Every finding on record at Aa Care Hospice

It is required that the hospice EP (Emergency Preparedness) training program includes the following: For all new hospice employees and those providing services under arrangement, initial training in EP policies and procedures consistent with their expected roles; Demonstration of staff knowledge of emergency procedures; EP training of all hospice employees and individuals providing services under arrangement at least every two (2) years; a) More frequent training occurs if there is a significant update of EP policies and procedures; A periodic review and rehearsal of the hospice’s EP plan with hospice employees (including non-employee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others; and Documentation of each training including the date(s), participants, and content. THIS IS A CONTINUING REQUIRED ACTION. This standard was not met as evidenced by personnel record review and interview. In 2 of 2 (100%) personnel records reviewed, the hospice did not ensure that new employees received emergency preparedness training upon hire. Personnel Record 1: Social Worker (SW) date of hire 10/16/2023. The personnel record contained no documented evidence that the SW had completed emergency preparedness training. Personnel Record 2: Volunteer Coordinator (VC) date of hire 10/12/2023. The personnel record contained no documented evidence that the VC had completed emergency preparedness training. During joint record review and interview on 11/21/2023, the Director of Patient Care Services (DPCS) agreed there was no documented evidence of emergency preparedness training in the personnel records. The DPCS stated they haven’t been assigned the training yet but should have been.

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 IS A CONTINUING REQUIRED ACTION. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical record reviewed of patients admitted on or after 10/13/2023, the hospice did not ensure that the interdisciplinary group completed the comprehensive assessment within 5 calendar days after the election of hospice care. Clinical Record 1: The patient elected the hospice benefit on 10/13/2023. The clinical record contained no documented evidence of an initial spiritual or psychosocial assessment. During joint review of the record and interview on 11/20/2023, the Director of Patient Care Services (DPCS) agreed there was no documented evidence that the initial spiritual and psychosocial assessments were completed. The DPCS stated “The patient declined the chaplain and social worker, but the nurse should have done the initial spiritual and psychosocial assessments, I am not sure why the nurse did not.”

It is required that hospice care and services provided to patients and families follow the individualized plan of care established by the hospice IDG (interdisciplinary group) in collaboration with the attending physician (if any), the patient or patient representative, and the primary caregiver in accordance with the patient’s needs. This standard was not met as evidenced by clinical record review and interview. In 4 of 5 (80%) clinical records reviewed, the agency did not ensure hospice care and services were provided to patients as ordered on the individualized plan of care. Clinical Record 1: The patient elected the hospice benefit on 10/13/2023. The plan of care (POC) dated 10/13/2023 ordered SN (Skilled Nurse) visits once a week. The clinical record contained no documented evidence that a nursing visit was provided to the patient the week of 10/15/2023 to 10/21/2023. The clinical record contained no documentation of a missed visit. Clinical Record 2: The patient elected the hospice benefit on 08/26/2022. The POC dated 10/20/2023 included an order for SN visits twice a week. For the week of 10/29/2023 to 11/04/2023 the SN provided a nursing visit on 11/02/2023, but there was no documented evidence of the second nursing visit for the week. The clinical record contained no documentation of the missed visit. During the week of 11/12/2023 to 11/18/2023, the SN provided a visit on 11/16/2023, but there was no documented evidence of a second nursing visit or reason for a missed visit. Clinical Record 3: The patient elected the hospice benefit on 06/23/2023. The POC dated 10/21/2023 included an order for SN visits once a week. For the week of 11/5/2023 to 11/11/2023, the clinical record contained no documented evidence of a nursing visit or reason for the missed visit. Clinical Record 5: The patient elected the hospice benefit on 10/16/2022. The POC dated 10/11/2023 included an order for SN visits once a week. For the week of 11/05/2023 to 11/11/2023, the clinical record contained no documented evidence of a nursing visit or reason for the missed visit. During a joint review of records and interview on 11/21/2023, the Director of Patient Care Services (DPCS) agreed there was no documented evidence that nursing visits were completed as ordered. The DPCS stated, “The visits were assigned but we discovered the nurses did not complete them.”

It is required that the hospice documents and maintains an effective infection control program that protects patients, families, visitors, and hospice staff by preventing and controlling infections and communicable diseases. The infection control program includes education of employees, contracted providers, patients, families, and other caregivers in infection control. THIS IS A CONTINUING REQUIRED ACTION. This standard was not met as evidenced by personnel record review and interview. In 2 of 2 (100%) personnel records reviewed, the hospice did not ensure new employees received infection control education upon hire. Personnel Record 1: Social Worker (SW) date of hire on 10/16/2023. The personnel record contained no documented evidence that the SW had completed infection control education. Personnel Record 2: Volunteer Coordinator (VC) date of hire 10/12/2023. The personnel record contained no documented evidence that the VC had completed infection control education. During joint personnel record review and interview on 11/21/2023, the Director of Patient Care Services (DPCS) agreed there was no documented evidence of infection control education in the personnel records. The DPCS stated they haven’t been assigned the training yet but should have been.

It is required that a hospice aide provides services ordered by the Interdisciplinary Group and included in the plan of care. THIS IS A CONTINUING REQUIRED ACTION. This standard was not met as evidenced by clinical record review and interview. In 4 of 4 (100%) clinical records reviewed with hospice aide (HA) services provided, the agency did not ensure hospice aide services were provided as ordered on the plan of care. Clinical Record 2: The patient elected the hospice benefit on 08/26/2022. The HA plan of care assignment dated 10/22/2023 included aide frequency of visits three times a week. The clinical record contained no documented evidence the hospice aide provided visits from 10/22/2023 through 11/20/2023. Clinical Record 3: The patient elected the hospice benefit on 06/23/2023. The HA plan of care assignment dated 10/23/2023 included aide frequency of visits four times a week. The HA plan of care assignment dated 10/30/2023 assigned aide frequency of visits five times a week, the HA assignment dated 11/06/2023 assigned aide visits four times a week, and the HA plan of care dated 11/13/2023 assigned aide visits three times a week. The clinical record contained no documented evidence hospice aide visits were provided from 10/23/2023 through 11/20/2023. Clinical Record 4: The patient elected the hospice benefit on 08/07/2023. The HA plan of care assignment dated 10/24/2023 included aide frequency of visits twice a week. There was no documented evidence hospice aide services were provided between 10/24/2023 through the patient’s death on 11/07/2023. Clinical Record 5: The patient elected the hospice benefit on 10/16/2022. The HA plan of care assignment dated 10/23/2023 included aide frequency of visits three times a week. The HA plan of care dated 10/30/2023 assigned aide frequency of visits five times a week, the HA plan of care dated 11/6/2023 assigned aide frequency of visits four times a week, and the HA plan of care dated 11/13/2023 assigned aide frequency of visits three times a week. The clinical record contained no documented evidence hospice aide services were provided from 10/23/2023 through 11/20/2023. During joint review of records and interview on 11/20/2023, the Director of Patient Care Services (DPCS) agreed, there was no documented evidence that hospice aide services were provided as ordered. The DPCS stated, “I know she has been visiting the patients, but she has not been documenting her visits.”

It is required that the hospice maintains, documents, and provides hospice volunteer orientation and training that is consistent with hospice industry standards; it includes the volunteer’s duties and responsibilities, the person to whom they report, the person to contact if they need assistance and instruction, hospice goals, services, and philosophy, confidentiality and protection of the patient’s and family’s rights, family dynamics and psychological issues surrounding terminal illness, death, and bereavement, procedures to be followed in an emergency and/or following the death of a patient, and guidance specific to individual responsibilities. Volunteers are supervised by a designated hospice employee. THIS IS A CONTINUING REQUIRED ACTION. This standard was not met as evidenced by document review and interview. The Volunteer manual was reviewed. There was no documented evidence of hospice volunteer orientation and training that was consistent with hospice industry standards, including the volunteer’s duties and responsibilities, the person to whom they report, the person to contact if they need assistance and instruction, hospice goals, services, and philosophy, confidentiality and protection of the patient’s and family’s rights, family dynamics and psychological issues surrounding terminal illness, death, and bereavement, procedures to be followed in an emergency and/or following the death of a patient, and guidance specific to individual responsibilities. During an interview on 11/21/2023, an active patient volunteer stated, there wasn't any training provided. We were just told during the interview upon hire what we can and cannot say. During joint review and interview on 11/21/2023, the Director of Patient Care Services (DPCS) stated, "I am still developing the volunteer training module, then we will train our volunteers." The DPCS agreed, there was no documented evidence the active volunteers have completed volunteer training with the required elements. The Volunteer manual was reviewed. There was no documented evidence of hospice volunteer orientation and training that was consistent with hospice industry standards, including the volunteer’s duties and responsibilities, the person to whom they report, the person to contact if they need assistance and instruction, hospice goals, services, and philosophy, confidentiality and protection of the patient’s and family’s rights, family dynamics and psychological issues surrounding terminal illness, death, and bereavement, procedures to be followed in an emergency and/or following the death of a patient, and guidance specific to individual responsibilities.

It is required that the hospice medical director or physician-designee provides written and signed recertification of the terminal illness to meet the hospice care benefit requirement. Recertification is completed no later than two (2) calendar days after the first day of each benefit period, and no more than fifteen (15) days before the next benefit period begins. This standard was not met as evidenced by clinical record review and interview. In 2 of 5 (40%) clinical records reviewed, the agency did not ensure recertification was completed no later than two calendar days after the first day of each benefit period. Clinical Record 2: The patient elected the hospice benefit on 08/26/2022. The clinical record contained no documented evidence that the hospice medical director or physician-designee provided written recertification for benefit period 7 dated 10/20/2023 through 12/18/2023, as of the date of record review on 11/20/2023, 31 days after the start of the benefit period. Clinical Record 3: The patient elected the hospice benefit on 06/23/2023. The clinical record contained no documented evidence that the hospice medical director or physician-designee provided written recertification for benefit period 9 dated 10/21/2023 through 12/19/2023, as of the date of record review on 11/20/2023, 30 days after the start of the benefit period. During joint record review and interview on 11/20/2023, the Director of Patient Care Services (DPCS) agreed there was no documented evidence that the recertifications were completed. The DPCS stated, “We are working on this with him, I am not sure if he realizes when they are due.”

It is required that the hospice maintains an emergency preparedness training program that is based on the emergency preparedness plan, risk assessment, policies and procedures, and the communication plan. The training program is reviewed and updated at least every two (2) years. The hospice EP training program includes initial training in EP policies and procedures consistent with their expected roles for all new hospice employees and those providing services under arrangement. This standard was not met as evidenced by interview and personnel record review. In 5 of 8 (63%) personnel records reviewed it was revealed that the hospice did not ensure that new employees and those providing services under arrangement received emergency preparedness training upon hire. Personnel Record 1: The Director of Patient Care Services (DPCS) was hired 12/2/2021. There was no evidence of emergency preparedness training. Personnel Record 2: The Registered Nurse (RN) was hired 9/1/2022. There was no evidence of emergency preparedness training. Personnel Record 6: The medical director was hired 2/2/2022. There was no evidence of emergency preparedness training. Personnel Record 5: The Hospice Aide (HA) was hired 5/17/2022. There was no evidence of emergency preparedness training. Personnel Record 8: The nurse practitioner was hired 10/21/2022. There was no evidence of emergency preparedness training. The DPCS reviewed the records with the site visitor on 10/12/2023 and confirmed the finding. In 5 of 8 (63%) personnel records reviewed revealed the hospice did not ensure that new employees and those providing services under arrangement received emergency preparedness training upon hire.

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 10 of 14 (71%) clinical records reviewed it was revealed that the hospice did not ensure that the interdisciplinary group completed the comprehensive assessment within 5 calendar days after the election of hospice care. Clinical Record 2: The Election of Benefits form was dated 10/16/2022. The need for a medical social worker (MSW) evaluation was documented in the comprehensive assessment. The MSW documented their initial visit on 11/1/2022 (16 days after the election of hospice care). There was no documentation as to why the assessment was not completed within 5 calendar days after the election of hospice care. Clinical Record 4: The Election of Benefits form was dated 9/5/2022. The need for spiritual care and medical social worker (MSW) evaluations was documented in the comprehensive assessment. The chaplain initial visit was documented on 9/14/2022 (9 days after the election of hospice care). The MSW initial visit was documented on 9/14/2022 (9 days after the election of hospice care). There was no documentation as to why the assessments were not completed within 5 calendar days after the election of hospice care. Clinical Record 6: The Election of Benefits form was dated 8/26/2022. The need for a spiritual care evaluation was documented in the comprehensive assessment. The chaplain documented their initial visit on 9/1/2022 (6 days after the election of hospice care). There was no documentation as to why the assessment was not completed within 5 calendar days after the election of hospice care. Clinical Record 7: The Election of Benefits form was dated 8/7/2023. The need for a spiritual care evaluation was documented in the comprehensive assessment. There was no evidence of documentation that the chaplain performed a spiritual care assessment within 5 calendar days after the election of hospice care. Clinical Record 8: The Election of Benefits form was dated 6/23/2023. The need for a spiritual care evaluation was documented in the comprehensive assessment. The chaplain documented their initial visit on 6/29/2023 (6 days after the election of hospice care). There was no documentation as to why the assessment was not completed within 5 calendar days after the election of hospice care. Clinical Record 10: The Election of Benefits form was dated 5/5/2023. The need for a spiritual care evaluation was documented in the comprehensive assessment. There was no evidence of documentation that the chaplain performed a spiritual care assessment within 5 calendar days after the election of hospice care. Clinical Record 11: The Election of Benefits form was dated 10/4/2022. The need for a spiritual care and a medical social worker (MSW) evaluation was documented in the comprehensive assessment. The chaplain documented their initial visit on 10/22/2022 (18 days after the election of hospice care). The MSW documented their initial visit on 10/28/2022 (24 days after the election of hospice care). There was no documentation as to why the assessments were not completed within 5 calendar days after the election of hospice care. Clinical Record 12: The Election of Benefits form was dated 2/7/2023. The need for a spiritual care and a medical social worker (MSW) evaluation was documented in the comprehensive assessment. The chaplain documented their initial visit on 2/15/2023 (8 days after the election of hospice care). The MSW documented their initial visit on 3/3/2023 (24 days after the election of hospice care). There was no documentation as to why the assessments were not completed within 5 calendar days after the election of hospice care. Clinical Record 13: The Election of Benefits form was dated 9/8/2023. The need for a spiritual care and a medical social worker (MSW) evaluation was documented in the comprehensive assessment. The chaplain documented their initial visit on 9/19/2023 (11 days after the election of hospice care). The MSW documented their initial visit on 9/15/2023 (7 days after the election of hospice care). There was no documentation as to why the assessments were not completed within 5 calendar days after the election of hospice care. Clinical Record 14: The Election of Benefits form was dated 12/29/2022. The need for a spiritual care and a medical social worker (MSW) evaluation was documented in the comprehensive assessment. There was no evidence of documentation that the chaplain or MSW performed a spiritual care or MSW assessment within 5 calendar days after the election of hospice care. The Director of Patient Care Services who reviewed records with the site visitor on 10/10/2023 and 10/11/2023 stated that she did not know why the comprehensive assessments were not completed within 5 calendar days after the election of hospice care. In 6 of 14 (43%) clinical records reviewed in which a comprehensive assessment was performed, revealed the hospice did not ensure that the interdisciplinary group completed the comprehensive assessment within 5 calendar days after the election of hospice care.

It is required that the hospice designates an Interdisciplinary Group (IDG) composed of individuals who work together to meet the physical, medical, psychosocial, emotional, and spiritual needs of the patient/family facing terminal illness and bereavement. IDG members provide the care and services offered by the organization. The IDG, in its entirety, supervises the care and services provided to the patient and family. THIS IS A CMS CONDTION LEVEL DEFICIENCY This CONDITION was not met as evidenced by the review of clinical records and interview which revealed that the agency failed to ensure comprehensive assessments were completed within five days as required [HCPC9.I/L523]; failed to ensure patients were offered volunteer services [HCDT 21.I/L644]; failed to ensure that the hospice aides provided the care that was included in the plan of care [HCDT 16.I /L626]; and failed to ensure that patient care was provided under the supervision of a Registered Nurse [HSRM 22.I/L591]. The cumulative effect of these systemic problems resulted in the agency's inability to ensure the provision of quality patient care in a safe environment.

It is required that the hospice documents and maintains an effective infection control program that protects patients, families, visitors, and hospice staff by preventing and controlling infections and communicable diseases. The infection control program includes education of employees, contracted providers, patients, families, and other caregivers in infection control. This standard was not met as evidenced by interview and personnel record review. In 5 of 8 (63%) personnel records reviewed it was revealed that the hospice did not ensure that the personnel files included documentation of infection control education for the employees and contracted providers. Personnel Record 1: The Director of Patient Care Services was hired 12/1/2021. There was no documented evidence that education in infection control was provided. Personnel Record 2: The Registered Nurse was hired 9/1/2022. There was no documented evidence that education in infection control was provided. Personnel Record 5: The Hospice Aide was hired 5/17/2022. There was no documented evidence that education in infection control was provided. Personnel Record 6: The medical director was hired 2/2/2022. There was no documented evidence that education in infection control was provided. Personnel Record 8: The nurse practitioner was hired 10/21/2022. There was no documented evidence that education in infection control was provided. The Director of Patient Care Services reviewed records with the site visitor on 10/12/2023 and confirmed the finding. In 5 of 8 (63%) personnel records reviewed revealed the hospice did not ensure that employees and contracted providers received education in infection control.

It is required that the hospice provides nursing care under the supervision of a registered nurse. This standard was not met as evidenced by clinical record review and interview. In 2 of 14 (14%) records reviewed in which a licensed vocational/practical nurse (LPN/LVN) provided services, it was revealed that the agency did not ensure that a registered nurse (RN) performed LPN/LVN supervisory visits. Clinical Record 12: The Election of Benefits form was dated 2/7/2023. There was no evidence that the RN performed LVN supervisory visits from 2/7/2023 through the patient's revocation on 5/31/2023. Clinical Record 14: The Election of Benefits form was dated 12/29/2022. There was no evidence that the RN performed LVN supervisory visits from 12/29/2022 through the patient's revocation on 2/3/2023. The Director of Patient Care Services, who was the RNCM, jointly reviewed the records with this site visitor on 10/11/2023 and confirmed the finding. In 2 of 14 (14%) records reviewed in which a licensed vocational/practical nurse (LPN/LVN) provided services, revealed that a registered nurse (RN) did not perform LPN/LVN supervisory visits.

It is required that a hospice aide provides services that are included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 2 of 3 (67%) clinical records reviewed in which a hospice aide (HA) provided services, it was revealed that the agency did not ensure that the care provided by the HA was consistent with the HA plan of care. Clinical Record 11: The Election of Benefits form was dated 10/4/2022. The HA plan of care dated 10/4/2022 directed the aide to provide a shower using a shower chair, skin care, mouth care, shaving with safety razor, use of walker, assist with dressing, and observation of fall precautions. There was no evidence of documentation that the HA provided hands on personal care such as bathing or assisting with ambulation from 10/4/2022 through the patient's discharge on 6/10/2023. Clinical Record 13: The Election of Benefits form was dated 9/8/2022. The HA plan of care dated 9/21/2022 directed the aide to provide a shower, shampoo, continence care, skin care, mouth care, use of walker, assist with dressing, observation of fall precautions, and the use of a 1-person transfer 4 times a week. The HA documented light housekeeping on 9/13/2022 which was prior to the initiation of the HA plan of care. The HA documented light housekeeping on 10/6/2022, 10/13/2022, 10/20/2022, 10/27/2022, 11/10/2022, 11/17/2022, 12/29/2022, and 1/6/2023. There was no evidence documented that the HA provided hands-on personal care such as bathing or assisting with ambulation. An interview with the Director of Patient Care Services on 10/11/2023 confirmed this finding. She stated that she had no idea that the HA was not providing services as ordered on the HA plan of care. In 3 of 3 (100%) clinical records reviewed in which a hospice aide (HA) provided services; it was revealed that the care provided by the HA was not consistent with the HA plan of care.

It is required that the hospice maintains, documents, and provides hospice volunteer orientation and training that is consistent with hospice industry standards; it includes the volunteer’s duties and responsibilities, the person to whom they report, the person to contact if they need assistance and instruction, hospice goals, services, and philosophy, confidentiality and protection of the patient’s and family’s rights, family dynamics and psychological issues surrounding terminal illness, death, and bereavement, procedures to be followed in an emergency and/or following the death of a patient, and guidance specific to individual responsibilities. Volunteers are supervised by a designated hospice employee. This standard was not met as evidenced by interview and personnel record review. ln 1 of 1 (100%) record reviewed in which the employee is employed as a volunteer, the hospice did not ensure that the volunteer received volunteer training. Personnel Record 7: The personnel record of the volunteer, with a hire date of 8/2022 was reviewed. There was no documentation found of evidence of volunteer training. The DPCS who reviewed records with this site visitor on 10/12/2023 confirmed this finding. The DPCS stated she did the training for the volunteer with the volunteer coordinator but did not know where the documentation of the training was. In 1 of 1 (100%) personnel record reviewed in which the employee is employed as a volunteer, the hospice did not ensure that the volunteer received volunteer training.

It is required that volunteers are used in day-to-day administrative and/or direct patient care roles. Volunteer services are noted in the plan of care and documented in the patient record, including the time spent. This standard was not met as evidenced by clinical record review and interview. In 13 of 14 (93%) clinical records reviewed, it was revealed that the agency did not ensure that there was evidence that a volunteer was offered and/or the patient declined volunteer services. Clinical Record 1: The Election of Benefits form was dated 11/3/2022. There was no documentation that a volunteer was offered/declined. Clinical Record 2: The Election of Benefits form was dated 10/16/2022. There was no documentation that a volunteer was offered/declined. Clinical Record 3: The Election of Benefits form was dated 9/10/2023. There was no documentation that a volunteer was offered/declined. Clinical Record 4: The Election of Benefits form was dated 9/5/2022. There was no documentation that a volunteer was offered/declined. Clinical Record 5: The Election of Benefits form was dated 8/30/2023. There was no documentation that a volunteer was offered/declined. Clinical Record 7: The Election of Benefits form was dated 8/7/2023. There was no documentation that a volunteer was offered/declined. Clinical Record 8: The Election of Benefits form was dated 6/23/2023. There was no documentation that a volunteer was offered/declined. Clinical Record 9: The Election of Benefits form was dated 6/9/2023. There was no documentation that a volunteer was offered/declined. Clinical Record 10: The Election of Benefits form was dated 5/5/2023. There was no documentation that a volunteer was offered/declined. Clinical Record 11: The Election of Benefits form was dated 10/4/2022. There was no documentation that a volunteer was offered/declined. Clinical Record 12: The Election of Benefits form was dated 2/7/2023. There was no documentation that a volunteer was offered/declined. Clinical Record 13: The Election of Benefits form was dated 9/8/2022. There was no documentation that a volunteer was offered/declined. Clinical Record 14: The Election of Benefits form was dated 12/29/2022. There was no documentation that a volunteer was offered/declined. The Director of patient Care Services who reviewed records with the site visitor on 10/10/2023 confirmed that they have not been documenting the offering and/or declination of volunteer services. In 13 of 14 (93%) clinical records reviewed, there was no evidence that a volunteer was offered and/or the patient declined volunteer services.

It is required that the hospice organizes, manages, and administers its resources to provide the hospice care and services to patients, families, and caregivers necessary for the palliation and management of the terminal illness and related conditions. THIS IS A CMS CONDTION LEVEL DEFICIENCY This CONDITION was not met as evidenced by clinical record review and interview with the Director of Patient Care Services which revealed significant issues with the organization and administration of services in the following areas: failure to ensure documentation of volunteer training and orientation [HSRM 31.I/L643]; failure to ensure infection control education [HIPC1.D/L582]; failure to obtain background checks on all staff with direct patient contact or access to patient records [HSRM 16.I/L796]; failure to ensure skills and competency assessments were performed and documented [HSRM 14.I/L663]; failure to ensure the agency provided staff with an initial orientation [HSRM 15.I/661]; and failure to ensure staff were trained in emergency preparedness [HSEP 5.D/37]. The cumulative effect of these deficiencies has resulted in the hospice agency's inability to ensure the provision of quality care under the Condition of Participation CRF 418.100, Organization and Administration of Services. The collective deficient practice illustrates systematic process failures that has the potential to affect all patients receiving hospice services from the agency.

It is required that the hospice provides an initial orientation for each employee that addresses the employee’s specific job duties, including infection control and organization procedures and policies and procedures on advance directives. Orientation on the hospice philosophy is also provided to all employees and contracted staff who have patient and family contact. This standard was not met as evidenced by interview and personnel record review. In 5 of 8 (63%) personnel records reviewed it was revealed that the hospice did not ensure that an initial orientation was provided to all employees. Personnel Record 1: The Director of Patient Care Services (DPCS) was hired 12/2/2021. There was no evidence that an orientation was provided at hire. Personnel Record 2: The Registered Nurse (RN) was hired 9/1/2023. There was no evidence that an orientation was provided at hire. Personnel Record 5: The hospice aide (HA) was hired 5/17/2022. There was no evidence that an orientation was provided at hire. Personnel Record 6: The medical director was hired 2/2/2022. There was no evidence that an orientation was provided at hire. Personnel Record 8: The nurse practitioner was hired 10/21/2022. There was no evidence that an orientation was provided at hire. The Director of Patient Care Services reviewed the records with the site visitor on 10/12/2023 and confirmed the finding. In 5 of 8 (63%) personnel records reviewed revealed the hospice did not ensure that an initial orientation was provided to employees.

It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services and, as necessary, provides in-service training and education programs where required. The hospice has written policies and procedures describing the method(s) of assessing competency and maintains a written description of the in-service training provided during the previous 12 months. This standard was not met as evidenced by interview and personnel record review. In 5 of 8 (63%) personnel records reviewed it was revealed that the hospice did not ensure that a competency assessment was completed on hire. Personnel Record 1: The Director of Patient Care Services (DPCS) was hired 2/2/2021. There was no documentation of a competency assessment. Personnel Record 2: The Registered Nurse was hired 9/1/2022. There was no documentation of a competency assessment. Personnel Record 5: The Hospice Aide was hired 5/17/2022. There was no documentation of a competency assessment. Personnel Record 6: The medical director was hired 2/2/2022. There was no documentation of a competency assessment. Personnel Record 8: The nurse practitioner was hired 10/21/2022. There was no documentation of a competency assessment. The DPCS reviewed records with the site visitor on 10/12/2023 and confirmed the finding. In 5 of 8 (63%) personnel records reviewed revealed the hospice did not ensure that a competency assessment was completed on hire.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum, the initial plan of care, updated plans of care, initial assessment, comprehensive assessment, updated comprehensive assessments, and clinical notes including the care and services provided. This standard was not met as evidenced by review of clinical records and interview. In 2 of 14 (14%) clinical records reviewed it was revealed that the agency did not ensure the patient's clinical record contained documentation of all of the services that were provided. Clinical Record 11: The Election of Benefits form was dated 10/4/2022. The HA plan of care dated 10/4/2022 directed the aide to provide a shower using a shower chair, skin care, mouth care, shaving with safety razor, use of walker, assist with dressing, and observation of fall precautions once a week. There was no hospice aide (HA) documentation from 10/4/2022 through the patient's discharge on 6/10/2023. Clinical Record 12: The Election of Benefits form was dated 2/7/2023. The HA plan of care dated 2/20/2023 directed the aide to provide a shower using a shower chair, skin care, mouth care, use of walker, assist with dressing, observation of fall precautions, and 1 person transfer twice a week. Between the dates of 3/9/2023 through 3/26/2023 and 3/28/2023 through 4/3/2023, there was no documentation of twice weekly visits from the HA. An interview with the Director of Patient Care Services on 10/11/2023 confirmed this finding. She stated that she had no idea that the HA was not documenting and didn't know why there was no documentation.

It is required that the hospice obtains a criminal background check on all hospice employees who have direct patient contact or access to patient records. This standard was not met as evidenced by interview and personnel record review. In 4 of 8 (50%) personnel records reviewed it was revealed that the hospice did not ensure that a criminal background check was completed on all hospice employees that had direct patient contact or access to patient records Personnel Record 2: The registered nurse was hired 9/1/2023. There was no evidence that a background check was obtained upon hire. Personnel Record 5: The hospice aide was hired 5/17/2022. There was no evidence that a background check was obtained upon hire. Personnel Record 7: The volunteer was hired 8/2022. There was no evidence that a background check was obtained upon hire. Personnel Record 8: The nurse practitioner was hired 10/21/2022. There was no evidence that a background check was obtained upon hire. Interview 1: The Director of Patient Care Services reviewed the records with the site visitor on 10/12/2023 and confirmed the finding. In 4 of 8 (50%) personnel records reviewed revealed the hospice did not ensure a criminal background check was completed on hospice employees.