Every finding on record at A Change of Seasons Hospice, Inc.

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. This standard was not met as evidenced by clinical record review and interview. In 5 of 14 (36%) clinical records reviewed, the agency did not ensure that the hospice Interdisciplinary Group completed an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care. CLINICAL RECORD 2: A review of the clinical record revealed that the patient elected the hospice benefit, was admitted to hospice service, and the comprehensive nursing assessment was documented on 04/24/2025. The nursing assessment did not include a psychosocial or spiritual assessment. Documentation that the patient declined Spiritual Counselor (SC) services was present. The initial Social Work (SW) assessment was documented on 05/01/2025 (day 7). The SW assessment included a psychological and spiritual assessment; however, the comprehensive assessment was not completed within five (5) calendar days after the election of hospice care. CLINICAL RECORD 3: A review of the clinical record revealed that the patient elected the hospice benefit, was admitted to hospice service, and the comprehensive nursing assessment was documented on 10/24/2024. The nursing assessment did not include a psychosocial or spiritual assessment. Documentation that the patient declined Spiritual Counselor (SC) services was present. The initial Social Work (SW) assessment was documented on 10/31/2024 (day 7). The SW assessment included a psychological and spiritual assessment; however, the comprehensive assessment was not completed within five (5) calendar days after the election of hospice care. CLINICAL RECORD 4: A review of the clinical record revealed that the patient elected the hospice benefit, was admitted to hospice service, and the comprehensive nursing assessment was documented on 07/01/2025. The nursing assessment did not include a psychosocial or spiritual assessment. The initial spiritual counselor assessment was documented on 07/09/2025 (day 8). The initial Social Work (SW) assessment was documented on 07/12/2025 (day 11). The comprehensive assessment was not completed within five (5) calendar days after the election of hospice care. CLINICAL RECORD 6: A review of the clinical record revealed that the patient elected the hospice benefit, was admitted to hospice service, and the comprehensive nursing assessment was documented on 06/20/2025. The nursing assessment did not include a psychosocial or spiritual assessment. Documentation that the patient declined Spiritual Counselor (SC) services was present. The initial Social Work (SW) assessment was documented on 07/22/2025 (day 32). The SW assessment included a psychological and spiritual assessment; however, the comprehensive assessment was not completed within five (5) calendar days after the election of hospice care. CLINICAL RECORD 14: A review of the clinical record revealed that the patient elected the hospice benefit, was admitted to hospice service, and the comprehensive nursing assessment was documented on 05/17/2025. The nursing assessment did not include a psychosocial or spiritual assessment. Documentation was present in the record that the patient declined both Social Work and Spiritual Counselor services. The comprehensive assessment was not completed within five (5) calendar days after the election of hospice care. The Alternate Administrator (Personnel Record 3) was interviewed on 07/30/2025 and stated, "There were reasons for the delay in the services, such as the patient requested a later visit by the social worker or the chaplain, but it wasn't documented in the chart. The nursing assessment in the EMR (electronic medical record) does not have a place for the nurse to document a psychosocial or spiritual assessment."

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, document review, and interview. In 5 of 14 (36%) clinical records reviewed, the agency did not ensure that the initial comprehensive included an assessment of the bereavement needs. Agency Policy #2026, Bereavement Services (Dated 04/01/2019), stated in part, "An initial bereavement risk assessment will be performed as part of the comprehensive assessment. Depending on the initial assessment, a plan of care will be developed to include specific counseling to patient and family members to be provided by the social worker, chaplain, or bereavement counselor. The [bereavement] plan of care will reflect family needs, as well as clear delineation of services to be provided and the frequency of service delivery.” CLINICAL RECORD 2: A review of the clinical record revealed that the patient elected the hospice benefit, was admitted to hospice service, and the comprehensive nursing assessment was documented on 04/24/2025. The initial Social Work (SW) assessment, with the bereavement risk assessment, was documented on 05/01/2025 (day 7). The comprehensive assessment, to include the bereavement risk assessment, was not completed within five (5) calendar days after the election of hospice care. CLINICAL RECORD 3: A review of the clinical record revealed that the patient elected the hospice benefit, was admitted to hospice service, and the comprehensive nursing assessment was documented on 10/24/2024. The initial Social Work (SW) assessment, with the bereavement risk assessment, was documented on 10/31/2024 (day 7). The comprehensive assessment, to include the bereavement risk assessment, was not completed within five (5) calendar days after the election of hospice care. CLINICAL RECORD 4: A review of the clinical record revealed that the patient elected the hospice benefit, was admitted to hospice service, and the comprehensive nursing assessment was documented on 07/01/2025. The initial Social Work (SW) assessment, with the bereavement risk assessment, was documented on 07/12/2025 (day 11). The comprehensive assessment, to include the bereavement risk assessment, was not completed within five (5) calendar days after the election of hospice care. CLINICAL RECORD 6: A review of the clinical record revealed that the patient elected the hospice benefit, was admitted to hospice service, and the comprehensive nursing assessment was documented on 06/20/2025. The initial Social Work (SW) assessment, with the bereavement risk assessment, was documented on 07/22/2025 (day 32). The comprehensive assessment, to include the bereavement risk assessment, was not completed within five (5) calendar days after the election of hospice care. CLINICAL RECORD 14: A review of the clinical record revealed that the patient elected the hospice benefit and was admitted to hospice care on 05/17/2025. Documentation in the record indicated that the patient declined both Social Work and Spiritual Counselor services. No initial bereavement assessment was documented, as it is embedded only in the Social Work initial visit assessment note. There was no other documentation in the record that an initial bereavement assessment was completed. The Administrator was interviewed on 07/30/2025 and stated, "The nursing assessment does not currently include a bereavement assessment. We will ask the software vendor to add a bereavement assessment to the nursing assessment."

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current prescription and over-the-counter (OTC) drugs. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by a review of clinical records and interviews. In 2 of 11 (18%) clinical records reviewed, it was revealed that the agency did not ensure the drug profile contained all of the patient's prescription medications. Clinical Record 6 - The patient was admitted on 8/16/2022 with a diagnosis of COPD. The benefit period reviewed was dated 8/16/2022-11/13/2022. The initial plan of care dated 8/16/2022 included orders for "oxygen 2 liters per nasal cannula as needed". Oxygen was not listed on the drug profile dated 8/16/22. Clinical Record 4 - The patient was admitted on 4/14/22 with a diagnosis of COPD. The benefit period reviewed was dated 4/14/2022-7/12/2022. The initial plan of care dated 4/14/2022 included orders for "oxygen 2 liters per nasal cannula". The patient was receiving continuous oxygen at 2 liters per nasal cannula. Oxygen was not listed on the drug profile dated 4/14/2022. During interview with the Administrator on 9/8/2022, she stated, "Oxygen should be on the medication profile, just like in home health."

It is required that consistent with current professional standards of practice, licensed professionals actively participate in the coordination of all aspects of patient care including conducting ongoing interdisciplinary comprehensive assessments, developing and evaluating the plan of care, contributing to patient and family counseling and education. Hospice “core” services are substantially provided directly by hospice employees in a manner consistent with acceptable standards of practice. “Core” services include nursing services, medical social work, and counseling. THIS IS A CMS CONDITION LEVEL CITATION OF DEFICIENCY. This Condition of Participation was not met as evidenced by a review personnel records and interviews. In 1 of 1 (100%) personnel record of staff hired to fill the role of social worker, it was revealed the agency did not ensure the core service of medical social work was available to be provided to hospice patients during the time frame of 4/15/2022 - 9/7/2022. Staff 11 – This social worker was hired on 2/18/2022 and submitted their resignation on 3/14/2022, with evidence of an exit interview conducted on their last day of employment on 4/15/2022. There was no evidence that the hospice employed this social worker during the period from 4/15/22 – 9/7/22. During interviews with the Administrator and Medical Director on 9/7/2022 and 9/8/2022, it was stated that agency policy is to have an MSW employed to provide social work services but have had difficulty recruiting an MSW since the resignation of the previous social worker and have a Performance Improvement Plan in place documenting their efforts. The Medical Director also presented a written attestation that described how he reviewed the social work-related needs of the patients and caregivers and if needs had been identified he would have taken steps to obtain the necessary services for the patients and their caregivers. The Administrator also stated stated that they expect to hire a replacement MSW prepared social worker during the week of this site visit review and subsequently reported the new hire, effective 9/7/22. The cumulative effect of this deficiency could negatively impact the agency's ability to provide safe, quality care that meets the needs of patients, families, and caregivers for the palliation and management of the terminal illness and related conditions.

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by a review of clinical records and interviews. In 3 of 8 (37%) clinical records reviewed of patients that received hospice aide services, hospice aide plans of care were not developed with specific directions to direct the aide in the completion of the assigned tasks. Clinical Record 7 - The patient was admitted on 4/20/2022, and the benefit period reviewed was dated 4/20/2022-7/182022. The aide plan of care dated 4/20/2022 ordered aide services at 1 visit per week and assigned the aide to perform a shower during every visit, a bed bath as the patient's condition declined, and nail care "as needed". There was no specific documentation present on the aide plan, and no evidence of communication between the nurse and aide, to direct the aide of when the patient's decline in condition would warrant changing the bath type from a shower to a bed bath. There was also no specific documentation that described when nail care should be provided "as needed". Clinical Record 0 - The patient was admitted to service on 5/24/2022 and the date of death was 7/15/2022. The benefit period reviewed was dated 5/24/2022-8/21/2022. The aide plan of care dated 5/24/2022 ordered aide visits at 1 visit each week, and assigned the aide to complete a shower during every visit and a bed bath "as needed". There was no specific documentation present on the aide plan, and no evidence of communication between the nurse and aide, to direct the aide of when the patient would require a bed bath "as needed". Clinical Record 5- The patient was admitted to hospice on 6/1/2022. The benefit period reviewed was dated 6/1/2022-8/29/2022. The aide plan of care dated 6/1/2022 assigned the aide to perform a shower at every visit 2 times per week, and perform a bed bath as condition declines. During interview with the Administrator on 9/8/2022, she stated they will develop a Performance Improvement Plan to educate staff on developing and updating aide care plans.

It is required that the hospice medical director or physician designee reviews the clinical information for each patient being evaluated for admission and provides written certification that it is anticipated that the patient's life expectancy is six months or less if the illness runs its normal course. The physician considers the following when making this determination: the primary terminal condition, related diagnosis(es), if any, 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. This standard was not met as evidenced by a review of clinical records and interviews. In 3 of 11 (0) clinical records reviewed, it was revealed that the agency did not ensure that during each benefit period documentation was completed that included a Certificate of Terminal Illness (CTI) completed by the Medical Director or physician designee.. Clinical Record 7 - The patent was admitted on 4/20/2022 with a diagnosis of Alzheimer's Disease. There was no documented evidence of a CTI completed by the Medical Director for the second benefit period dated from 7/18/2022 - 10/16/2022. Clinical Record 4 - The patient was admitted on 4/14/2022 with a diagnosis of COPD. There was no documented evidence of a CTI completed by the Medical Director for the second benefit period dated from 7/13/2022 - 10/10/2022. Clinical Record 1 - The patient was admitted on 6/3/2021 with the diagnosis of Alzheimer's Disease. There was no documented evidence of a CTI completed by the Medical Director for the second benefit period dated from 9/1/2021 - 11/29/2021. During interview with the Administrator on 9/8/2022 it was stated they believed that the CTI was required to be completed with the Face-to-Face document visit every 6 months.

It is required that a social worker who holds a bachelor’s degree is supervised by a CMS-qualified MSW who has a degree from a school of social work accredited by the Council on Social Work Education and has one (1) year of experience in a health care setting. This standard was not met as evidenced by a review of personnel records and interviews. In 1 of 1 (100%) personnel record of the social worker that was employed by the agency revealed the agency did not ensure the social worker was supervised by a CMS-qualified MSW during her employment at the agency. Staff 11 – This social worker was hired on 2/18/2022 and resigned from the agency effective 4/15/2022. The personnel record documented education verification that the social worker received her bachelor’s degree in social work (BSW) on May 2, 2020. During the time of her employment, there was no evidence that the hospice employed or contracted with a master’s prepared social worker (MSW) to provide direct supervision of the BSW prepared social worker. During interview with the Medical Director on 9/7/2022, they presented a written attestation that described how he reviewed the social work-related needs of the patients and caregivers and provided supervisory oversight of the employed BSW. During interview with the Administrator on 9/7/2022, she stated she believed the Medical Director was eligible to provide supervisory oversight of the BSW staff member and was going to do some additional research. No additional information was provided prior to the end of the site visit review.