Every finding on record at 5 Star Hospice, LLC

It is required that the hospice Interdisciplinary Group, in consultation with the individual's attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review and interview. In 5 of 14 (36%) clinical records reviewed for patients receiving hospice services revealed the hospice agency did not ensure the initial comprehensive assessment was completed no later than five (5) calendar days after the election of hospice care. Clinical Record 1: The patient's election of benefit began on 02/23/2024. There were orders written on 02/13/2024 requesting an initial assessment to be completed by the social worker and chaplain for accepted services. There was no documented evidence of completed initial assessments by the social worker or chaplain. Clinical Record 2: The patient's election of benefit began on 03/22/2024. The chaplain completed an initial assessment on 03/29/2024. This was completed two days past the five-day requirement. Clinical Record 4: The patient's election of benefit began on 05/09/24. The patient accepted social worker services and was ordered on 05/09/2024. There was no documented evidence of a completed visit by the social worker within five calendar days after the election of hospice. Clinical Record 10: The patient elected hospice on 05/10/2024. There were orders written on 05/10/2024 for initial assessments to be completed by the social worker and the chaplain. There were no documented visits as of 05/30/24. Clinical Record 11: The patient elected hospice on 11/09/2023. The social worker's initial assessment was completed on 11/17/2023. This was three days late. During an interview on 05/30/2024, the Assistant Director of Nursing agreed the social worker and chaplain had not completed initial assessments within five calendar days of the election of hospice.

It is required that the comprehensive assessment includes an initial bereavement assessment of 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 considered in the bereavement plan of care. This standard was not met as evidenced by clinical record review and interview. In 3 of 14 (21%) clinical records reviewed revealed the hospice agency did not ensure that the comprehensive assessment included an initial bereavement assessment of 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. Clinical Record 1: The patient's election of benefit began on 02/13/2024. There was no documented evidence that an initial bereavement assessment had been completed for the patient's family. Clinical Record 4: The patient's election of benefit began on 05/19/2024. One attempt was made on 5/14/24 with no successful contact with the patient's family. There were no other attempts documented to complete an initial bereavement assessment of the patient's family. Clinical Record 10: The patient's election of benefit began on 05/10/2024. There was no documented evidence that an initial bereavement assessment had been completed for the patient's family as of 5/30/24. During an interview on 05/30/2024, the Assistant Director of Nursing agreed that the patient's families had not had an initial bereavement assessment completed. The Assistant Director of Nursing stated that the Chaplain/Bereavement Coordinator/Licensed Vocational Nurse was possibly responsible for too many duties.

It is required that the update of the comprehensive assessment is completed by the hospice Interdisciplinary Group, who, in collaboration with the individual’s attending physician, if any, consider the changes that have taken place since the initial assessment. The update of the comprehensive assessment includes information on the patient’s progress toward desired outcomes and reassessment of the patient’s response to care. The assessment update is completed as frequently as the condition of the patient requires and no less frequently than every 15 days. This standard was not met as evidenced by clinical record review and document review. In 3 of 14 (21%) clinical records reviewed receiving hospice services revealed that the hospice agency did not ensure the patients received a comprehensive assessment by a registered nurse no less frequently than every fifteen (15) days. Document 1: Policy 013115 Hospice-CHAP, Plan of Care, stated in part, based on the updated comprehensive assessment, in collaboration with the individuals attending, if any, the IDG will review, revise and document the individualized plan as frequently as the patient's condition requires, but no less frequently than every fifteen calendar days. Clinical Record 1: The patient's election of benefit began on 02/13/2024. The skilled nurse frequency was ordered one time a week (1xw). The patient received visits by the licensed vocational nurse (Personnel Record #6) weekly. The registered nurse made visits on 02/23/2024, 04/05/2024 and 04/12/2024. The patient did not receive a comprehensive assessment by a registered nurse every fifteen days. Clinical Record 2: The patient's election of benefit began on 03/22/2024. The skilled nurse frequency was ordered one time a week (1xw). The registered nurse visited on 03/22/2024 to complete the initial comprehensive nursing assessment. The registered nurse did not visit again to complete a comprehensive assessment until 04/19/2024 and again on 05/17/2024. Clinical Record 6: The patient's election of benefit began on 02/02/2024. The skilled nurse frequency was ordered two times a week (2xw) a week. The patient received a comprehensive assessment by a registered nurse on the weeks of 02/05/2024, 02/29/20243 and 04/25/2024. The licensed vocational nurse made visits for all other weeks. During an interview, the administrator stated they are having issues with late documentation. The patients are being seen but documentation is not being completed timely.

It is required that the hospice designates a registered nurse member of the IDG to provide coordination of care; ensure continuous assessment of each patient’s and family’s needs; and to ensure the implementation of the interdisciplinary plan of care. The hospice care and services provided to patients and families follow the individualized plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) of clinical records reviewed revealed the agency did not ensure the registered nurse implemented the IDG plan of care. Clinical Record 4: The patient's election of benefit began on 05/09/2024. The skilled nurse frequency was ordered one time a week (1xw). The registered nurse completed an initial assessment on 05/09/24. There were no other documented visits for skilled nursing or reason the patient was not seen as ordered. During an interview, the administrator stated they are having issues with late documentation. The patients are being seen but documentation is not being completed timely.

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable diseases, including the use of standard precautions, such as hand hygiene and safe handling of equipment in the patient’s care environment if it is likely to have been contaminated with body fluids. This standard was not met as evidenced by interview and observation. In 1 of 3 (33%) home visits observed for patients receiving hospice services revealed the hospice agency did not ensure acceptable standards of practice to prevent the transmission of infections were utilized such as hand washing and safe hand of equipment that has been contaminated with body fluids. Document 1: Policy 042723 Hospice, Hand Hygiene, stated in part, decontaminate hands before having direct contact with clients. Home Visit 1: During the home visit (Home Visit 1) with the registered nurse/director of nursing (RN/DON) (Personnel Record 2) on 05/30/2024, the RN was observed washing her hands, using her wet hand to turn off the faucet, then dried her hands with clean paper towels. The RN proceeded to provide wound care. A pair of scissors were removed from the bag with wound supplies and the soiled dressing was removed with the scissors. The scissors were returned to the bag with clean wound supplies without proper cleaning. During an interview on 05/29/2024, the RN (Director of Nursing) stated she knew what she had done wrong during the visit by turning of the water with her wet hand and not cleaning the scissors after removing the soiled dressing.