Every finding on record at Willow Hospice Care, Inc.

Upon patient record review 1 of 14 (Patient #3) 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 #3: Patient's initial nursing assessment was completed on 09/02/24. The election of benefits stated an effective date of 09/03/24. This is not within 48 hours after election of benefits.

Upon patient record review, 3 of 14 (Patient #1, 2, 3) 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 patient is prescribed Miralax. There are no directions on medication profile for the reconstitution of the medication for administration. Patient #2: The patient is prescribed Miralax. There are no directions on medication profile for the reconstitution of the medication for administration. Patient #3: The patient is prescribed Miralax. There are no directions on medication profile for the reconstitution of the medication for administration.

Upon patient record review, 5 of 14 (Patient #3, 6, 7, 8, 10) 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 #3: Patient had comprehensive assessment on 3/2/24. The next RN visit was 3/30/24 which is equal to 28 days. This does not meet requirement of assessment update occurring no less than every 15 days. Patient #6: Patient's last RN assessment was 10/24/24. This does not meet the requirement of assessment update occurring no less than every 15 days. Patient #7: Patient's last RN assessment was 10/23/24. This does not meet the requirement of assessment update occurring no less than every 15 days. Patient #8: Patient's last RN assessment was 10/18/24. This does not meet the requirement of assessment update occurring no less than every 15 days. Patient #10:Patient's last RN assessment was 10/18/24. This does not meet the requirement of assessment update occurring no less than every 15 days.

Upon patient record review, 2 of 14 (Patients #2, 9) 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 #2: Patient caregiver called stating patient was complaining of cough and congestion on 5/20/24. Mucinex was ordered, no visit made. On 5/21/24 another call was received and patient was continuing with complaints of cough. Duoneb was ordered. No nursing visit made. Next visit was 06/01/24 but no mention of new medications, cough, congestion, or response to treatment. On 09/26/24, a call was received that patient was having increased bruising. Patient caregiver advised to hold aspirin. No visit was made. Next nursing visit was 10/03/24. Patient #9: Patient had LVN visit on 09/05/24. After that visit, call was received from caregiver complaining of constipation and insomnia. Orders received for Miralax and Melatonin. No nursing visit was made until an LVN visit 09/12/24.

Upon patient record review, 1 of 14 (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: POC had incorrect SOC date of 3/2/24 vs. 3/3/24 as listed on Election of Benefits form.

Upon patient record review, 10 of 14 (Patient #1, 2, 3, 4, 5, 6, 7, 8, 9, 10) 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. Patients #1-10: All patients Plan of Care's included frequency orders for SN, MSW, and SC that included, "Visits may be completed using telehealth if feasible and appropriate to do so" Telehealth is not an acceptable means of visit frequency as telehealth may not take the place of in person visits.

Upon patient record review, 3 of 14 (Patient #1, 2, 3) 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 patient is prescribed Miralax. There are no directions in order for the reconstitution of the medication for administration. Patient #2: The patient is prescribed Miralax. There are no directions in order for the reconstitution of the medication for administration. Patient #3: The patient is prescribed Miralax. There are no directions in order for the reconstitution of the medication for administration.

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. During visit with patient #3, LVN did not ensure there was a bag barrier prior to setting her bag on the sofa for visit.

Upon patient record review 1 of 14 (Patient #1) 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: During home visit with surveyor, the Aide obtained vital signs including BP, Pulse, Respirations, Temperature, and pulse ox. Obtaining vital signs was not assigned on the Aide POC.

Upon patient record review, 2 of 14 (Patient #3, 10) 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 #3: The CTI listed the benefit period as 3/2/24 vs. 3/3/24 which is was the patient chose on the Election of Benefit form. Patient #10: There is no evidence that the medical director signed the CTI for the benefit period 10/12/24-12/10/24 although there was a narrative.

Upon personnel record review, 2 of 13 (Personnel #9,10) 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 #9: This personnel has a Bachelors in Social Work and an MBA. She has a license as a BSW. There is no evidence of supervision by an MSW as described in paragraph (b)(3)(i)(A) of CFR 418.114. Personnel #10: This personnel has a Bachelors in Human Services and a Masters in Gerontology. There is no evidence of supervision by an MSW as described in paragraph (b)(3)(i)(A) of CFR 418.114.