Every finding on record at Zenith Hospice

Upon patient record review, 6 of 14 (Patients #1, 2, 7, 8, 9, and 10) did not contain evidence that the patient was provided the right to choose a health care provider, including an Attending Physician: Patients #1, 2, 7, 8, 9, and 10: These EOB(s) did not contain documented evidence of these patients' right to choose/designate an Attending Physician. This section of the EOB had been left blank.

Upon patient record review 1 of 14 (Patient #9) did not contain evidence that the Hospice Interdisciplinary Group, in consultation with the individual's Attending Physician (if any), had completed the Comprehensive Assessment no later than 5 calendar days after the election of Hospice care: Patient #9: SOC 03/13/25. There was no documented evidence of psychosocial Comprehensive Assessment component within (5) days of admission.

Upon patient record review, 4 of 14 (Patients #4, 6, 7, and 9) did not contain evidence that the Comprehensive Assessment included a Bereavement Risk Assessment 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 Risk Assessment is incorporated into the Plan of Care and is considered in the Bereavement Plan of Care: Patients #4, 6, 7, and 9: These records did not contain documented evidence that the SOC Comprehensive Assessment included a Bereavement Risk Assessment component.

Upon patient record review, 6 of 14 (Patient #1,#2,#3,#4,#6,#10) did not contain evidence that the Plan of Care included all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments: Patient #1: The POC included, "Offer Glucerna supplement as ordered." This is not an individualized/complete order, as it does not include an amount or frequency. The POC also included, "Patient instructed to use warm/cold compresses", without details such as the frequency, duration, purpose of, etc ... Patient #2: The 04/03/25 IDG POC included, "Offer Ensure supplement as ordered." This is not an individualized/complete order, as it does not include an amount or frequency. Patient #3: The POC included, "Offer Ensure supplement." This is not an individualized/complete order, as it does not include an amount or frequency. The POC included, "Apply Mupirocin topical cream 2%. Apply topically on 'affected area' two times a day". There is no identified area of the body/purpose for which to apply this. Patient #4: The 04/03/25 IDG POC included, "Offer Glucerna supplement as ordered." This is not an individualized/complete order, as it does not include an amount or frequency. Patients #6 and 9: These POC(s) included, "Provide supplements as ordered." This is not an individualized/complete order, as it does not include an amount or frequency. Patient #10: The POC included, "Offer Glucerna supplement." This is not an individualized/complete order, as it does not include an amount or frequency.

Upon patient record review, 1 of 14 (Patient #3) did not contain a Plan of Care which included all services necessary for the palliation and management of the terminal illness and related conditions; specifically equipment and supply needs: Patient #3: During the 04/08/25 Surveyor-attended home visit, it was noted that the patient had a commode. This was not included on the 04/03/25 IDG POC.

Upon patient record review, 4 of 14 (Patients #2, 3, 5, and 7) did not contain evidence that the IDG had ensured that the care and services were provided in accordance with the Plan of Care: Patient #2: The 04/03/25 IDG POC contained a SW visit frequency of 1x per month. The SW had made visits in July, September, and December 2024, and February 2025 (only at the beginning of each new 90/60 certification period; which was based upon a 06/29/24 frequency order). Patient #3: The 04/03/25 IDG POC contained a SW visit frequency of 1x per month. The SW had made visits on 04/30/24, 07/24/24, 10/22/24, 12/21/24, and 02/13/25. Patient #5: The 04/03/25 IDG POC contained a SW visit frequency of 1x per month. The SW had made visits on 01/27/25 and 03/04/25. No visits made in February 2025. Patient #7: The 04/03/25 IDG POC contained a SW visit frequency of 1x per month. The SW had made visits on 02/18/25, but not visits in March 2025.

Upon patient record review, 1 of 14 (Patient #14) did not contain evidence that the Hospice offers Bereavement counseling that includes: • 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 such service delivery Patient #14: A post-death Bereavement Risk Assessment was conducted on 12/05/24. However, a Bereavement Plan of Care was not established for bereavement personnel to follow. (Bereavement personnel did provide multiple bereavement interventions.)

Upon personnel record review, 1 of 12 (Personnel #8) did not contain evidence that an Aide Skills Competency had been conducted which included all CMS requirements: Personnel #8: DOH 01/01/25. An Aide Skills Competency was conducted on 01/01/25. However, the following skills were not evaluated for: Normal Range of Motion and Positioning. ROM was assessed for 'verbally', and the line item for Positioning had been left blank. The remaining subject areas which may be evaluated through written examination, oral examination, or after observation of a Hospice Aide with a patient or with a pseudo-patient as part of a simulation were not assessed for: • Basic elements of body functioning and changes in body function that must be reported to an Aide's supervisor • The physical, emotional, and developmental needs of, and ways to work, with the populations served by the Hospice.

Upon patient record review, 1 of 14 (Patient #3) did not contain evidence that the Hospice Aide assignment/POC included all Aide assignments and any other pertinent information required for the Aide to provide the assigned care/services: Patient #3: The Aide POC assigned the Aide to obtain vitals. The Aide obtained temperature, pulse, respirations, and blood pressure at her visits. However, there were no RN-assigned parameters identified, outside of which the Aide should report any abnormal results.

Upon patient record review, 7 of 14 (Patients #1, 2, 3, 7, 8, 9, and 10) did not contain evidence that each patient record contained: A signed Hospice Election of Benefit (EOB) Statement in accordance with 418.24 and/or the provision of a Patient Notification of Hospice Non-Covered Items, Services, and Drugs; when requested: Patients #1, 7, 8, and 10: These EOB(s) did not contain documented evidence of these patients' choice to designate an Attending Physician. This section had been left blank. These EOB(s) reflected that these patients wanted to be provided with a Patient Notification of Hospice Non-Covered Items, Services, and Drugs. There was no documented evidence that the Hospice had furnished such addendum to the patient. Patient #2: The EOB did not contain documented evidence of the patient's choice to designate an Attending Physician. This section had been left blank. Patient #3: The EOB reflected that the patient wanted to be provided with a Patient Notification of Hospice Non-Covered Items, Services, and Drugs. There was no documented evidence that the Hospice had furnished such addendum to the patient. Patient #9: The EOB did not contain documented evidence of the patient's choice to designate an Attending Physician. The patient had checked that they did wish to designate and Attending. However, the section to enter the Physician's name had been left blank. The EOB reflected that the patient wanted to be provided with a Patient Notification of Hospice Non-Covered Items, Services, and Drugs. There was no documented evidence that the Hospice had furnished such addendum to the patient.

Upon patient record review, 4 of 14 (Patients #1, 3, 4, and 8) did not contain evidence that all entries were legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice: Patient #1: The 03/18/25 admission Consent documented, "The patient has no Advance Directives." However, the POLST dated 03/18/25 included an order for DNR. Unclear documentation. Patient #3: The 04/26/24 admission Consent documented, "The patient has no Advance Directives." However, the POLST dated 04/26/24 included an order for DNR. Unclear documentation. Patient #4: On the 04/01/25 CTI, the Medical Director notes, "Patient is a Full code." However, the POLST dated 01/01/25 includes an order for DNR. Unclear documentation. Patient #8: The 03/12/25 admission Consent documented, "The patient has no Advance Directives." However, the POLST dated 03/12/25 included an order for DNR. Unclear documentation.

Upon patient record review, 1 of 14 (Patient #11) did not contain evidence that the Hospice had forwarded a Transfer Summary, and a copy of the patient record if requested, to the receiving Medicare/Medicaid-certified facility, when transferring the patient to such facility: Patient 11: The patient was transferred to the hospital 01/28/25, with the Hospice having been notified by the patient's family of such transfer on the same date. There was not evidence of a Transfer Summary having been forwarded to this next healthcare provider.

Upon patient record review, 1 of 14 (Patient #12) did not contain evidence that the Discharge Summary included all CMS-required information, as follows: Patient #12: Discharged on 02/24/25. The DC Summary did not include the following required content: • A summary of the patient's stay, including treatments, symptoms and pain management • The patient's current Plan of Care • The patient's latest Physician orders

Upon personnel record review, 1 of 12 (Personnel #10) did not contain evidence of a Criminal Background Check having been 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 #10: DOH 06/23/23. The criminal background check was not obtained until 03/06/24.

Upon patient record review, 5 of 5 (Patient #1, #2, #3, #4 and #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: • Drug side effects Patient #1 On the medication profile, the potential side effects column referenced a teaching addendum for medication SE’s based on medication classifications incorrectly as follows: Hydralazine 15 mg daily referenced Anti-hypotensive class side effects for this drug, not for Vasodilator class side effects. Olmesartan 40 mg referenced this med for GERD side effects, not Angiotensin II Receptor Agonist side effects. Ibuprofen daily referenced as Acetaminophen class side effects for this drug, not for NSAID class side effects. Patient #2 On the medication profile, the potential side effects column referenced a teaching addendum for medication SE’s based on medication classifications incorrectly as follows: Ramipril 25 mg daily referenced as a Beta Blocker class side effects for this drug, not for Ace Inhibitor class side effects. Isorbide 30 mg BID referenced this med for Beta Blocker side effects, not Vasodilator side effects. Clonidine 0.1 mg PRN referenced as Beta Blocker class side effects for this drug, not for Alpha Blocker class side effects. Nitroglycerin 0.4 mg PRN referenced as a Beta Blocker class side effects for this drug, not for Vasodilator class side effects. Aspirin 81 mg daily referenced this med for Beta Blocker side effects, not Antiplatelet. Patient #3 On the medication profile, the potential side effects column referenced a teaching addendum for medication SE’s based on medication classifications incorrectly as follows: Diclofenac 100 mg BID referenced Acetaminophen class side effects for this drug, not for NSAID class side effects. HCTZ 12.5 mg daily referenced this med for Beta Blocker side effects, not Diuretic class side effects. Patient #4 On the medication profile, the potential side effects column referenced a teaching addendum for medication SE’s based on medication classifications incorrectly as follows: Ibuprofen 800 mg BID referenced as Acetaminophen class side effects for this drug, not for NSAID Class Side Effects. Amlodipine 10 mg daily referenced Beta Blocker class side effects for this drug, not for Calcium Channel Blockers class side effects. Patient #5 On the medication profile, the potential side effects column referenced a teaching addendum for medication SE’s based on medication classifications incorrectly as follows: Bystolic 10 mg daily referenced as Beta Blocker class side effects for this drug, not for Irritable Bowel Syndrome class Side Effects. Amlodipine 10 mg daily referenced Beta Blocker class side effects for this drug, not for Calcium Channel Blockers Class side effects.

Upon patient record review, 2 of 5 (Patient #1 and #2) 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 #1, #2: The record reflected that this patient had a shower bench. This item was not included on the Plan of Care.

Upon patient record review 1 of 1 applicable (Patient #5) did not have evidence 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 #5 The visit frequency for HHA was ordered 1x weekly. During the week of 6-20-21, there was no evidence of any HHA visits.

Upon patient record review, 1 of 5 (Patient #4) 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 #4 The physician CTI had incorrect Benefit Period (BP) dates listed as 7/27/21 to 9/24/21 for BP-1. The dates for BP-1 should be 7/27/21 to 10/24/21 to equal 90 days.

Upon patient record review, 1 of 5 (Patient #4) 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 #4 Discharge order dated 8-1-21 indicated DC from Forever Hospice, not Zenith Hospice.