Loma Linda Hospice Care Inc.

“Upon patient record review, agency 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 Unable to abate condition level deficiency as there have been no new admissions since prior survey to demonstrate compliance.”

“Upon patient record review, 3 of 5 (Patient #1, 2, 3) 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: The form does not include physician written certification statement of 6 month or less life expectancy. “Given the advanced nature of the disease, it is my medical opinion that the patient is approaching the final stages of heart failure with a prognosis of six months or less. the patient and family have been counseled on the progression of the condition and are aware of the likely outcomes. “ is in the space allocated for RN assessment narrative. Patient #2: Physician narrative includes details that are inconsistent with POC and RN/LVN notes for this patient. The physician references that patient is on oxygen 2lpm 24 seven and that uses multiple inhalers without improvement. Upon review, there is no oxygen ordered or inhalers listed in orders, med profile, POC or RN/LVN notes. Furthermore, “Given the advanced nature of the disease, it is my medical opinion that the patient is approaching the final stages of heart failure with a prognosis of six months or less. the patient and family have been counseled on the progression of the condition and are aware of the likely outcomes” is in the space allocated for RN Assessment narrative. MD narrative ends with plan continue hospice care in view of declining, but does not include related certification of 6 month or less prognosis. Patient #3: The F2F documentation, partially copied to the Certifying Physician Narrative does not include specific prognosis. “Given the advanced stage of COPD, it is my medical opinion that the patient’s condition is deteriorating with a life expectancy of six moths or less. The patient and their family have been informed about the prognosis and are aware of the anticipated outcomes” is documented in the space allocated for RN Assessment narrative.”

“Upon personnel record review, 7 of 10 (Personnel #1,2,3,4,5,9,10) did not have evidence Emergency Preparedness training including: • Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles • Demonstrate staff knowledge of emergency procedures • Provide emergency preparedness training at least annually • Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others • Maintain documentation of all emergency preparedness training There is no evidence of emergency preparedness training in the reference employee files.”

“Upon patient record review, 7 of 14 (Patient #1,2,6,7,8,10,11) 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 All referenced patients had orders for “Oxygen 1-5L per NC for shortness of breath or to maintain O2 sat above 90%.” Oxygen was not included on the medication profile.”

“Upon patient record review, 5 of 14 (Patient #1,3,4,6,8) 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-There is no evidence that the RN updated the comprehensive assessment prior to recertification on 08/02/24, the RN was performing supervisory visits however, there was no assessment of the patient. #3-There is no evidence that the RN updated the comprehensive assessment prior to recertification on 07/03/24, the RN was performing supervisory visits however, there was no assessment of the patient.. #4-There is no evidence that the RN updated the comprehensive assessment prior to recertification on 08/21/24, the RN was performing supervisory visits however, there was no assessment of the patient. #6-There is no evidence that the RN updated the comprehensive assessment prior to recertification on 07/22/24, the RN was performing supervisory visits however, there was no assessment of the patient. #8-There is no evidence that the RN updated the comprehensive assessment prior to recertification on 06/24/24.\, the RN was performing supervisory visits however, there was no assessment of the patient.”

“Upon patient record review, 1 of 14 (Patient #14) did not have evidence the hospice offers bereavement counseling that includes: • Making bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. Bereavement counseling also extends to residents of a SNF/NF or ICF/IID when appropriate and identified in the bereavement plan of care • 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 service delivery #14-There is no evidence of a post-death bereavement plan of care.”

“Upon personnel record review, 1 of 10 (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. #5-There are no evidence of skills competencies for the aide.”

“Upon observation, there was no evidence the hospice is primarily engaged in providing the following care and services: • Nursing services • Medical social services • Physician services • Counseling services, including spiritual counseling, dietary counseling and bereavement counseling • Hospice aide, volunteer, homemaker services • Physical therapy, occupational therapy, speech-language pathology services • Short-term inpatient care • Medical supplies (including drugs and biologicals) and medical appliance The hospice has a facility name, but no contract for inpatient or respite was produced for review prior to the end of survey. No employee files for therapists were available for review.”

“Upon patient record review, 4 of 14 (Patient #1,4,5,10) 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 #1- CTI dated 12/26/23 does not contain a narrative statement. #4- Narrative statement on CTI dated 2/23/24 states “see separate document” - there is no separate document attached. #5-Narrative statement on CTI dated 02/14/24 states “see separate sheet” - there is no attachment. #10-Narrative statement on CTI dated 02/14/24 states “see separate report” - there is no attachment.”

“Upon patient record review, 7 of 14 (Patient #1,3,4,5,6,9,10) 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. #1-Narrative statement for CTI dated 08/02/24 does not contain evidence of patient specific data supporting the terminal diagnosis. #3-Narrative statement for CTI dated 07/03/24does not contain evidence of patient specific data supporting the terminal diagnosis. #4-Narrative statement for CTI dated 05/23/24 states “see separate report,” not report is attached. Narrative statement for CTI dated 08/21/24 is blank. #5-Narrative statement for CTI dated 05/14/24 states “ per review RN assessment, patient is appropriate for benefit period 2. Narrative statement for CTI dated 08/12/24 contains a face to face assessment, but no indication of decline or change in condition from benefit period 2 to 3. #6-Narrative statement on CTI dated 04/23/24 does not contain evidence of information related to the need for hospice services. #9-Narrative statement for CTI dated 06/17/24 does not contain evidence of patient data related to decline or change in condition is included. #10- Narrative statement for CTI dated 08/12/24 contains a face to face assessment, but no indication of decline or change in condition from benefit period 2 to 3.”