Every finding on record at Warmth Hospice L.L.C.

Condition of Participation: Emergency Preparedness

Upon observation, there was no evidence the hospice has developed and maintained an emergency preparedness plan that must be reviewed, and updated at least every two years. There was not evidence of when the Emergency preparedness Plan was last reviewed.

Upon observation, there was no evidence the The Emergency Preparedness plan addresses patient population, including, but not limited to: • The ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans

Upon observation, there was no evidence the Emergency Plan communication plan must includes alternate means for communicating with hospice's employees and Federal, state, tribal, regional, and local emergency management agencies.

Upon observation, there was no evidence the Emergency Plan communication plan includes: • A method for sharing information and medical documentation for patients under the hospice's care, as necessary, with other health care providers to maintain the continuity of care • A means, in the event of an evacuation, to release patient information as permitted under 45 CFR 164.510(b)(1)(ii) • A means of providing information about the general condition and location of patients under the facility's care as permitted under 45 CFR 164.510(b)(4)

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. This had not been updated in over 2 years.

Upon observation, there was no evidence the agency has conducted exercises to test the emergency plan every two years. There was not evidence of participation in a a full-scale exercise that is community-based. No evidence of testing or implementation of the emergency plan in over 2 years.

Upon patient record review, 1 of 5 records (Patient #5) 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 #5: The record indicated all admission legal paperwork including the benefit election was signed by an unknown person named "Sara". The signature did not include a last name and it was by using DocuSign. This person was not listed as a responsible party, relative, emergency contact and or a POA. Leadership could not verify who this person was and indicated she could have been a "surrogate".

Upon patient record review, 1 of 14 records (Patient #5) 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 #5: The record indicated all admission legal paperwork including the benefit election was signed by an unknown person named "Sara". The signature did not include a last name and it was signed by using DocuSign. This person was not listed as a responsible party, relative, emergency contact and or a POA. Leadership could not verify who this person was and indicated she could have been a "surrogate".

Upon patient record review, 1 of 14 records (Patient #5) 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 #5: The record indicated all admission legal paperwork including the benefit election was signed by an unknown person named "Sara". The signature did not include a last name and it was signed by using DocuSign. This person was not listed as a responsible party, relative, emergency contact and or a POA. Leadership could not verify who this person was and indicated she could have been a "surrogate".

Upon patient record review, 1 of 14 records (Patient #5) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient #5: The record indicated all admission legal paperwork including the benefit election was signed by an unknown person named "Sara". The signature did not include a last name and it was by using DocuSign. This person was not listed as a responsible party, relative, emergency contact and or a POA. Leadership could not verify who this person was and indicated she could have been a "surrogate".

Upon patient record review, 1 of 14 records (Patient #5) did not have evidence of the appropriate documentation for release of confidential information. Patient #5: The record indicated all admission legal paperwork including the benefit election was signed by an unknown person named "Sara". The signature did not include a last name and it was signed by using DocuSign. This person was not listed as a responsible party, relative, emergency contact and or a POA. Leadership could not verify who this person was and indicated she could have been a "surrogate".

Upon patient record review, 1 of 14 records (Patient #5) did not have evidence that the patient received information about the services covered under the hospice benefit. Patient #5: The record indicated all admission legal paperwork including the benefit election was signed by an unknown person named "Sara". The signature did not include a last name and it was signed by using DocuSign. This person was not listed as a responsible party, relative, emergency contact and or a POA. Leadership could not verify who this person was and indicated she could have been a "surrogate".

Upon patient record review, 1 of 14 records (Patient #5) 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 #5: The record indicated all admission legal paperwork including the benefit election was signed by an unknown person named "Sara". The signature did not include a last name and it was signed by using DocuSign. This person was not listed as a responsible party, relative, emergency contact and or a POA. Leadership could not verify who this person was and indicated she could have been a "surrogate".

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

Upon patient record review 1 of 14 records (Patient #9) 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 #9: The record indicated the start of care on the election form with date 8/18/23, the initial assessment by the nurse was not completed until 8/21/23.

Upon patient record review 4 of 14 records (Patient #5, #6, #7, #9) 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 #5: The records did not show evidence of the comprehensive assessment for the Social Worker within 5 calendar days. The patient was admitted on 4/10/23. The Comprehensive Assessment was not completed until (4/20/23)10 days after the start of care date. Patient #6: Records did not show evidence of the comprehensive assessment for the Social Worker within 5 calendar days. The patient was admitted on 6/13/23. The Comprehensive Assessment was not completed until (6/28/23) 15 days after the start of care. Patient #7: The Social Worker Comprehensive Assessment was not completed until (4/20/23) 9 days after the start of care date on 4/11/23. Patient #9: The Social Worker Comprehensive Assessment was not completed until 8/25/23. Notice of Election for the start of care was 8/18/23.

Upon patient record review, 3 of 14 records (Patient #1,#4,#5) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #1: The medication profile indicated nystatin 100,000u/g topical powder BID fungal rash and Triamcinolone 0.1% ointment to affected area 2 times daily until skin issues resolved. There was not evidence of a specific location. There were duplicate orders for Acetic Acid 0.25 solution for bladder irrigation, one order indicated daily and one order indicated 2 X per week as needed. Patient #4: The medication record had two orders for Acetaminophen, Acetaminophen 650mg 1 rectal suppository every 6 hours prn as needed fever >99 and another order was written as Acetaminophen 650mg oral every 4 hours prn pain/fever. The order did not have parameters regarding a max dose in a 24 hour period. Also for the liquid Tylenol the record did not have evidence of fever parameters. Patient #5: During the home visit the medication profile did not match the ALF Medication Administration Record, the following medications were not present in the facility (Lidocaine 4% patch, Loperamide, Ondansetron).

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

Upon patient record review, 2 of 14 records (Patient #1,#4) 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 #1: A communication note dated 12/29/23 by the nurse indicated the assisted living reported the patient had no urine output and his bed was wet and he required a catheter change. The weekend nurse will assess and change as needed. There was no evidence of follow up until 1/04/24. Patient #4: There were wound care orders written as treatment for the left hip involving cleaning the skin with wound cleanser, pat dry and apply Silvakollgen and calcium alginate every other day and as needed when soiled. There was no evidence that wound care was provided and the wound was not assessed.

Upon patient record review, 2 of 14 records (Patient #6, #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 #6: There was no evidence of end of life care planning, including mortuary information and the patient remained a full code. Patient #7: There was no evidence of end of life care planning, the patient remained a full code.

Upon patient record review, 7 of 14 records (Patient # 1,2,3,4,6,7,8,9) 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,#3,#4,#6,#7,#8,#9 The spiritual care frequency was one time and then prn, there was no evidence of a quantifier for the prn visit.

Upon patient record review, 2 of 14 records (Patient #1, #4) 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: The Physicians Order indicated nystatin 100,000u/g topical powder BID fungal rash and Triamcinolone 0.1% ointment to affected area 2 times daily until skin issues resolved. There was not evidence of a specific location. Patient #4: The nurse documentation indicated sutures needed to be removed and apply triple antibiotic ointment but the record did not show evidence of orders for the suture removal and triple antibiotic ointment. There were incomplete orders for the indicator for the Acetaminophen, the order was written as Acetaminophen 650mg 1 rectal suppository every 6 hours prn as needed fever >99 and another order was written as Acetaminophen 650mg oral every 4 hours prn pain/fever. There was no evidence of a max daily dose in a 24 hour period. The wound care order for the left hip was to clean the skin with wound cleanser, pat dry and apply Silvakollgen and calcium alginate every other day and as needed when soiled. There were incomplete wound care orders due to no covering.

Upon client record review, 1 of 14 (Patient #14) 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 #14: The patient was discharged on 2/8/24 for no longer meeting hospice medical criteria, there was no evidence of IDT meeting minutes with discharge planning or discussions of decline until the date of discharge 2/8/24. There was no documentation by any discipline.

Upon patient record review, 6 of 14 (Patient #1,#4,#7,#8,#9,#10) did not have 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 #1: The record indicated the patient was started on Nystatin and Triamcinolone on 12/24/23 with skin issues and there was no evidence in the plan of care that the plan of care was updated with individualized goals and interventions. Patient #4: The patient had a UTI and was started on CIPRO on 7/5/23 and the record did not show evidence that the plan of care was updated with a resolved date as the target date was set for 8/30/23. In addition: The patient had 5 falls during 7/13/23 -1/31/24 and there was no evidence in the record that the care plan had any safety precautions. The patient developed a wound on 2/23/24 to the left hip and a laceration above the left eyebrow forehead are and the record did not show individualized wound interventions and wound goals. Patient #7: There was a foley place on 4/11/23, there was no evidence of care planning to include interventions and goals. Patient #8: There was no evidence of care planning for the wound care to include individualized goals and interventions. Patient #9: There was no evidence of care planning for the sacral wound care to include individualized goals and interventions. Patient #10: There was no evidence of care planning for the End of Life and no Mortuary Name was listed.

Upon client record review, 1 of 14 (Patient #1) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1: The order for the foley catheter indicated a 16 French catheter size 5cc balloon inflation, the nurse documentation from 1/10/24 indicated an 18 french foley catheter was placed. There was not evidence of an MD order to change the size of the foley catheter. Patient #4: There were wound care orders written as treatment for the left hip involving cleaning the skin with wound cleanser, pat dry and apply Silvakollgen and calcium alginate every other day and as needed when soiled. There was no evidence that wound care was provided.

Upon observation, there was no evidence the organization develops, implements, and maintains an effective, on-going, organization wide Quality Assessment and Performance Improvement (QAPI) program. There was not evidence of . All patient care disciplines • Description of how the program will be administered and coordinated • Methodology for monitoring and evaluating the quality of care • Priorities for resolution of problems • Monitoring to determine effectiveness of the action

Upon observation, there was no evidence the board of directors/governing body approves the frequency and detail of the data collection.

Upon observation, there was no evidence QAPI activities focus on high risk ,high volume, or problem prone areas.

Upon observation, there was no evidence Quality Assessment and Performance Improvement activities focus on high risk, high volume or problem-prone areas by considering incidence, prevalence, and the severity of problems.

Upon observation, there was no evidence Quality Assessment and Performance Improvement activities focus on high risk, high volume or problem-prone areas by understanding how they affect palliative outcomes, patient safety and quality of care.

Upon patient record review, 2 of 14 records (Patient #10,#11) 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 #10, #11: There was no evidence of a bereavement care planning to include interventions and goals that reflect the needs of the bereaved.

Condition of Participation: Hospice Aide and Homemaker Services. L607

Upon personnel record review, 1 of 12 records (Personnel #10) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) ·Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff. ·Reading and recording temperature, pulse, and respiration ·Safe transfer techniques and ambulation. ·Normal range of motion and positioning ·Appropriate and safe techniques in personal hygiene and grooming that include-- ·(A) Bed bath ·(B) Sponge, tub, and shower bath ·(C) Shampoo, sink, tub, and bed ·(D) Nail and skin care ·(E) Oral hygiene ·(F) Toileting and elimination The other subject areas in this section may be evaluated through written examination, oral examination or after observation of a Hospice Aide with a patient. Personnel #10: There was not evidence that the competency assessment was performed with a patient or pseudo-patient.

Upon patient record review, 1 of 14 records (Patient #1) 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 #1: The patient was on Eliquis 2.5mg daily there was not evidence that bleeding precautions was on the aide plan of care.

Upon patient record review 1 of 14 records (Patient #3) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care Patient #3: The aide plan of care indicated to provide a shower each visit (Aide Frequency was 2 x per week) upon observation visit the aide indicated he would provide a bed bath and had been doing a bed bath for 5 months. The aide was observed while giving a bed bath.

Upon patient record review 1 of 14 records (Patient #3) 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 #3: The aide supervisory questions answered by the nurse included "do the aide services meet the needs of the patient and is the care plan up to date?" The plan of care update was not applicable. The RN consistently answered yes in her supervisor visits that the patients needs were being met and did not answer yes to updating the plan of care and the aide indicated he had been giving a bed bath for the past 5 months which a shower was ordered.

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. There is not evidence that the governing body and administrator provide oversight for current/updated emergency management plan and the QAPI program. In addition, the agency has submitted billing with incorrect certification of terminal illness information.

Condition of Participation: Medical Director.

Upon contract review, 1 of 3 contracts (CL, Alternate Medical Director) did not have evidence of a contract to fulfill the role of alternate medical director, if applicable. The contract indicated that this physician was the Medical Director. Organizational chart and agency leadership provided validation that this physician was the alternate and the Medical Director was another physician that was on staff.

Upon patient record review, 1 of 14 (Patient #9) 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 #9: The Hospice Election Date on the legal documentation had a start of care date 8/18/23, the Nurse had a verbal certification date of 8/21/23, and the Physician signed the Certification on 8/21/23.

Upon patient record review, 2 of 14 (Patient #4, 8) 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 #4: Certification for the 10th Benefit Period did not show evidence of the Physician signing the certification. The Certification was signed by the Nurse Practitioner. Patient #8: Certification for the 2nd Benefit Period did not show evidence of a timely verbal certification documented by the Registered Nurse. The verbal was documented taken on 8/25/23 for the time period of 11/23/23 to 2/20/24.

Upon patient client record review, 2 of 14 records (Patient #1,#5) 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 #1: Hospice Benefit Election did not contain evidence of the effective date of the election. The area indicated for the start of care date was blank. Patient #5: The record indicated all admission legal paperwork including the benefit election was signed by an unknown person named "Sara". The signature did not include a last name and it was by using DocuSign. This person was not listed as a responsible party, relative, emergency contact and or a POA. Leadership could not verify who this person was and indicated she could have been a "surrogate".

Upon patient client record review, 2 of 14 (Patient #12 and 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 #12: The Medical record indicated that the patient was discharged due to non-compliance. An order was obtained from the Medical Director to discharge the patient. The record also indicated that the agency had the patient sign a revocation. Patient #14: The patient was discharged due to no longer meeting hospice criteria. There was not evidence of a Notice of Medicare Non-coverage. The agency obtained an order for discharge from the Medical Director, however in addition, the agency had the patient sign a revocation.

Upon observation, there was not evidence a copy is provided of the hospice written policies and procedures on the management and disposal of controlled drugs to the patient or patient representative and family. Patient #5: The record indicated all admission legal paper work including the benefit election was signed by an unknown person named, "Sara." The signature did not include a last name and it was signed by using DocuSign. The record did not list or include this person as a responsible party, relative, emergency contact or a POA. Leadership could not verify who this person was and indicated she could have been "Surrogate."

Upon observation, there was no evidence the hospice discussed the policies and procedures for managing the safe use and disposal of controlled drugs with the patient or representative and the family in a language and manner that they understand to ensure that these parties are educated regarding the safe use and disposal of controlled drugs. Patient #5: The record indicated all admission legal paper work including the benefit election was signed by an unknown person named, "Sara." The signature did not include a last name and it was signed by using DocuSign. The record did not list or include this person as a responsible party, relative, emergency contact or a POA. Leadership could not verify who this person was and indicated she could have been "Surrogate."

Upon client record review,1 of 14 (Patient #5) did not have evidence that the written policies and procedures for managing controlled drugs was provided and discussed. Patient #5: The record indicated all admission legal paperwork including the benefit election was signed by an unknown person named "Sara". The signature did not include a last name and it was by using DocuSign. This person was not listed as a responsible party, relative, emergency contact and or a POA. Leadership could not verify who this person was and indicated she could have been a "surrogate".

Upon personnel record review, 2 of 12 records (Personnel #6,#7) 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. Personnel #6,#7: There was not evidence of a criminal background check.

Upon personnel record review, 1 of 12 records (Personnel #9) did not have evidence of criminal background checks being obtained in accordance with state requirements. 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 #9: There was not evidence of a criminal background check.