Every finding on record at Vital Care Hospice LLC

Upon observation, there was no evidence the hospice develops and maintains an emergency preparedness communication plan that complies with federal, state, and local laws and must be reviewed and updated every two years. Per communication plan phone tree there were staff members who were no longer employed with agency and date listed was 12/15/2022.

Upon observation, there was no evidence the Emergency Plan communication plan includes all of the following: • Names and contact information for the following: • Hospice employees • Entities providing services under arrangement • Patients' physicians • Other hospices The employee list was outdated and listed from 12/15/2022. It did not contain any of the entities providing services under arrangement or other hospice.

Upon observation, there was no evidence of emergency preparedness training and testing program that is based on the emergency plan, policies and procedures and the communication plan. All exercises/training/testing were dated from year 2022 there was nothing current.

Upon personnel record review, 9 of 13 (Personnel #1, 2, 3, 4, 5, 7, 11, 12, 13) did not contain evidence that the Emergency Preparedness training included: • Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles • Demonstrate staff knowledge of emergency procedures • Provide emergency preparedness training at least annually • Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others • Maintain documentation of all emergency preparedness training There was no documentation of any emergency preparedness training since year 2022.

Upon observation, there was no evidence the agency has conducted exercises to test the emergency plan every two years. The last noted year there was any exercises/testing were from year 2022.

Condition of Participation: Patient’s Rights. L500

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. Patients #5, 8, 9 did not have evidence of receipt of this information as there were no consents or Election of Benefits form.

Upon patient record review, 3 of 14 (Patient #5, 8, 9) did not contain 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. Patients #5, 8, 9 did not have evidence of receipt of this information as there were no consents or Election of Benefits form.

Upon patient record review, 3 of 14 (Patient #5, 8, 9) did not contain 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. Patients #5, 8, 9 did not have evidence of receipt of this information as there were no consents or Election of Benefits form.

Upon patient record review, 3 of 14 (Patient #5, 8, 9) 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. Patients #5, 8, 9 did not have evidence of receipt of this information as there were no consents or Election of Benefits form.

Upon client record review, 4 of 14 (Patient #5, 7, 8, 9) did not contain 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 #7: RN initial assessment did not indicate that patient/family were involved in care planning as all pages between 2-9 were left blank. Page 8 contained the questions regarding patient/family involvement. Patient #8: RN initial assessment did not indicate that patient/family were involved in care planning as all pages between 3-9 were left blank. Page 8 contained the questions regarding patient/family involvement. Patients #5, 8, 9 did not have evidence of receipt of this information as there were no consents or Election of Benefits form.

Upon patient record review, 8 of 14 (Patient #5, 6, 7, 8, 9, 11, 12, 14) did not contain evidence that the patient chose a health care provider, including an attending physician. Patient #5: There were no consents of any type identified in this chart as they were paper and not in the EMR not allowing for patient to choose attending physician. Patient #6: Right to choose an attending physician section was left blank. Patient #7: Right to choose an attending physician section was left blank. Patient #8: There were no consents of any type identified in this chart as they were paper and not in the EMR not allowing for patient to choose attending physician. Patient #9: There were no consents of any type identified in this chart as they were paper and not in the EMR not allowing for patient to choose attending physician. Patient #11: Right to choose an attending physician section was left blank. Patient #12: Right to choose an attending physician section was left blank. Patient #14: Right to choose an attending physician section was left blank.

Upon patient record review, 3 of 14 (Patient #5, 8, 9) did not contain evidence of the appropriate documentation for release of confidential information. Patients #5, 8, 9 did not have evidence of receipt of this information as there were no consents or Election of Benefits form.

Upon patient record review, 3 of 14 (Patient #5, 8, 9) did not have evidence that the patient received information about the services covered under the hospice benefit. Patients #5, 8, 9 did not have evidence of receipt of this information as there were no consents or Election of Benefits form.

Upon patient record review, 3 of 14 (Patient #5, 8, 9) 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. Patients #5, 8, 9 did not have evidence of receipt of this information as there were no consents or Election of Benefits form.

Upon patient record review 3 of 14 (Patient #1, 7, 8) did not contain evidence that the hospice conducted and documented in writing a patient-specific comprehensive assessment that identifies the patient's need for hospice care and services, and the patient's need for physical, psychosocial, emotional, and spiritual care. This assessment includes all areas of hospice care related to the palliation and management of the terminal illness and related conditions. Patient #1: RN initial assessment did not address skin integrity, mental status/confusion, psychosocial needs, spiritual needs, support systems, and family need for counseling and education, patient/family ability to administer meds, DME/supplies, activities permitted, mental status, memory recall, skin assessment, spiritual assessment or DME/supply needs. In addition, assessment did not address: safety issues/measures, sensory, cardiovascular, memory recall, mental status or functional limitations, functional assessment, imminence of death. Patient #7: RN initial assessment: page 1 only contained name, date and diagnoses'. Pages 2-9 all questions were left blank. RN comprehensive assessment did not address any of the following: pain, dyspnea, nausea, vomiting, constipation, restlessness, anxiety, sleep disorders, skin integrity, confusion, emotional distress, spiritual needs, support systems, and family need for counseling and education. All pages between 2-9 were left blank. In addition, did not address: safety issues/measures, sensory, cardiovascular, memory recall, mental status, functional limitations, abuse screen, pain assessment, respiratory/dyspnea, nutrition/hydration, activities of daily living/ability to perform and family/caregivers ability/willingness to help, f Patient #8: RN initial assessment: page 1 only contained name, date and diagnoses'. Pages 2-9 all questions were left blank. RN comprehensive assessment did not address any of the following: functional limitations, activities permitted, mental status, skin integrity, musculoskeletal, sensory, cardiovascular, safety issues/measures, psychosocial, and spiritual needs. Page three was left blank as well as page seven. In addition, did not address: safety issues/measures, sensory, cardiovascular, memory recall, mental status or functional assessment, imminence of death, pain, respiratory, genitourinary and bowel assessment.

Upon patient record review 1 of 14 (Patient #9) did not contain evidence 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 #9: MSW initial assessment was not completed. A routine visit was made 05/22/25 which was outside the 5 day period.

Upon patient record review, 3 of 14 (Patient #3, 8, 10) did not contain evidence 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: Order date 05/19/25; Acetaminophen Extra Strength Tablet 500mg - 2 tabs every 6 hours as needed. No maximum dose was included. Patient #8: Order date 09/30/24; Tylenol 500mg 2 tabs every 6 hours as needed. No maximum dose was included. Patient #10: Acetaminophen 650mg suppository 1 every 4 hours as needed. Acetaminophen 325mg tab 2 tabs every 6 hours as needed. No maximum dose was included.

Upon patient record review, 2 of 14 (Patient #4, 7) did not contain evidence that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual's attending physician, if any) • Changes that have taken place since the initial assessment • Information on the patient's progress toward desired outcomes • Reassessment of the patient's response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days Patient #1: 7th recertification POC ordered SN 2x/weekly; no visits were made between 10/10/25-11/15/25, greater than every 15 days. Patient #3: All POCs ordered SN visits as 1x/weekly. There have been no visits made after 01/11/26 as the notes dated for 01/21/26 and 01/28/26 have not been started therefore greater than 15 days. Patient #4: Patient with multiple wounds and only RN visits made were for recertification purposes but 01/14/26 note was not completed/signed/dated. The only other RN visit made was on 12/14/25. Patient #7: There were no visits notes for entire 1st certification period which did not allow for verification of comprehensive assessment updates being made.

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

Upon patient record review, 1 of 14 (Patient #4) did not contain 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 #4: Patient has multiple wounds as evidenced by pictures that were provided during home visit. Per patient record the RN has not made a visit, LVN is only nurse making visits, to assess patient outside of recertification assessments dated 12/14/25 and 01/14/26 (which is not entirely completed). There was no evidence that the wounds were being assessed by LVN or RN. During home visit RN did not assess wounds.

Upon patient record review, 1 of 14 (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: Initial POC 02/03/24 was blank except for name, dates, diagnoses' and signatures.

Upon patient record review, 3 of 14 (Patient #3, 8, 10) 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 #3: Initial POC/all updated; Acetaminophen Extra Strength Tablet 500mg - 2 tabs every 6 hours as needed. No maximum dose was included. Patient #8: Updated POC/all following after order date 09/30/24; Tylenol 500mg 2 tabs every 6 hours as needed. No maximum dose was included. Patient #10: Initial POC/all updated; Acetaminophen 650mg suppository 1 every 4 hours as needed. Acetaminophen 325mg tab 2 tabs every 6 hours as needed. No maximum dose was included. Jevity 1.5cal liquid 65ml/hr x20 hours. There were no flush orders or residual checks ordered.

Upon patient record review, 1 of 14 (Patient #7) did not contain evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient #7: There was no evidence of visits being completed for entire 1st certification period. RN recertification assessment 07/25/24 was not started/blank and there were no other visits by an RN during 3rd certification period. There was no evidence of RN visit being made between 02/26/25-03/15/25 (6th certification). The plan of care had not been revised during these times as comprehensive assessments were not being completed and there was no documented progress of patient's progress towards outcome/goals from the plan of care.

Upon client record review, 7 of 14 (Patient #1, 3, 5, 7, 8, 9, 10) did not contain evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1: 7th recertification POC ordered SN 2x/weekly; no visits were made between 10/10/25-11/15/25. 8th recertification POC did not have a visit frequency listed for SN/MSW/SC. SN made 1-2 visits weekly. MSW made 1 monthly visit. 9th recertification POC ordered SN 1x/weekly; weeks of 11/30/25, 12/14/25 and 01/11/26 all had 2 visits made. MSW was noted to be as declined but visits were made 11/21/25 and 12/19/25. 10th recertification POC ordered SN 1x/weekly; week of 01/18/26 2 were made. MSW ordered 1x/monthly; no visit made in January 2026. Patient #3: All POCs ordered SN visits as 1x/weekly; weeks of 11/23/25 and 01/11/26 2 visits were made. There have been no visits made after 01/11/26 as the notes dated for 01/21/26 and 01/28/26 have not been started. Patient #5: All POCs ordered SN 1x/weekly; weeks of 06/15/25, 07/20/25, 08/10/25, 10/05/25 and 10/09/25 there were no visits made. Patient #7: 5th certification POC ordered SN visits 2x/weekly; all weeks from 11/24/24 - 01/20/25 only had 1 visit. MSW ordered 1x/monthly; there were no visits made. 4th recertification POC ordered SN 1x/weekly; there were no visits made week of 10/20/24. 3rd recertification POC ordered SN 1x/weekly; week of 08/18/24 there were no visits made. MSW ordered 1x/monthly; there was only one visit made during July for entire period. 2nd certification POC ordered SN 1x/weekly; this certification period began 04/26/24 and the first visit wasn't made until 06/13/24 and there were no visits made weeks of 06/23/24 and 06/30/24. MSW ordered 1x/monthly; no visits made. Initial POC ordered SN visits 1x/weekly but there were no visits made the entire certification period. MSW ordered 1x/monthly visits but there were no visits made the entire certification period. RN recertification 07/25/24 was not started/blank. NP F2F note 11/11/24 was not started/blank. NP notes 09/11/24 and 01/20/25 were not started/blank. Patient #8: 6th recertification POC ordered SN 1x/weekly; week of 12/29/24 one visit made. MSW was indicated as declined but 2 visits were made. 5th recertification POC was blank and did not contain orders for frequency of visits. SN and MSW made visits. 4th recertification POC ordered MSW 1x/monthly; no visits were made in November 2024. Initial POC did not indicate a frequency for any disciplines; there were no visit notes of any type for this period. NP note 07/28/24 was not started/blank. NP F2F 01/26/25 was not started/blank. MSW notes 07/10/24, 07/13/24 and 07/16/24 were not started/blank. Patient #9: All POCs ordered SN 1x/weekly; Week of 05/04/25 no visits were made, RN note 05/06/25 was not started/blank. Patient #10: 7th recertification POC ordered MSW 1x/monthly; there were no visits October 2025. 5th recertification period ordered SC 1/monthly; there have been no visits made. NP F2F 02/01/25 was not started/blank.

Upon patient record review, 1 of 14 (Patient #4) did not have evidence that the IDG documents the sharing of information between all disciplines providing care and services in all settings, whether the care and services are provided directly or under arrangement. Patient #4: Patient was seen by SNF wound care team for multiple wounds and there was no evidence of communication with said wound care team.

Condition of Participation: Hospices that Provide Hospice Care to Residents of a SNF/NF or ICF/MR.

Upon patient record review, 2 of 14 (Patient #4, 8) did not contain evidence that licensed professional actively participated in the coordination of all aspects of the patient's hospice care, including participating in ongoing interdisciplinary comprehensive assessments, developing and evaluating the plan of care, and contributing to patient and family counseling and education. Patient #4: Per RN note 07/31/25: Sacrum ulcer - "cleanse with NSS/wound cleanser, pat dry \apply Medihoney, calcium alginate cover with foam dressing every day". There was no indication that MD was made aware of wound. Patient continues with multiple wounds, as evidenced by pictures presented during home visit, and there was no indication of any wounds having been discussed with hospice physician. Patient #8: RN note 03/25/25 - "the skilled nurse performed wound care and dressing on the index toe of the right foot and left little toe during the visit today". There was no indication that MD was made aware of these wounds.

Upon patient record review, 2 of 14 (Patient #7, 9) did not contain evidence that Social work services are based on the patient's psychosocial assessment and the patient/family's needs and acceptance of these services. Patient #7: There were no visit notes for entire 1st certification period therefore unable to verify if SW made an assessment visit. SW was involved in patients care as other visits were made during patients time on hospice services. Patient #9: SW did not complete an assessment but began making routine visits on 05/22/25.

Condition of Participation: Hospice Aide and Homemaker Services. L607

Upon patient record review 7 of 14 (Patient #1, 2, 6, 7, 8, 9, 10) did not contain evidence of documentation that a hospice aide provided 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 #1: Aide POC/IDG for 10th certification period ordered 3x/weekly visits: Week of 01/25/26 there were four visits and there haven't been any made since last visit on 01/30/26. Aide POC/IDG for 9th certification period ordered 2x/weekly visits: Week of 01/04/26 there was only one visit made. Week of 01/11/26 there were 4 visits made. Aide POC/IDG for 8th certification period was blank not indicating a visit frequency and aide made two visits weekly. Patient #2: All Aide POC/IDGs indicated 2x/weekly visits: week of 12/07/25 there was only one visit made and there haven't been any visits made since 01/15/26. Patient #6: All Aide POC/IDG indicated 2x/weekly visits: there were no visits made after 12/18/25 and patient did not discharge from services until 12/28/25. Aide noted dated 12/11/25 was not signed/dated. Patient #7: All Aide POC/IDG indicated 3x/weekly visits: week of 09/22/24 there were only 2 visits made as the visit for 09/28/24 was not "started" and was blank not indicating a visit having been made. Patient #8: Aide POC/IDG for 5th certification period was blank not indicating a visit frequency and aide made 2x/weekly visits. Aide POC/IDG for 4th certification period indicated 2x/weekly visits: week of 11/24/24 there was only one visit made. Aide note dated 08/22/24 was not signed/dated. Patient #9: Initial Aide POC/IDG indicated 2x/weekly visits: week of 06/22/25 there was only one visit made. Week of 05/05/25 there was only one visit made as the note dated 05/05/25 was not "started" yet and was blank not indicating a visit was made. Patient #10: 5th recertification Aide POC ordered 1x/weekly visits; there were no visits made.

Upon patient record review 3 of 14 (Patient #3, 4, 7) did not contain evidence 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 #3: Certification period 1 did not have any supervisory visits completed. Certification period 2 only had one completed on 08/17/25. Certification period 3 only had one completed on 11/29/25. Certification period 4 only had one completed on 01/14/26 but note is not signed/dated. Patient #4: The only supervisory visit completed for entire length of hospice services to date was at recertification 12/14/25. Patient #7: There were no supervisory visits made between 02/26/25-03/15/25 due to visits being missed and not made up.

Upon personnel record review, 1 of 13 (Personnel #7) did not contain evidence in the hospice aide personnel file that a registered nurse made an annual on-site visit to the location where a patient is receiving care in order to observe and assess each aide while he or she is performing care. Personnel #7: there was no evidence of any on-site visits being made for observation of aide care.

Upon observation, there was no evidence the annual report documents the use of volunteers providing day to day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract personnel. Per fiscal year 2025 overall volunteer use percentage was 4.52%.

Condition of Participation: Organization and Administration of Services.

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 as evidenced by the Alternate Administrator (personnel #2) did not meet agency job description. Job description states "A Bachelor's degree in Business Administration, Masters Degree in health care or related field preferred. Three (3) to five (5) years experience in health care management. There is no evidence of any of these qualification in the personnel file. Resume shows 10/21 to present as licenses CNA and Office Manager at Concierge Home Care - Ormond from 4/19 - 12/19. Per Policy the Administrator and Alternate Administrator are only required to have 3-5 years of health care experience. The policy and job descriptions do not match. Administrator acknowledged this and said the "wording" will be changed. In addition, there is lack of oversight of agency as evidenced by human resource management missing key components of files such as observations and evaluations of staff along with missing Criminal Background checks, outdated Emergency Preparedness plan, and lack of evidence to adhere to Medicare regulations for patient consents and revocations as well as maintaining complete and accurate patient records.

Upon personnel record review, 5 of 13 (Personnel #2, 7, 11, 12, 13) did not contain evidence that the hospice employees and contract employees have received orientation on the hospice philosophy. Personnel #2, 7, 11, 12, 13: there was no evidence of orientation having been completed.

Upon personnel record review, 5 of 13 (Personnel #2, 7, 11, 12, 13) did not contain evidence that the hospice employees have received orientation on their specific job requirements. Personnel #2, 7, 11, 12, 13: there was no evidence of job requirement orientation having been completed.

Upon personnel record review, 2 of 13 (Personnel #6, 12) did not contain evidence that a skills competency assessment, specific to each discipline had been conducted for all personnel including volunteers initially during orientation. Personnel #6, 12: there was no evidence of skills competency assessments completed.

Upon patient record review, 1 of 14 (Patient #8) did not contain 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 #8: Initial CTI as follows; page 1 blank except name, date and diagnosis'. Page 2 blank except for signature. Page 3 did not contain a narrative. There were no medication/treatment orders.

Upon patient record review, 2 of 14 (Patient #1,7) did not contain 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 #1: 8th recertification CTI did not contain a narrative or signatures confirming life expectancy of 6 months or less, page 3 was left blank and did not contain a physician signature. Patient #7: 2nd recertification CTI did not contain a full narrative/summary; "69 y/o female with hospice dx of Senile degeneration of brain w/other comorbidities: HTN, hypothyroidism, hld. Patietn"

Upon patient record review 1 of 14 (Patient #7) did not contain evidence that a patient record was maintained for each hospice patient. Patient #7: the entire 1st certification period is missing from the record. The first documented visit was noted to be 06/13/24 by nurse. Patient admitted 1/27/24.

Upon patient client record review, 8 of 14 (Patient #5, 6, 7, 8, 9, 11, 12, 14) did not contain evidence that each patient record contained: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient #5: There were no consents or Election of benefit form of any type identified in this chart as they were paper and not in the EMR. There was no indication that the patient/representative had the right to chose the attending physician or received the notice of patients rights. Patient #6: Right to choose an attending physician section was left blank. Patient #7: Right to choose an attending physician section was left blank. Patient #8: There were no consents or Election of benefit form of any type identified in this chart as they were paper and not in the EMR. There was no indication that the patient/representative had the right to chose the attending physician or received the notice of patients rights. Patient #9: There were no consents or Election of benefit form of any type identified in this chart as they were paper and not in the EMR. There was no indication that the patient/representative had the right to chose the attending physician or received the notice of patients rights. Patient #11: Right to choose an attending physician section was left blank. Patient #12: Right to choose an attending physician section was left blank. Patient #14: Right to choose an attending physician section was left blank.

Upon patient client record review, 6 of 14 (Patient #1, 4, 6, 7, 8, 10) did not contain 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 #1: LVN note 12/2/25 was not signed/dated. Patient #4: RN recertification assessment 01/14/26 was not signed/dated. Patient #6: RN note 11/25/25 was not signed/dated. Patient #7: RN note 01/18/25 was not signed/dated. Patient #8: NP F2F note 09/22/24 was not signed dated. RN recertifications for 09/30/24 and 11/29/24 were not signed/dated. RN notes 06/11/24 and 07/02/24 were not signed/dated. Patient #10: RN note 11/05/25 was not signed/dated.

Upon patient record review, 2 of 14 (Patient #7, 8) did not contain evidence that the interdisciplinary group, as part of the review of the plan of care, determined the ability of the patient and/or family to safely self-administer drugs and biologicals to the patient in his or her home. If the patient and/or family are not capable of safely administering drugs and biologicals in the home, the hospice must address this issue in the patient's plan of care. Patient #7: RN initial assessment 01/27/24 did not address this as the question was left blank. Patient #8: RN initial assessment 02/03/24 did not address this as the question was left blank

Upon patient record review, 1 of 14 (Patient #4) did not contain evidence that the hospice assumes responsibility for professional management of the resident's hospice services in accordance with the hospice plan of care. The hospice is responsible for providing all hospice services including: • Ongoing assessment, care planning, monitoring, coordination and provision of care by the Hospice IDG • Assessment, coordination and provision of any needed general inpatient or continuous care • Consultation about the patient's care with facility staff • Coordination by the hospice RN for the implementation of the plan of care for the patient • Provision of hospice aide services, if these services are determined necessary by the IDG to supplement the nurse aide services provided by the facility • Provision, in a timely manner, of all supplies, medications, and DME needed for the palliation and management of the terminal illness and related conditions • Financial management responsibility for all medical supplies, appliances, medications and biologicals related to the terminal illness and related conditions • Determination of the appropriate level of care to be given to the patient (routine homecare, inpatient, or continuous care) • Arranging any necessary transfers from the facility, in consultation with the facility personnel Patient #4: There was no evidence of consultation with facility staff regarding patients care/wounds and providing all necessary supplies to care for them.

Upon SNF/NF contract review, 1 of 4 (Southview Manor SNF contract) did not contain evidence of the manner in which the SNF/NF and the hospice are to communicate with each other and how each will document such communications to ensure that the needs of patients are addressed and met 24 hours a day. Southview Manor Inc contract did not contain evidence of lines of communication between the facility and hospice agency.

Upon SNF/NF contract review, 1 of 4 (Southview Manor SNF contract) did not contain evidence that specified the provision of hospice services in the facility, including: A provision that the SNF/NF or ICF/IID immediately notifies the hospice if: • A significant change in a patient's physical, mental, social or emotional status occurs • Clinical complications appear that suggest a need to alter the plan of care • When a need to transfer a patient from the SNF/NF or ICF/MR arises, and the hospice makes arrangements for, and remains responsible for, any necessary continuous care or inpatient care necessary related to the terminal illness and related conditions • A patient dies Southview Manor contract did not contain contain evidence that when a need to transfer a patient from the SNF/NF or ICF/MR arises, and the hospice makes arrangements for, and remains responsible for, any necessary continuous care or inpatient care.

Upon SNF/NF contract review, 1 of 4 (Southview Manor SNF contract) did not contain evidence that it is the SNF/NF's responsibility to continue to furnish 24 hour room and board care, meeting the personal care and nursing needs at the same level of care that would have been provided by the family at the facility before hospice care was elected. Southview Manor contract did not contain evidence of meeting the personal care and nursing needs at the same level of care that would have been provided by the family at the facility before hospice care was elected. Contracted stated they would furnish 24 hour room and board care but it did not mention at level to which it would be provided.

Upon SNF/NF contract review, 1 of 4 (Southview Manor SNF contract) did not contain evidence that it is the hospice's responsibility to provide services at the same level and to the same extent as those services would be provided if the SNF/NF resident were in his or her own home. Southview Manor contract did not provide evidence that it is the hospice's responsibility to provide services at the same level and to the same extent as those services would be provided if the SNF/NF or ICF/IID resident were in his or her own home.

Upon client record review, 3 of 14 (Patient #2, 4, 6) did not contain evidence that a written hospice plan of care was established and maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided is in accordance with this hospice plan of care. Patient #2: 2nd, 3rd and 4th recertification POCs ordered SC 1x/month and no visits were ever made. 3rd and 4th recertification POCs indicated that SW had been declined but three visits were made during 3rd period and 1 visit was made during 4th. Patient #4: 3rd recertification POC ordered SN 2x/weekly; week of 12/14/25 3 visits made. Week of 12/21/25 1 visit made due to LVN note 12/26/25 not being started. There was no evidence that the agency was involving the SNF in care planning for patient. Patient with multiple wounds and there was no evidence that the plan of care was being updated regarding these ongoing issues. The interventions/goals were not addressing these wounds as well. In addition, there was no evidence that these were being discussed with wound care team at SNF. Patient #6: All POCs ordered SN 1x/weekly; week of 07/27/25 there were no visits made. 2nd and 3rd recertification POCs indicated that MSW was declined. There were 2 visits made in September and December and 1 made in August and October 2025.

Upon observation, there was no evidence there is a designated member of the IDG responsible for any patient who is a resident of the SNF/NF or ICF/IID. The designated IDG member is responsible for providing overall coordination of the hospice care of the resident with the facility's personnel. There was no evidence that an RN was coordinating care for the residents in a SNF as evidenced by patient #4 wounds not being coordinated for care with SNF wound team.

Upon personnel record review, 6 of 13 (Personnel #1, 2, 7, 11, 12, 13) did not have evidence of criminal background checks being obtained in accordance with Illinois state requirements HR.C20 Criminal Background checks. Note: In the absence of state requirements, criminal background checks are obtained within three months of the date of employment for all states that the individual has lived or worked in the past 3 years. Personnel #1: Upon initial review of file, first day of survey, there was no evidence of criminal background checks being completed. During third day of survey Administrator stated they were in his "drive" and just needed added to the file. Personnel #2: There was no evidence of background checks being completed for this employee. The form granting permission for this to be completed was there but no evidence it was done. Personnel #7: Upon initial review of file, first day of survey, there was no evidence of criminal background checks being completed. During second day of survey Administrator provided a print out with employees picture on it but it did not reference any background check being completed. Personnel #11: Upon initial review of file, first day of survey, there was no evidence of criminal background checks being completed. During third day of survey Administrator they were in his "drive" and just needed added to the file. Personnel #12: Upon initial review of file, first day of survey, there was no evidence of criminal background checks being completed. During third day of survey Administrator they were in his "drive" and just needed added to the file. Personnel #13: Upon initial review of file, first day of survey, there was no evidence of criminal background checks being completed. During third day of survey Administrator they were in his "drive" and just needed added to the file.

Upon patient record review, 5 of 7 (Patient #1, 2, 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 1, 2, 3, 4, 5: The comprehensive initial nursing assessment indicates the patient is full code status and that they will follow up on code status and hospitalizations. There are no follow up conversations with the patients or families related to code status or hospitalization preferences, and no follow up discussions among the IDT related to resuscitation preferences. No care plans were developed on admission, or at any time thereafter, to address code status/resuscitation and hospitalization preferences related to the terminal illness.

Upon patient record review, 1 of 7 (Patient #2) 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: • 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 2: Orders for the chaplain are entered only as PRN visits for spiritual support. During the comprehensive initial social work assessment, further MSW services and visits were declined; however, orders for PRN visits by the MSW were entered. (corrected onsite)

Upon patient record review, 7 of 7 (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 equipment and supply needs. Patient 1, 2, 3, 4, 5, 6, 7: All DME utilized by the patient for management of the terminal illness must be included on the plan of care. This was not included on the plan of care for any patients. (corrected onsite for all active patients)

Upon patient record review, 1 of 7 (Patient #4) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient 4: The hospice aide care plan is incomplete. Check boxes specifying the type of activity to be performed at every visit have been left blank. (corrected onsite)

Upon patient record review 2 of 7 (Patient #2 and 7) 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 2: There is no evidence of discipline orders for the hospice aide. The aide completed visits. (corrected onsite) Patient 7: The hospice aide care plan, dated 08.15.2022, indicates the aide is to prepare meals at every visit. The aide documented in the narrative portion of her notes during the week of 08.28.2022 that the patient's daughter prefers to prepare meals. From that week until the time of hospice discharge, the aide no longer prepared meals as ordered in the care plan. There is no communication between the aide and the SN relating to discontinuation of meal preparation, and no revision to the care plan.

Upon patient client record review, 7 of 7 (Patient #1, 2, 3, 4, 5, 6, 7) did not have evidence that each patient record contains Advance Directives. Patient 1, 2, 3, 4, 5, 6, 7: There was no evidence of Advance Directives or a complete/signed copy of a POLST form for any patient.

Upon patient client record review, 2 of 7 (Patient #1, 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 1: On the comprehensive initial social work assessment, dated 11.28.2022, white out tape was used in at least three places, making the contents of the documentation unclear. Patient 5: On the comprehensive initial social work assessment, dated 11.27.2022, checkboxes were marked indicating the patient as DNR code status and showing the patient had advance directives on file; the remainder of the patient record consistently indicates the patient as full code status and no advance directives or POLST form is present. The Director of Nursing confirmed that the MSW checked these boxes in error.