wheezing, the plan of care does not include orders for the use of Duoneb. Patient 03: The orders on 11/18/23 for Diclofenac Sodium 3% topical gel, apply BID PRN does not include an application site. Patient 04: The medical record reflects that the patient uses Oxygen 2L prn for shortness of breath, the plan of care does not include orders for oxygen. Patient 05: The medication order on 12/1/23 for Latanoprost 0.005% opthalmic solution 1 sol Qday for glaucoma, does not include which eye to instill the medication. The medication order on 12/1/23 for Calmoseptine 20.6% topical ointment apply PRN daily, does not include an application site. In addition, upon admission on 10/15/23, the record reflects that the patient uses oxygen 2-4L PRN for shortness of breath, the plan of care does not include orders for oxygen. Patient 06: Upon admit on 6/17/23, the record indicates that the patient utilizes oxygen 2-4L PRN for shortness of breath, the plan of care does not include orders for oxygen. Patient 07: The medication orders on 10/31/23 for Voltaren 1% topical gel apply 2 grams to the affected area four times a day, does not include an application site. In addition, upon admit on 5/25/23, the record indicates that the patient utilizes oxygen 2-5L PRN for shortness of breath, the plan of care does not include orders for oxygen.

Upon client record review, 2 of 14 (Patient #1, 3) 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. Patient 01: The patient record reflects an IDG meeting on 12/1/23, there has been no updated IDG for this patient since that date. Patient 03: There is no evidence in the patient record that the written plan of care was developed by the IDG in consultation with the patients selected attending physician, a physician other than the hospice medical director.

Upon client record review, 6 of 14 (Patient #1, 3, 4, 5, 7, 8) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 01: The frequency order for SN visits is 2 times per week, the patient received 1 visit for the week of 11/26/23, did not receive any visits for the week of 12/3/23, and received 1 visit for the week of 12/10/23. Patient 03: The frequency order for the SN visits is 1 time per week, the record does not reflect any visits made since 12/1/23. Patient 04: The plan of care includes orders for MSW and Spiritual Care visits 1x per month, there is no evidence of visits for the month of November. Patient 05: The plan of care includes orders for SN visits 4 times per month and 1 prn. The patient received 6 routine visits in the month of November, there are no documented visits for the month of December. Patient 07: The plan of care includes orders for SN visits 1 time per week, there are no documented SN visits in the patient record since 12/1/23. Patient 08: The plan of care includes order for SN visits 1 time per week. The patient did not receive a SN visit the week of 12/3/23.

Upon observation, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient 01: During the home visit it was observed that the LVN placed her nursing bag directly onto an open box in the patient room without utilizing a barrier. The LVN placed her stethoscope around her neck, before and after using it for patient care, she used gloved hands to reach inside her pockets and to use her cell phone for documenting purposes while wearing gloves and continuing to perform patient care. The LVN placed her phone and nursing tools on a tray on top of a cart that had food items and was not cleaned prior to use and had no barrier. Patient 07: During the home visit it was observed that the LVN placed her nursing bag directly on the floor of the patients home without the use of a barrier. The LVN placed her stethoscope around her neck before and after using it for patient care, she used gloved hands to reach inside of her pockets and to use her cell phone for documenting purposes while wearing gloves and continuing to perform patient care. Upon cleaning the digital thermometer, O2 sat detector and blood pressure cuff/device, the LVN placed the tools back into her nursing bag without allowing for proper drying time.

Upon personnel record review, 1 of 13 (Personnel #7 ) did not have evidence that the hospice routinely provide substantially all core services directly by hospice personnel (The hospice issues a W-2 form for the employee). These services include: • Physician services (may contract for physician services) • Nursing • Medical social services • Counseling Personnel #7: The personnel record review for the MSW indicates that they are under contracted services and not a hired employee.

Upon patient record review, 2 of 14 (Patient #13, 14) did not have evidence the hospice offers 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 13: The patient record does not contain information that bereavement services were offered to the family, there is no post death bereavement assessment, no visit notes and no communication notes that indicate that services were offered to the family. Patient 14: The patient record does not contain information that bereavement services were offered to the family, there is no post death bereavement assessment, no visit notes and no communication notes that indicate that services were offered to the family.

Upon patient record review, 3 of 14 (Patient #3, 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: • The primary terminal condition • Related diagnosis • Current subjective and objective medical findings • Current medication and treatment orders • Information about the medical management of any of the patient's conditions unrelated to the terminal illness Patient 03: The certificate of terminal illness for certification for the period starting 11/12/23 does not include objective and subjective data to support the terminal illness. Patient 04: The certificate of terminal illness for certification for the period starting 10/28/23 does not include objective and subjective data to support the terminal illness. Patient 07: The certificate of terminal illness for certification for the period starting 5/25/23 does not include objective and subjective data to support the terminal illness.

Upon patient record review, 5 of 14 (Patient #1, 2, 6, 7, 9) 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 01: The certificate of terminal illness for recertification for the period starting 11/25/23 does not include objective and subjective data to support the terminal illness. Patient 02: The certificate of terminal illness for recertification for the period starting 11/24/23 does not include objective and subjective data to support the terminal illness. Patient 06: The certificate of terminal illness for recertification for the period starting 9/15/23 does not include objective and subjective data to support the terminal illness. The certificate of terminal illness for recertification for the period starting 12/14/23 does not include objective and subjective data to support the terminal illness. Patient 07: The certificate of terminal illness for recertification for the period starting 8/23/23 does not include objective and subjective data to support the terminal illness. The certificate of terminal illness for recertification for the period starting 9/15/23 does not include objective and subjective data to support the terminal illness. The certificate of terminal illness for recertification for the period starting 11/21/23 does not include objective and subjective data to support the terminal illness. Patient 09: The certificate of terminal illness for recertification for the period starting 8/7/23 does not include objective and subjective data to support the terminal illness.

Upon patient client record review, 5 of 14 (Patient #1, 4, 7, 9, 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 01: The Election of Hospice Benefit document in the patient record does not include the effective start of care date. The Election of Hospice Benefit form does not indicate the election or declination of patient/caregiver wishes to receive the "Patient Notification or Hospice Non-Covered Items, Services and Drugs" addendum. Patient 04: The Election of Hospice Benefit document in the patient record does not include the effective start of care date. Patient 07: The patient was admitted on 5/25/23, the Election of Hospice Benefit is not signed by the patient or representative. Patient 09: The patient was admitted on 5/9/23, the Election of Hospice Benefit indicates a start date of 5/8/23. Patient 14: The patient was admitted on 10/7/22, the Election of Hospice Benefit does not include the effective start of care date.

Upon patient client record review, 3 of 14 (Patient #2, 4, 5) 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 02: The patient was admitted on 11/24/23, the initial comprehensive assessment completed by the RN, is not properly authenticated with a date and signature in the electronic medical record. A skilled nursing visit was performed by the LVN on 12/12/23, the visit has not been signed and dated by the visiting nurse. Patient 04: The patient received the initial psychosocial assessment on 11/1/23, the documentation has not been properly completed and is not authenticated with a signature and date. A skilled nursing visit completed on 12/2/23, the documentation is not authenticated with a signature and date. Patient 05: The patient received a MSW visit on 12/10/23, the documentation has not been authenticated with a signature and date.