Every finding on record at Zenith Healthcare Inc

Upon patient record review, 4 of 14 (Patient #1,3,8,9) 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 RN documentation indicated that patient has oxygen at 2LNC PRN available within the home for shortness of breath. No evidence that the oxygen was placed on the current medication profile. Corrected on site. During home visit and medication reconciliation, the active medication profile contained two entries for Lorazepam, one scheduled and one prn, that were not on the active SNF medication profile. Patient 3: The current medication list includes several schedule acetaminophen products and PRN products that contain acetaminophen. No evidence that a max amount of acetaminophen was listed with any of those medication. Current plan of care contains Senna 8.6 and Bisacodyl 10mg supp both listed as PRN daily for constipation. No evidence that instructions were given on when to use which medication for constipation. Corrected on site. Patient 8: Miralax on the active medication profile does not have instructions on how to dilute. Corrected on site Patient 9: Current medication list includes 2 entries for Senna, both instructed to be given orally, one was scheduled and one was prn. The medical record indicated that the patient has a PEG tube, dysphagia, and was taking nothing by mouth.

Upon patient record review, 6 of 14 (Patient #6,7,8,9,13,14) 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 6: No evidence that the bereavement risk assessment was completed within 5 days of the election of hospice. Patient admitted on 03/7/2025, assessment completed on 03/14/2025. Patient 7: No evidence that the bereavement risk assessment was completed within 5 days of the election of hospice. Patient admitted on 12/6/2024, assessment completed on 12/13/2024. Patient 8: No evidence that the bereavement risk assessment was completed within 5 days of the election of hospice. Patient admitted on 08/26/2024, assessment completed on 12/31/2024. Patient 9: No evidence that the bereavement risk assessment was completed within 5 days of the election of hospice. Patient admitted on 06/26/2024, assessment completed on 07/31/2024. Patient 13: No evidence that a bereavement risk assessment was completed. Patient 14: No evidence that the bereavement risk assessment was completed within 5 days of the election of hospice. Patient admitted on 05/17/2024, assessment completed on 05/27/2024.

Condition of participation: Interdisciplinary group, care planning, and coordination of services. The hospice must designate an interdisciplinary group or groups as specified in paragraph (a) of this section which, in consultation with the patient's attending physician, must prepare a written plan of care for each patient. The plan of care must specify the hospice care and services necessary to meet the patient and familyspecific needs identified in the comprehensive assessment as such needs relate to the terminal illness and related conditions.

Upon patient record review, 3 of 14 (Patient #2,6,9) 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 2: Patient currently takes Eliquis 2.5mg as a blood thinner. There was no evidence of problems, goals, and interventions related to risk for bleeding included in the plan of care. Corrected on site. Patient 6: Patient currently takes Keppra for epilepsy, has a related dx of epilepsy on the POC. No evidence that problems, goals, and interventions related to safety for seizure activity included in the plan of care. Corrected on site Patient 9: Patient has a PEG and has history of difficulty swallowing/dysphagia related to Parkinsonism. No evidence of problems, goals, and interventions related to risk for aspiration includes in the plan of care. Corrected on site.

Upon patient record review, 2 of 14 (Patient #6,7) 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 6: SW and SC only have PRN orders on POC. No evidence of routine visits on plan of care. No evidence of a frequency for PRN visits. Patients 7: SW only has PRN orders on POC. No evidence of routine visits on plan of care. No evidence of a frequency for PRN visits.

Upon patient record review, 3 of 14 (Patient #1,3,8) 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 RN documentation indicated that has oxygen at 2LNC PRN available within the home for shortness of breath. No evidence that an order was received for oxygen. Corrected on site Patient 3: The RN documentation indicated that the patient had a foley catheter in place that had been replace several times (11/02/24 & 03/29/2025) by the hospice RN. No evidence that an order was received to include foley catheter size, change frequency, or care standards. Also the current medication list includes several scheduled acetaminophen products and PRN products that contain acetaminophen. No evidence that a max amount of acetaminophen was listed with any of those medication. Current plan of care contains Senna 8.6 and Bisacodyl 10mg supp both listed as PRN daily for constipation. No evidence that instructions were given on when to use which medication for constipation. Corrected on site. Patient 8: The POC has an active order for Miralax powder that does not include instructions on how to dilute the powder. Corrected on site.

Upon patient record review, 2 of 14 (Patient #3,4) 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 equipment and supply needs. Patient 3: No evidence that supplies related to foley catheter insertion or maintenance was included in the current supply list. Patient 4: The medical record indicated that the patient uses a walker for help with altered mobility. No evidence that a walker was included on the current DME list.

Upon client record review, 3 of 14 (Patient #4,6,9) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 4: Plan of care has an order for the volunteer to visit the patient 2 times a week was placed on 05/06/2025. No evidence that the patient received a visit from the volunteer at the time of survey. Patient 6: Plan of care indicated the SN frequency was ordered as once a week. No evidence that the patient received a visit for the week of 05/11/25-05/17/25. No evidence that this visit was missed at the request of the patient or that an order was received to stopped visits for that month. Patient 9: Plan of care indicated the SW frequency was ordered as monthly. No evidence that the patient received a visit for the month of November 2024. The SW entered a note on 11/30/2024 stating that the MSW was out of town for the holiday. No evidence that this visit was missed at the request of the patient or that an order was received to stopped visits for that month.

Upon patient record review 1 of 14 (Patient #4) did not have evidence that the IDG ensures that the care and services provided are based on all assessments of the patient and family needs. Patient 4: Plan of care indicates that the family requested volunteer services and there is no evidence that the patient received a visit from the volunteer at the time of survey.

Upon observation, there was no evidence the hospice is in compliance with accepted professional standards and principles for all non-core services which includes volunteers.

Upon observation, there was no evidence volunteers are used in day to day administrative and/or direct patient care roles. No evidence that the agency has active volunteers.

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. Agency volunteer hours for 2024 was 0%.

Condition of Participation: Organization and administration of services. The hospice must organize, manage, and administer its resources to provide the hospice care and services to patients, caregivers and families necessary for the palliation and management of the terminal illness and related conditions.

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 and Administrator did not ensure patient needs could be met by providing needed non core services of volunteer.

Upon patient record review, 1 of 14 (Patient #1) 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 1: CTI narrative written by the medical director was an exact copy of the RN admission assessment narrative, only adding that the pt is appropriate for hospice.

Upon patient record review, 3 of 14 (Patient #2,3,4) 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 2,3,4: CTI narrative written by the medical director was an exact copy of the RN recert assessment narrative, only adding that the pt is appropriate for hospice.

Upon client record review, 1 of 14 (Patient #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 12: The medical record indicated that the patient revoked hospice. No evidence that a copy of the discharge summary was sent to the patients attending physician.

Upon client record review, 1 of 14 (Patient #12) did not have evidence that the discharge summary includes all required information. Patient 12: No evidence that the discharge instructions contained a summary of the patient's stay, current plan of care and the patient's latest physician orders. Corrected on site.

Condition of participation: Personnel qualifications

Upon personnel record review, the agency 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. The agency did not have any volunteers.

Upon personnel record review, 1 of 12 records (Personnel #12) did not have evidence that a skills competency assessment, specific to each discipline had been conducted for all personnel including volunteers initially during orientation. Personnel #12: Office Manager who also signed a job description as a volunteer, had no evidence that orientation with a competency assessment had been completed as a volunteer.

Upon patient client record review, 3 of 5 records (Patient #1, #2, #3) did not have evidence that each patient record contains Advance Directives. Patient #1: There was no evidence a copy of the advance directive (noted on the consent form) was obtained for the medical record. Patient #2: There was no evidence a copy of the advance directive (noted on the consent form) was obtained for the medical record. Patient #3: There was no evidence a copy of the advance directive (noted on the consent form) was obtained for the medical record.

Upon patient record review 3 of 5 (Patient #2, 3, 4) 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 #2 - admitted on 08/11/202, but the psychosocial assessment completed 08/20/2021 and the spiritual assessment not completed at all. Patient #3 - admitted on 08/08/2021, but no spiritual assessment completed at time of survey - Corrected on site. Patient #4 - admitted 09/09/2021 no spiritual assessment completed.

Upon patient record review, 1 of 5 (Patient #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 #3 - Nystatin powder and Oxygen not on medication profile. Corrected on site.

Upon patient record review, 5 of 5 (Patient #1, 2, 3, 4, 5) 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.

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

Upon patient record review, 1 of 5 (Patient #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 #3 - POC did not include Nystatin or Oxygen.

Upon patient record review, 3 of 5 (Patient #1, 2, 3) 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 #1 - No IDG notes 10/19/2021 - 11/30/2021. Patient #2 - No IDG notes 09/01/2021 - 11/30/2021. Patient #3- No IDG notes 09/21/2021 - 11/30/2021.

Upon patient record review, 3 of 5 (Patient #1, 3, 4) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1 - POC dated 08/11/2021 included a frequency for MSW 1 x month. No evidence of a MSW visit made in November. POC also included a frequency for SC of 1x month. There was no evidence of a SC visit in the chart. Patient #3 - The record indicated that the MSW conducted a phone visit on 09/09/2021 and 10/08/2021. There was not evidence that telehealth was included in the plan of care. SN provided wound care on admission visit and weekly but there was no evidence of an order for wound care. Corrected on site. Patient #4 - POC dated 09/09/2021 included SC eval but there was no evidence in the record that a visit was ever made. MSW made visit on 10/05/2021 but patient was discharged 10/02/2021.

Condition of Participation: Hospice Aide and Homemaker Services. L607

Upon personnel record review, 1 of 1 applicable (Personnel #5) 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. There was no process in place or form utilized to assess the CNA competencies, therefore no competency completed for the agency CNA.

Upon patient record review, 3 of 4 applicable (Patient #1, 2, 4) did not have evidence in the patient record that hospice aide assignments and duties 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, 2, 4 - All assigned tasks on the aide plan of care did not include a frequency.

Upon patient record review 4 of 4 applicable (Patient #1, 2, 3, 4) 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 #1 - CNA documented vital signs every visit but this was not ordered on the care plan. CNA visit note dated 08/16/2021 and 11/01/2021 tasks assigned were not documented as completed. Patient #2 - CNA documented vital signs every visit but this was not ordered on the care plan. CNA visit frequency 2wk only provided 1 visit week 1. CNA visit notes 09/04/2021, 09/09/2021, 09/11/2021 documented shower and no redness noted. No other assigned tasks were documented as performed. CNA visit notes 09/18/2021, 10/30/2021, 11/03/2021 documented shower, oral care and perineal care and no redness noted. No other assigned tasks were documented as performed. CNA visit date 10/27/2021 provided bed bath but shower on care plan. Patient #3 - CNA documented vital signs every visit but this was not ordered on the care plan. CNA visit frequency 2 x wk but on 08/23/2021 order written to decrease to 1 x wk but CNA continued to see 2xwk until end of certification. Aide did not provide dressing, hair care, foot care, perineal care, shampoo, skin care, back rub oral hygiene, nail care, linen change, turning, incontinence care starting on 08/11/2021 thru 10/30 2021 but ordered every visit. Shaved patient 09/04/2021, 09/11/2021, 10/23/2021 and 10/30/2021 but task was not assigned. Patient #4 - CNA documented vital signs every visit but this was not ordered on the care plan. Bed bath on CNA care plan but provided shower on 09/15/2021, 09/18/2021, 09/22/2021 and 09/29/2021. Also, no other assigned tasks were documented as performed.

Upon patient record review, 2 of 5 (Patient #1, 2) 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 #1 - SOC 08/11/2021 - record did not contain written certification that it is anticipated that the patient's life expectancy is 6 months or less if the illness runs its normal course. Corrected on site. Patient #2 - SOC 09/01/2021 - the record did not contain written certification that it is anticipated that the patient's life expectancy is 6 months or less if the illness runs its normal course. Corrected on site.

Upon patient record review, 2 of 2 applicable (Patient #1, 2) 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 #1, 2 - At time of survey the MD had not completed written documentation that it is anticipated that the patient's life expectancy is 6 months or less.

Upon patient record review, 5 of 5 (Patient #1, 2, 3, 4, 5) did not have evidence that each patient record contains: • Signed election statement in accordance with 418.24 Patient #1, 2, 3, 4, 5 - The EOB/Consent on all 5 patients did not have evidence of an effective date. The designated space for the effective date was left blank.

Upon personnel record review, 1 of 1 applicable (Personnel #11) 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 #11 There was no personnel file available for review.

Upon personnel record review, 1 of 1 applicable (Personnel #10) did not have evidence all Occupational Therapy Services are provided by a qualified licensed Occupational Therapist (OT) in accordance with the state's Occupational Therapy Practice Act and the hospice's policies and procedures and/or job descriptions. Personnel #10 there was no personnel file available for review.

Upon personnel record review, 1 of 1applicable (Personnel #9) did not have evidence all Physical Therapy Services are provided by a qualified licensed Physical Therapist (PT) in accordance with the state's Physical Therapy Practice Act and the hospice's policies and procedures and/or job descriptions. Personnel #9 There was no personnel file available for review.

Upon personnel record review, 3 of 5 applicable (Personnel #9, 10, 11) 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 #9, 10, 11 There was no personnel record available for review.