Every finding on record at With Grace Ministries Inc.

Upon patient record review, 4 of 14 (Patient #5, 7, 11, 14) did not have evidence in the patient record that the comprehensive assessment takes into consideration the imminence of death.

Upon patient record review, 5 of 14 (Patient #7, 8, 12, 13, 14) 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 #7 - No Initial Bereavement assessment complete as of 06/05/24. (completed during survey) Patient #8 - No Initial Bereavement assessment complete as of 06/05/24. (completed during survey) Patient #12 - No Initial Bereavement assessment complete as of 06/05/24. (completed during survey) Patient #13 - No Initial Bereavement assessment complete as of 06/05/24. (completed during survey) Patient #14 - No Initial Bereavement assessment complete as of 06/05/24. (completed during survey)

Upon patient record review, 1 of 14 (Patient #5) 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 #5 - Order for wound care 05/03/24 did not contain the site of wound care.

Upon patient record review, 3 of 14 (Patient #5, 7, 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 equipment and supply needs. Patient #5 - No DME on POC but patient has hospital bed, over bed table, W/C, walker and Oxygen concentrator. (corrected on site) Patient #7 - No DME on POC but patient has hospital bed, over bed table, W/C, walker and Oxygen concentrator. (corrected on site) Patient #14 - No DME on POC but patient has hospital bed and pressure relieving mattress. (corrected on site)

Upon client record review, 7 of 14 (Patient #5, 8, 9, 10, 11, 12, 14) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #5 - SC visit frequency 04/03/24 1-2m 4m - No visits made in April. Patient #8 - SN visit note on 05/30/24 cleaned wound with NS applied ABD pad - did not document the calmoseptine applied topically. Patient #9 - SC visit frequency 04/21/24 1-2 m 4m - No visits made in April or May. Patient #10 - SC visit frequency 04/11/24 1-2m 3m - No visits made in May. Patient #11 - SC visit frequency 03/21/24 1-2m 3m - No visits made in May. Patient #12 - SC visit frequency 04/21/24 1-2m 3m - No visits made in May. MSW visit frequency 1-2 m 3 - No visits made in April or May. In addition, SN visit note 04/29/24 SN instructed thin warm liquids for next 3 days but no evidence of order written by physician. Patient #14 - SC visit frequency 03/01/24 1-2m 2m - No visits made in April.

Upon patient record review 4 of 14 (Patient #5, 6, 11, 14) 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 #5 - Aide visit frequency effective 04/03/24 3wk 1, 5wk 12 only 4 visits made week 9 - no reason documented for missed visit. Patient #6 - Aide visit frequency effective 04/07/24 3wk 12, only 2 visits made week 3 - no reason documented for missed visit. Patient #11 - Aide visit frequency effective 03/21/24 1wk 1, 5wk 12, only 4 visits made week 2 and 3 visits made week 11 - no reason documented for missed visit. Patient #14 - Aide visit frequency effective 02/29/24 1wk 1, 3wk 13 only 2 visits made 11 and 12 - no reason documented for missed visit.

Upon patient record review 2 of 14 (Patient #9, 11) 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 - Aide supervisory visit made 05/14/24 then again on 05/29/24 - 15 days between Aide supervisory visits. Patient #11 - Aide supervisory visit made 03/26/24 then again on 04/10/24 - 15 days between Aide supervisory visits.

Upon patient client record review, 1 of 14 (Patient #1) did not evidence that each patient record contains physician orders. Patient #1 - No order documented by MD that patient no longer terminally ill and discharge from hospice services.

Upon patient client record review, 2 of 14 (Patient #5, 6) 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 #5 - SN visit note 04/12/24 "wound care completed as ordered" and SN visit note 04/22/24 "patient continues to have wound done 1 x week" with no evidence of specific details of wound care provided. POC 03/19/24 updated that wound healed. Patient #6 - Vol documented missed visit date as 02/04/2005 however, patient did not admit until 4/4/24.

Upon client record review, 1 of 14 (Patient #1) 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 #1 - Discharge summary completed but was sent to the Medical Director and not to the PCP.

Upon patient record review, 5 of 11 (Patient #1, 3, 4, 8, 10) 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. Patient #1, 3, 8, 10- The medication profile included polyethylene glycol 3350 powder for reconstitution, administer 17 gm(s) orally 1 x daily. The diluent was not included. Corrected on site Patient #1, 3- The medical record contained information that the patient was using oxygen. Oxygen was not included on the medication list. Corrected on site Patient #4- The medication list included Aspercreme with lidocaine 4% topical film. Apply 1 patch daily. The location for application was not included. Also, diclofenac sodium 1% topical gel. Apply topically 2 x daily. The location for application was not included. Corrected on site.

Upon patient record review, 6 of 11 (Patient #1, 3, 4, 6, 8, 10) 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, 8, 10- The plan of care included an order for polyethylene glycol 3350 powder for reconstitution, administer 17 gm(s) orally 1 x daily. The order did not include the diluent. Corrected on site. Patient #3- The medical record contained information that the patient was on oxygen. The plan of care did not include oxygen. Corrected on site. Patient #4- The plan of care included orders for Aspercreme with lidocaine 4% topical film. Apply 1 patch daily. The order did not include the location to be applied. Also, order for diclofenac sodium 1% topical gel. Apply topically 2 x daily. The order did not include the location to be applied. Corrected on site. Patient #6- The plan of care included orders for wound care daily to right upper chest. SN frequency was ordered 1-2 x week. The order did not indicate who was responsible for wound care. Corrected on site.

Upon patient record review, 4 of 11 (Patient #1, 4, 8, 9) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1- Plan of care included SN frequency 3w13, 3PRN. Evidence of 2 SN visits week of 3/11/22 and 6 SN visits week for 3/13/22, no evidence of additional visits being PRN visits. Patient #4- The plan of care included SN frequency 1-2 x week. SN visits documented 1/17/22, 1/18/22 and 1/21/22. No evidence if additional visit was PRN. Patient #8- The plan of care included SC frequency of 1-2 x month. There was no evidence of SC visit for April. Patient #9- The plan of care included SN frequency 1-2 x week. SN visits documented 4/26/22, 4/27/22 and 4/28/22. No evidence if additional visit was PRN.

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. Personnel #5 with patient #10, placed bag on the floor without providing a barrier underneath as required per the bag policy.

Upon observation, there was no evidence in QAPI reports that the hospice maintains a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the hospice's Quality Assessment and Performance Improvement program. The agency did not have any evidence to support infection tracking had been integrated as part of the QAPI program.

Upon patient record review, 2 of 11 (Patient #7, 9) 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 #7- The patient was on warfarin. Bleeding precautions were not included on the aide plan of care. Corrected on site Patient #9- The patient was on oxygen and plavix. The aide plan of care did not include bleeding or oxygen precautions. Corrected on site

Upon patient record review 3 of 11 (Patient #2, 4, 5) did not have evidence documentation in the patient record that a hospice aide provides services that are: Ordered by the interdisciplinary group and Included in the plan of care Patient #2- The plan of care included Aide frequency 1w1, 5w12. There was evidence of 3 Aide visits week of 2/2/22, 4 visits week of 2/6/22 and then no additional visits after 2/13/22. Patient #4- The plan of care included an order for Aide 1w1. There was no evidence of an aide visit being made. Patient #5- The plan of care included an order for Aide 5 x week. There was no evidence of aide visits the week of 2/4/22.

Upon patient record review, 1 of 11 (Patient #5) 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 #5- There was no evidence of a physician's narrative as part of the certification.