East Valley Hospice, Inc.

“Upon patient record review, 4 of 5 (Patient #1,2,3,4) 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 #1-RN frequency ordered every 14 days - no RN visits documented since 08/14/24 therefore no RN assessments were completed no less frequently than every 15 days. #2-Comprehensive assessment was only completed by an LPN and no evidence of a comprehensive assessment head-to toe assessment completed by the RN prior to benefit period #2 dated 09/02/24-11/30/24. #3-Comprehensive assessment was only completed by an LPN and no evidence of a comprehensive assessment head-to toe assessment completed by the RN from 08/01/24-08/22/24. #4-RN frequency ordered every 14 days - no RN visits documented since 08/15/24 therefore no RN assessments were completed no less frequently than every 15 days.”

“Upon patient record review, 2 of 14 (Patient #3,11) 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 #3, No evidence of bereavement assessment completed. Patient #11, No evidence of bereaved family member identified on bereavement assessment completed on 5/15/24.”

“Upon patient record review, 1 of 14 (Patient #11) 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 #11, RN visit completed on 2/2/24 then on 2/27/24. No evidence of continuous assessment of this patient.”

“Upon patient record review, 5 of 14 (Patient #1,3,5,7,13) 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 #1, No evidence of psych social care plan identifying no funeral home and full code status. No evidence of initial care plan addressing wound care. Patient #3, No evidence of psych social care plan addressing full code status. No evidence of care plan addressing hemodialysis, who transports to dialysis, who manages the central line, safety issues related to central line such as bleeding complications. Patient #5, No evidence of psych social care plan for addressing family wanting to be re-evaluated for additional hours through IHSS. Patient #7, No evidence of psych social care plan addressing full code status. Patient #13, No evidence of psych social care plan to addressing no funeral home, stating daughter will provide when information is found. No evidence of spiritual care plan to address pray to support patient faith.”

“Upon client record review, 13 of 14 (Patient #1,2,3,4,5,6,7,8,9,10,11,13,14) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1, Frequency RN every 14 days, Visit made on 6/25/24 then 7/5/24. No evidence visits were every 14 days. Patient #2, Frequency RN every 14 days, Visits made on 5/21/24 and 5/23/24. No evidence visits were every 14 days. MSW completed evaluation on 5/23/24 via telephone. No evidence of order for visits to be completed via telephone. Patient #3, Frequency LVN 1x/week, first visit completed by LVN was 2/22/24. No evidence of LVN visit the week of 2/15/24. RN every 14 days, visits completed 3/8/24, 3/13/24. No evidence of visits every 14 days. Patient #4, Frequency RN every 14 days, patient seen on 6/6/24 then 6/19/24. No evidence of visits every 14 days. Frequency SN 1x/week, patient seen by LVN on 6/12/24 and RN on 6/12/24. Patient #5, Frequency SN 1x/week, Patient seen 2x the week of 6/4/24, 6/18/24, 6/25/24, 7/6/21. Patient # 6, Frequency SN 1x/week, patient seen 2x week of 5/29/24, 6/10/24. Patient #7, Frequency SN 1x/week, patient seen 6/12/24 by LVN and 6/12/24 by RN. Patient seen 2x the week of 6/26/24. Patient #8, Frequency SN 2x/week, patient seen 6/5/24 by LVN and 6/5/24 by RN. Patient #9, Frequency MSW every recertification, patient seen 5/26/24 and 6/21/24. No evidence of orders for monthly visits. Patient #10, Frequency SN 1x/week, SN visits on 5/9/24, 5/14/24, 5/15/24, 5/17/24. No evidence visits were completed 1x/week. Patient #11, Frequency RN every 14 days. RN visits on 2/2/24 then 2/27/24. No evidence of visit every 14 days. Patient #13, Frequency MSW every certification. visits made 1/8/24 and 4/1/24. Certification period 1/5/24 to 4/3/24. No evidence of order for extra scheduled visit. RN frequency 2x/week, LVN visit 3/25/24, RN visit 3/25/24 LVN visit 3/27/24. No evidence visit schedule was followed. Patient #14, Frequency SN 3x/week. No evidence of SN visits the week of 10/20/23.”

“Upon observation, there was no evidence the QAPI program uses quality indicator data, including patient care and other relevant data in the design of its program. The hospice must use the data collected to: • Monitor the effectiveness and safety of services and quality of care • Identify opportunities and priorities for improvement Agency documents, b/p cuff, hand hygiene, flu vaccines, employees, anticoagulation, comfortable dying, continuous care, DME, pharmacy, medication error, grievance, satisfaction survey, incident report, infection control, oxygen safety. Incident report, infection control, comfortable dying and oxygen safety have collected data. Each of these reports have evaluation and goals. No evidence of how to accomplish these goals.”

“Upon patient record review 6 of 14 (Patient #1,2,3,7,8,14) 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 #1, aide care plan identifies under bath hygiene; safety razor. No evidence task was completed on aide sheet. Patient #2, aide frequency 1x/week, aide visits on 5/21/24 and 5/25/24. Patient #3, aide frequency 3x/week. No evidence of aide visits the week of 2/15/24. Aide care plan documents vitals every visit. No evidence task was completed on 6/17/24 or 6/26/24. Patient #7, aide frequency 2x/week effective 5/29/24. No evidence of aide visits the week of 5/29/24. Aide note on 6/3/24 documents as completed; objects within reach and bed in low position. No evidence of aide care plan directing these tasks to be completed. 6/5/24 Aide documents as completed; objects within reach. No evidence of aide care plan directing this task to be completed. Patient #8, aide frequency 2x/week effective 5/22/24. No evidence of aide visits the week of 5/22/24. Patient #14, aide frequency 2x/week. No evidence of visits on 10/20/23, only one visit the week of 10/25/23 and 3 visits provided on 11/20/24, 11/22/24, 11/24/24.”

“Upon patient record review 1 of 14 (Patient #1) did not have evidence in the patient record that the hospice aides report: • Changes in the patient’s medical, nursing, rehabilitative, and social needs to a registered nurse, as the changes relate to the plan of care and quality assessment and improvement activities • Hospice aides must also complete appropriate records in compliance with the hospice’s policies and procedures Patient #1, Aide care plan states to notify RN is b/p less than 90/60. On 6/22/24, b/p 103/58 documented on aide sheet. No evidence aide reporting b/p to RN. On 6//15/24, b/p 105/55 documented on aide sheet. No evidence of aide reporting b/p to RN.”

“Upon patient record review, 1 of 14 (Patient #3) 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 #3, No evidence of certifying physician narrative includes current status. Narrative states “I certify that patient’s condition is terminal and may lead to death in six months or less if the disease continues to run its normal course.” “ I attest/confirm that I composed this narrative based on my review of patients medical records, team assessment and/or examination of the patient” IDT discussed patient’s current condition and all agreed to continue hospice services at this time. Patient documented face to face narrative for certification #2. Certification signed on 5/15/24 stating patient has 3+ pitting edema. SN visit notes on 5/6, 5/7, 5/14, 5/21, all document “none” for assessment of edema.”

“Upon patient client record review, 3 of 14 (Patient #10,11,13) 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 #10, Patient acknowledgement of informed consent was completed and signed by staff. No evidence patient signed consent. Signature space left empty. Patient #11, Patient did not complete election date on acknowledgement of informed consent. Patient #13, Patient is missing page 2 of acknowledgement of informed consent which would identify the election date.”

“Upon patient record review, 1 of 14 (Patient #13) did not have evidence that the hospice assumes responsibility for professional management of the resident’s hospice services in accordance with the hospice plan of care. The hospice is responsible for providing all hospice services including: • Ongoing assessment, care planning, monitoring, coordination and provision of care by the Hospice IDG • Assessment, coordination and provision of any needed general inpatient or continuous care • Coordination by the hospice RN for the implementation of the plan of care for the patient • Provision, in a timely manner, of all supplies, medications, and DME needed for the palliation and management of the terminal illness and related conditions • Financial management responsibility for all medical supplies, appliances, medications and biologicals related to the terminal illness and related conditions • Determination of the appropriate level of care to be given to the patient (routine homecare, inpatient, or continuous care) Patient #13, Level of care changed on 4/12/24 to continuous care. No evidence of RN assessment prior to change of level of care or during the time patient was on continuous care which ended due to death on 4/13/24.”