Every finding on record at Vmkj Healthcare LLC

Upon personnel record review, 6 of 13 (Personnel #4,5,7,8,9,10) did not have evidence Emergency Preparedness training including: • 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 Personnel #4,5,7,8,9,10 no evidence of emergency preparedness training completed.

Upon patient record review, 9 of 14 (Patient #2,5,6,7,9,10,11,13,14) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient #2,5,6,7,9,10,11,13,14 No evidence noted on consent of choice of health care provider, including an attending or declination.

Upon patient record review 1 of 14 (Patient #12) 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 #12, Order for MSW initial then PRN, no psychosocial assessment completed by any discipline.

Upon patient record review, 5 of 14 (Patient #1,3,11,13,14) 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 #1,3,13,14, Order for Oxygen 2l/nc, may titrate up to 5l if 02 sat below 92%, no evidence of order on medications sheet. Patient #11, Order of Oxygen 2l/nc may titrate up to 5l as needed, no evidence of order on medication sheet.

Upon patient record review, 1 of 14 (Patient #12) 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 #12, No bereavement assessment completed.

Upon patient record review, 14 of 14 (Patient #1,2,3,4,5,6,7,8,9,10,11,12,13,14) did not have evidence in the patient record 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 #1,2,3,4,5,6,7,8,9,10,11,12,13,14, comprehensive notes were missing MSW updates and MSW signature except for IDG on 8/4/23 was the only MSW assessment and signature by MSW.

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

Upon patient record review, 14 of 14 (Patient #1,2,3,4,5,6,7,8,9,10,11,12,13,14) did not have evidence 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 #1,2,3,4,5,6,7,8,9,10,11,12,13,14, MSW wrote her interventions and goals in her assessment note. No evidence of initial care plan.

Upon patient record review, 13 of 14 (Patient #1,2,3,4,5,6,7,8,9,10,12,13,14) 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, MSW frequency initial then PRN. SC frequency initial and PRN. Patient #2, MSW frequency initial then PRN. Patient #3, MSW frequency initial then PRN. SC frequency initial then PRN. Patient #4, MSW frequency initial then PRN. SC frequency initial and PRN. Patient #5, MSW frequency initial then PRN. SC frequency initial then PRN. Patient #6, MSW frequency initial then PRN. SC frequency initial then PRN,. Patient #7, MSW frequency initial then PRN. Patient #8, MSW frequency initial then PRN. SC 1x/month and PRN. Patient #9, MSW frequency initial then PRN. Patient #10, MSW initial then PRN. SC frequency initial then PRN. Patient #12, MSW initial then PRN. SC initial then PRN. Patient #13,MSW frequency initial then PRN. Patient #14, MSW frequency initial and PRN.

Upon patient record review, 4 of 14 (Patient #1,3,13,14) 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 #1,3,13,14, Order for Oxygen 2l/nc, may titrate up to 5l if 02 sat below 92%, no evidence of frequency for continuous or PRN.

Upon patient record review, 1 of 14 (Patient #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 #7, Plan of care has no evidence of any DME, nursing assessment states patient ambulates with assistive device. No evidence of supplies documented on POC, patient has wound care.

Upon client record review, 13 of 14 (Patient #1,2,3,4,5,6,7,8,10,11,12,13,14) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1, SN frequency 2x/week and 2 PRN, patient seen 1 time weeks of 12/24/23, 1/7/24, 1/14, and 1/28 on these dates 12/27/23, 1/9/24, 1/16/24, 1/29/24. MSW frequency initial then PRN, patient seen 11/12/23 for a telephone visit, no evidence of order for telephone order visit. SC frequency initial and PRN, patient seen 11/14/23 for telephone visit, no evidence of telephone visit order. Patient #2, SN frequency 2x/week and 2 PRN, patient seen 1 time for weeks of 12/31/23, 1/7/24, 1/21, 1/28 on these dates 1/2/24, 1/9/24, 1/23/24, 1/30/24. MSW frequency initial then PRN, patient seen 7/24/23 telephone visit, 10/14/23 telephone PRN recert. No evidence of telephone visit order. SC made telephone visits on 7/26/23, 10/13/23, 1/12/14, no evidence of telephone visit order. Patient #3, SN frequency 1x/week, patient seen 7/9/23, then by both RN and LVN on 7/12/23, 11/1/23 and 11/4/23 for total of 3 visits each week. MSW frequency initial then PRN, patient seen 6/30/23 and 10/20/23. SC frequency initial then PRN, patient seen 7/9/23, 8/5/23, 9/10/23, 10/8/23, 11/4/23,12/3/23, 1/3/24. Patient #4, SN frequency 2x/week and 2 PRN, patient seen 1 time for weeks 12/24/23, 1/7/24, 1/14, 1/28 on these dates 12/27/23, 1/9/24, 1/16/24, 1/29/24. Only 1 visit that week. MSW frequency initial then PRN, patient seen 12/29/23 for a telephone visit, no evidence of order for telephone visit. SC frequency initial and PRN, patient seen 12/28/23 for telephone visit, no evidence of telephone visit order. Patient #5, MSW frequency initial then PRN, seen 12/16/23 for telephone visit, no evidence for telephone visit order. SC frequency initial then PRN, visits made 12/15/23, 1/6/24. Patient #6, SN frequency 2x/week and 2 PRN, patient seen 3 times week of 1/7/24 on 1/8/24, 1/9/24, 1/12/24, and 1 time the two following weeks on 1/17/24, 1/24/24. MSW frequency initial then PRN, patient seen 12/13/23 for telephone visit, no evidence of telephone visit order. SC frequency initial then PRN, patient seen 12/13/23, 1/6/23. Patient #7, MSW frequency initial then PRN, patient seen 10/11/23 for telephone visit, No order for telephone visit. Patient #8, MSW frequency initial then PRN , patient seen 9/29/23 for telephone visit, No order for telephone visit. SC 1x/month and PRN, patient seen 10/1/23 for telephone visit, 11/20/23 for telephone visit, No order for telephone visit. Patient #10, SN 2x/week and 2 PRN, patient seen 1 time weeks of 1/7/24, 1/21, 1/28 on these dates 1/8/24, 1/22/24, 1/31/24. MSW initial then PRN, patient seen 1/10/24 for telephone visit. No evidence of order for telephone visit. SC frequency initial then PRN, patient seen 1/12/24 for telephone visit, no evidence of order for telephone visit. Patient #11, MSW declined, SW seen patient 3/3/23, no frequency orders. SC declined, patient seen 6/13/23 for telephone visit, no order for telephone visit or frequency visit. Patient #12, SN frequency 2x/week and 2 PRN, patient seen 6 times week of 7/16 on 7/16/23, 7/18/23, 7/19/23, 7/20/23, 7/21/23, 7/22/23, 7/23/23. MSW initial then PRN, no MSW assessment or nursing assessment completed. SC initial then PRN 8/1/23 telephone visit, no evidence of an order for a telephone visit. Patient #13, SN 2x/week and 2 PRN, patient seen once week of 6/11/23 on 6/13/23. SC declined patient seen 6/16/23, 7/8/23, no orders. Patient #14, SN frequency 2x/week and 2 PRN, patient seen 1 time weeks of 10/8/23 and 10/15 on 10/10/23, 10/19/23, and 1 time week of 11/5/23, 11/19, 12/10 on 11/9/2311/21/23, 12/13/23.

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 #2 and #3: The agency personnel went in and out of bag without washing hands during patient visit.

Upon observation, there was no evidence the hospice is in compliance with accepted professional standards and principles for all core services which includes nursing services, medical social services and counseling services. No evidence of MSW meeting accepted professional standards. Personnel #6, Personnel does not meet criteria for Medical Social Worker. Personnel completed a 36 hour workshop for social service certification program and has a Bachelor in Nursing from Philippines.

Condition of Participation: Hospice Aide and Homemaker Services. L607

Upon patient record review, 5 of 14 (Patient #2,5,6,9,12) 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 #2,5,6,9,12, Aide care plan instructs bath type as shower chair. No evidence of identifying type of bath to be given.

Upon patient record review 10 of 14 (Patient #1,2,3,4,5,6,7,8,10,13) 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 #1, aide frequency 2x/week, visits on 11/13/23, 11/16/23, 11/20/23, no evidence of aide visits in the first week. Patient #2, aide frequency 2x/week, visits on 7/26/23, 7/27/23, 7/28/23, seen 3x/week. Patient #3, aide care plan instructed diet as tolerated, encourage fluids, no evidence this was completed by aide. Patient #4, aide frequency 2x/week, visits on 12/29/23, 1/1/24/13/24, 1/5/24, seen 1x/week for first week then 3x/week. Patient #5, aide frequency 2x/week, visits on 12/18/23, 12/20/23, 12/22/23, seen 3x/week. Patient #6, aide frequency 2x/week, visits on 12/21/23, 12/25/23, 12/28/23, only one visit the first week. Patient #7, aide frequency 2x/week, visits on 10/24/23, 10/26/23, 11/14/23, 11/16/23, missed 2 weeks of aide visits. Patient #8, aide frequency 2x/week, visit on 9/29/23, 10/2/23, 10/4/23, 10/6/23, seen once first week then 3x/week. Patient #10, aide frequency 2x/week, visit on 1/17/24, 1/19/24, missing visits on first week. Patient #13, aide frequency 2x/week, visit on 6/16/23, 6/23/23, 6/27/23, 6/30/23. No evidence of second visit the first week.

Upon patient record review 1 of 14 (Patient #9) 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 #9, RN supervisory visits completed on 10/13/23 then again on 10/28/23, supervisory visit 15 days instead of 14 days.

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.

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. The governing body did not ensure the social worker met required qualifications to fulfill core service role.

Upon personnel record review, 10 of 13 (Personnel #1,2,3,4,5,6,7,8,9,10 ) did not have evidence the hospice employees and contract employees have received orientation on the hospice philosophy. Personnel #1,2,3,4,5,6,7,8,9,10, No evidence of orientation on hospice philosophy documented in each chart.

Upon personnel record review, 2 of 13 (Personnel #8,9 ) did not have evidence that the hospice employees have received orientation on their specific job requirements. Personnel #8, 9, No evidence of completed competency.

Condition of Participation: Medical Director.

Upon patient record review, 10 of 14 (Patient #2,3,6,7,8,9,10,11,12,14) 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 #2,3,6,7,8,9,10,11,12,14, No evidence of narrative completed by Medical Director on CTI, stated see attached.

Upon patient record review, 8 of 14 (Patient #2,3,7,8,9,11,13,14) 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 #2,3,7,8,9,11,13,14, No evidence of documentation of life expectancy is 6 months or less.

Upon patient client record review, 10 of 14 (Patient #2,4,5,6,7,9,10,11,13,14) 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 #2,5,6,7,9,10,11,13,14 No evidence noted on consent of choice of health care provider, including an attending or declination. Patient #4, No evidence of date on election of benefit.

Upon patient client record review, 1 of 14 (Patient #12) did not have evidence that each patient record contains Advance Directives. Patient #12, Advanced Directive incomplete on consent form.

Upon patient client record review, 9 of 14 (Patient #2,5,6,7,10,11,12,13,14) 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 #2,5,6,7,10,11,12,13,14, Advanced Directive incomplete on consent form.

Upon client record review, 2 of 14 (Patient #11,12) did not have evidence that if a patient revokes the election of hospice care or is discharged from hospice in accordance with §418.26, the hospice must forward to the patient's attending physician: • A copy of the hospice discharge summary • The patient's clinical record, if requested Patient #11, 12, No evidence of discharge summary was sent to MD.

Upon client record review, 2 of 14 (Patient #11,12) did not have evidence that the discharge summary includes all required information. Patient #11,12, missing summary of patient stay, including treatments, symptoms and pain management.

Upon personnel record review, 1 of 13 (Personnel #6) did not have evidence that all Medical Social Services are provided by a qualified Medical Social Worker in accordance with the state's Social Work Practice Act, the hospice's policies and procedures and/or job descriptions. Personnel #6, Social worker has no evidence of baccalaureate degree in social work and no qualified personnel as Medical Social Worker.

Upon personnel record review, 1 of 13 (Personnel #13 ) did not have evidence that all Speech Therapy Services are provided by a qualified licensed Speech-Language Pathologist (SLP) or Audiologist in accordance with the state's Speech-Language Pathology Practice Act and the hospice's policies and procedures and/or job descriptions. Personnel #13, no evidence of HR record.

Upon personnel record review, 3 of 13 (Personnel #11,12,13 ) did not have evidence the hospice obtained a criminal background check on all contracted individuals who have direct patient care and access to patient records. Patient #11,12,13, No evidence of background check for contract therapy, PT, OT, ST.