Every finding on record at Able Caring and Hospice Services Inc

Based on record review and interview, the hospice failed to ensure that RN completed an initial assessment within 48 hours after the election of hospice care for 2 of 8 discharged patients (#3 & #5), in that the patients initial assessments were mostly incomplete and did not contain the clinical information of the patients. This failure placed the patients at risk for negative outcome due to assessment not being completed to identify problems and provide interventions to control patients symptom and ensure comfort. Refer to L0522 Based on record review and interview, the hospice IDG failed to update comprehensive assessment as frequently as the condition of the patient requires, but no less frequently that every 15 days for 8 of 8 discharged patients reviewed (#1 - #8) in that there was no documentation that the patients assessments were updated. This failure placed the patients at risk for negative outcome due to lack of interdisciplinary oversight of care delivery to ensure that problems not being promptly identified and addressed. Refer to L0533

Based on record review and interview, the hospice failed to ensure that RN completed an initial assessment within 48 hours after the election of hospice care for 2 of 8 discharged patients (#3 & #5) in that the patients initial assessments were mostly incomplete and did not contain the clinical information of the clients. This failure placed the patients at risk for negative outcome due to assessment not being completed to identify problems and provide interventions to control patients symptom and ensure comfort. --- Patient #5 Review of Patient #5's CR revealed hospice election date of 7/17/23. Review of RN Initial Assessment on the electronic CR showed that the assessment only contained the date of 7/17/23, time of 7/17/23 and 4:00 pm – 5:00 pm, and treatment preference. The document did not reveal assessment of the patient to include vital signs, pain assessment, physical and cognitive ability, mental status, integument (skin), respiratory, cardiovascular, digestive, genitourinary, fall assessment, and review of medications. The document was signed by RN B. During interview with ADON on 2\7\24 at 12:48 pm, she was asked why initial assessment was not completed for patient #5. ADON stated that she did not know why initial assessment was not completed for the patient. ADON added that RN CM was the DON at the time the patient was admitted. During telephone interview with RN B on 2/9/24 at 9:55 am, she was asked why patient #5s initial assessment was not completed. RN B stated that she was only assigned the weekly visits for the patient. RN B added that she was not working for the agency as at the date patient #5 was admitted. RN B explained that she applied to the agency on 7/26/23 and her first day at the agency was 7/31/23. RN B added that she started going to see patient the first week of August. RN B stated that she did not know how her signature got on patient #5s initial assessment. RB B was asked if anyone else had access to her log in information. RN B stated that her computer access was created and given to her by the ADON. During interview with Adm/DON on 2/9/24 at 1:38 pm, he was asked why RN initial assessment was not completed for patient #5. Adm/DON stated that assessment not being completed for the patients was one of the issues already identified during the hospice survey in January 2024, and they were in the process of correcting the deficiencies. Adm/DON added that they were working towards correcting the deficiencies identified during the last survey. Adm/DON acknowledged that he was responsible for making sure that care provided was documented. Review of agencys undated policy titled ";Assessments", read in part: ";The initial assessment will be completed by a RN within 48 hours after the election of hospice care is completed............" Patient #3 Review of Patient #3's clinical record revealed that patient elected for hospice services on 10/03/2022. Review of patients electronic clinical record revealed an uncompleted initial assessment document that was conducted and signed by ADON on 10/03/2022. The document revealed that ADON did not assessed patient #3s pain level, functional limitations, Sensory limitations, psychological status, Neurological status, Braden scale for predicting pressure sore risk, Respiratory status, Cardiovascular status, Digestive/Nutritional and fluid intake screening, Genito-Urinary (Kidney & Bladder) system status, fall assessment, patients need for durable medical equipment, and review of medications. During interview with ADON on 02/12/2024 at 2:30p.m. the ADON confirmed she conducted the initial assessment for patient #3 on10/03/2022, but when the ADON was asked she why the initial assessment was not completed since 10/03/2022 the phone call was abruptly disconnected, and surveyor was unable to reconnect with the agencys ADON until exit. During interview with agencys Administrator/DON on 02/12/2024 at 2:35p.m., the administrator expressed disappointment at the agencys nursing staffs poor performance with regards to documentation of services rendered to patients and stated that the agency was already being cited with immediate jeopardy by CMS authorized hospice agencys accreditation company that recently conduct a recertification survey at the agency 01/19/2024. The administrator/director of Nurses further stated, ";Now I can see my mistakes. I depended on them (Previous Case manager & ADON) to run the business because they told me that they have done it before, and I trusted them completely. I should have been checking things by myself to make sure that they were doing what they were supposed to be doing... I know we have dropped the ball, but I promised if we are given the opportunity to continue doing business, we will not repeat these mistakes again."

Based on record review and interview, the hospice IDG failed to update comprehensive assessment as frequently as the condition of the patient requires, but no less frequently that every 15 days for 8 of 8 discharged patients reviewed (#1 - #8) in that there was no documentation that the patients assessments were updated. This failure placed the patients at risk for negative outcome due to lack of interdisciplinary oversight of care delivery to ensure that problems not being promptly identified and addressed. --- Patient #5 Review of Patient #5's CR revealed hospice election date of 7/17/23 and terminal diagnosis of malignant neoplasm (Cancer) of unspecified site of unspecified female breast. Review of benefit period 7/17/23 – 10/14/23 showed an incomplete RN Initial Assessment dated 7/17/23, MSW assessment dated 7/17/23, Chaplain and bereavement assessments dated 7/20/23. Further review of the CR showed that there was no IDG assessment and updates for the period. Patient #6 Review of Patient #6s CR revealed hospice election date of 7/10/23 and terminal diagnosis of unspecified protein-calorie malnutrition. Review of benefit period 7/10/23 – 10/5/23 showed RN Initial Assessment dated 7/10/23, MSW assessment dated 7/12/23, Chaplain and bereavement assessments dated 7/13/23. Further review of the CR showed that there was no IDG assessment and updates for the period. Patient #7 Review of Patient #7s CR revealed hospice election date of 4/20/23 and terminal diagnosis of chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs). Review of benefit period 4/20/23 – 7/18/23 showed RN Initial Assessment dated 7/10/23, and MSW, Chaplain and bereavement assessments dated 4/24/23. Further review of the CR showed that there was no IDG assessment and updates for the period. Patient #8 Review of Patient #8s CR revealed hospice election date of 4/20/23 and terminal diagnosis of senile degeneration of the brain (a decrease in the ability to think, concentrate, or remember). Review of benefit period 4/20/23 – 7/18/23 showed RN Initial Assessment dated 4/20/23, MSW assessment dated 4/21/23, Chaplain and bereavement assessments dated 4/22/23. Further review of the CR showed that there was no IDG assessment and updates for the period. During interview with ADON on 2/8/24 at 1:32 pm, she stated that the IDG met every other Wednesday and reviewed each patients care. ADON added that the IDG meeting notes were filed in the IDG/POC binder. Review of the IDG/POC binder from March 2023 to December 2023 revealed IDG meeting agenda that only reflect the names of the hospice patients at the time of the meetings. There were no individual IDG notes completed for each patient that indicated the care issues discussed and any update to the care being provided. When ADON was asked why IDG notes were not completed on the patients, ADON stated that she did not know why the IDG notes were not completed. ADON added that if the IDG notes were not in the electronic CR or in the IDG/POC binder, then the IDG notes were not completed. ADON further stated that RN CM was the DON during the period under review and she was responsible for making sure IDG notes were completed. During interview with Adm/DON on 2/9/24 at 1:38 pm, he was asked why there were no IDG notes in the patients CR. Adm/DON stated that IDG notes not being completed for the patients was one of the issues already identified during the hospice survey in January 2024, and they were in the process of correcting the deficiencies. Adm/DON added that RN CM was the former DON responsible for making sure that IDG notes were completed, and the staff failed to ensure that was done. Adm/DON stated that RN CM was terminated in January after the survey. Adm/DON acknowledged that he was making sure that care provided was properly documented. During telephone interview with MD on 2/9/24 at 3:59 pm, he stated that the IDG meetings were held via zoom every other Wednesday. MD was asked why there were IDG notes in the patients CR. MD stated IDG assessment and updates not being completed was one of the problems identified during the hospice survey in January 2024. MD stated that they have developed plans to correct the deficient practices identified and they were currently working towards correcting the problems. Review of agencys undated policy titled ";Assessments", read in part: ";The hospice IDG in consultation with the individuals attending physician (if any), will complete the comprehensive assessment no later than 5 calendar days after the election of hospice care." ";The hospice will ensure the update of the comprehensive assessment will: 1. Be accomplished by the hospice IDG. 4. Accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days." Patient #1 Review of patient #1s clinical record revealed patient elected for hospice services on 04/20/2023 with terminal diagnosis of chronic congestive heart failure (Is a long-term medical condition that results when a persons heart cannot pump blood well enough to give the body a normal supply. This usually cause blood and fluids collect in a persons lungs and legs over time). Review of the initial benefit period from 04/20/2023 revealed incomplete skilled nursing visit notes by ADON. The visit notes had no records of patients vital signs (clinical measurements that indicate the state of a patient's essential body functions, pulse, respirations, blood pressure, temperature) for the entire benefit period. Review of patients electronic clinical record (ECR) showed the initial comprehensive nursing assessment dated 04/20/2023 and incomplete recertification assessment dated 07/14/2023, medical social worker (MSW) initial assessment dated 04/22/2023 and subsequent MSW monthly assessment dated 05/17/2023, 06/16/2023 and 07/17/2023, and the chaplain initial bereavement assessment dated 04/22/2023. Review of patient #1s ECR for the benefit period 04/20/2023 to 07/18/2023 had no record of hospice agencys interdisciplinary group meetings (IDG) during the entire benefit period to review and update patient #1s healths condition and only one plan of care dated 07/12/2023 that was unsigned by the physician. Review of patients CR showed no plan of care developed for that benefit period. And review of the initial comprehensive nursing assessment record had no documentation of types of services to be provided to patient/family and frequency of visits. Review of patient #1s clinical records for the second benefit period from 07/19/2023 to 10/16/2023 revealed same plans of care with different dated 07/26/2023, 08/09/2023, 08/23/2023, 09/06/2023, 09/20/2023, and 10/04/2023. Continued review of the patients ECR showed that received skilled nursing, Home Health Aide services, and MSW services. Further review of patient #1s revealed that patient did not receive chaplain services and there were records of IDG meetings to review patients care needs and updates. Patient #2 Review of patient #2s clinical record revealed patients hospice election date of 04/19/2023 with terminal diagnosis of chronic obstructive pulmonary disease (COPD) - Is a chronic inflammatory lung disease that causes obstructed airflow from the lungs. Review of patients ECR revealed that the agency provided hospice services to patient for two consecutive benefit periods from 04/19/2023 to 07/17/2023 and from 07/18/2023 to 10/13/2023. Review of the patients ECR showed initial comprehensive Nursing assessment of 04/19/2023, initial bereavement assessment dated 04/20/2023, and MSW initial assessment dated 04/21/2023. Review of the two benefit periods revealed no initial nor updated plans of care was developed for patient #2 during the entire benefit periods. Review of the entire benefit periods showed no records of agency IDG meetings to review patient #2 hospice care and update the service to meet patients/caregivers needs. Patient #3 Review of patient #3s clinical records revealed patient elected for hospice service on 10/03/2022 with terminal diagnoses of HIV-AIDS (HIV -human immunodeficiency virus is a virus that attacks the bodys immune system. If HIV is not treated, it can lead to AIDS -acquired immunodeficiency syndrome), Hepatitis C (Is a viral infection that causes inflammation of the liver. Hepatitis C can lead to serious liver damage), disseminated histoplasmosis encapsulate (Is a recurrent life-threatening fungal infection that can quickly spread in a persons body due to the bodys inability to fight of the infection. This disease usually seen in patient with compromised immune system like HIV-AIDS patients or patient suffering from other immunodeficient diseases.), and Toxoplasmosis (This is an infection caused by a single-celled parasite called Toxoplasma gondii). Review of the patients ECR showed that patient received hospice services for three consecutive benefit periods from 10/03/2022 to 12/31/2022, 01/01/2023 – 03/31/2023, and 04/01/2023 to 05/30/2023. Review of patients ECR during these benefit periods revealed a complete initial comprehensive nursing assessment dated 10/03/2023 with two incomplete recertification assessments dated 12/12/2022, and 03/20/2023. Patient #3s ECR review also revealed patient received MSW and chaplain services. Continued review of patients ECR revealed same plan of care with different dates unsigned by the patients physician. Further review of the patient #3s ECR showed no record of agencys IDG meetings for the entire 3 benefits to assess patients/caregivers needs and update the services patient was receiving. Patient #4: Review of patient #4s clinical record revealed patients hospice election date of 04/18/2023 with terminal diagnosis of Cerebral infarct (Is a medical condition that is caused by a disruption of blood flow to the brain due to problems with the blood vessels that supply it. A lack of adequate blood supply to brain cells deprives them of oxygen and other vital nutrients which can cause parts of the brain to die off). Review of patients ECR revealed patient received hospice services for two consecutive benefit periods from 04/18/2023 – 06/11/2023 and 06/12/2023 – 09/14/2023 with an initial comprehensive nursing assessment dated 04/18/2023 and two recertification assessment dated 05/29/2023(incomplete) and 09/07/2023. Review of patients ECR also showed that patient chaplain services with initial assessment dated 04/19/2023 with another visit on 05/19/2023 as well as MSW services with initial assess conducted on 04/21/2023. Review of patient #4s ECR revealed no plans of care and no IDG meetings for the entire service periods. During interview with the Alternate Director of Nursing (ADON) on 02/07/2024 at 2:12p.m. the Nurse stated that they(agency) conduct IDG meetings every 14 days. When the ADON was asked where the agencys IDG meeting documents were located? The ADON stated in the IDG folder or in ECR and if you cannot find it in any of these locations then it was not done.

Based on record review and interview, the hospice failed to ensure that hospice care and services furnished to patients and their families followed an individualized written POC established by the hospice IDG for 6 of 8 discharged patients reviewed (#1, #2, #4, #5, #7 & #8) in that the IDG did not develop POC for the patients. This failure placed the patients at risk for negative outcome due to patient receiving care that was not approved by the IDG to be necessary and safe for the patients. Refer to L0543 Based on record review and interview, the hospice IDG failed to review, revise and document in the individualized plan as frequently as patients condition required, but no less frequently than every 15 calendar days for 1 of 8 patients reviewed (#6) in that there was no indication that the patients initial POC was reviewed and updated by the IDG. This failure placed the patients at risk for negative outcome due to the IDG not reviewing patient care to promptly identify and address care problems to ensure symptoms control and comfort. Refer to L0552

Based on record review and interview, the hospice failed to ensure that hospice care and services furnished to patients and their families followed an individualized written POC established by the hospice IDG for 6 of 8 discharged patients reviewed (#1, #2, #4, #5, #7 & #8) in that the IDG did not develop POC for the patients. This failure placed the patients at risk for negative outcome due to patient receiving care that was not approved by the IDG to be necessary and safe for the patients. --- Patient #5 Review of Patient #5's CR revealed hospice election date of 7/17/23 and terminal diagnosis of malignant neoplasm (cancer) of unspecified site of unspecified female breast. Review of benefit period 7/17/23 – 10/14/23 showed an incomplete RN Initial Assessment dated 7/17/23, MSW assessment dated 7/17/23, Chaplain and bereavement assessments dated 7/20/23. Review of the CR showed that POC was not developed for the episode. Review of visit notes showed the following notes: RN B visits on 8/9/23, 8/23/23, 9/6/23, 9/20/23 & 10/4/23, LVN visits on 8/2/23, 8/16/23, 8/30/23, 9/23/23 & 9/27/23, and MSW visits on 8/18/23 & 9/18/23. During interview with ADON on 2/7/23 at 12:48 pm, she was asked why there were no POCs for patient #5 in the electronic CR. ADON stated that the POCs were on paper in a binder designated for IDG meeting reports and POCs. Review of the IDG/POC binder revealed no POCs were completed for patient #5. During follow-up interview with ADON on 2/7/24 at 2:15 pm, she acknowledged that there were not POCs for the in the binder. ADON stated that if the POCs were not in the electronic CR and the IDG/POC binder, then the POCs were not completed. ADON was asked how care was provided to the patient without POCs. ADON stated that she was not the nurse for the patient. ADON was asked who was responsible for making sure that POCs were completed for patients. ADON stated that the DON was responsible for making sure that POCs were completed for the patients. ADON stated that RN CM was the DON in 2023. During telephone interview with RN B on 2/9/24 at 9:55 am, RN B stated that she started going to see patient the first week of August. RN B stated that she conducted SN visits every other week. RN B was asked why patient #5 had no POCs. RN B stated that the DON was responsible for completing the POCs. RN B stated that she was only instructed by the ADON to conduct SN visit every other week. RN B acknowledged that she did not review any POC before going out to see the patient. Patient #7 Review of Patient #7s CR revealed hospice election date of 4/20/23 and terminal diagnosis of chronic obstructive pulmonary disease. Review of benefit period 4/20/23 – 7/18/23 showed RN Initial Assessment dated 7/10/23, and MSW, Chaplain and bereavement assessments dated 4/24/23. Review of the CR showed that POC was not developed for the episode. Further review of the benefit period 4/20/23 – 7/18/23 showed the following visit notes: ADON visits on 4/28/23, 5/11/23, 6/22/23 & 7/14/23, LVN visits on 4/21/23, 5/4/23, 6/15/23, 6/29/23 & 7/6/23, and MSW visits on 5/23/23 & 6/23/23. Review of visit notes showed the following notes: ADON visits on 7/20/23, 7/27/23, 8/3/23, 8/10/23, 8/17/23, 8/24/23, 8/31/23, 9/7/23, 9/14/23, 9/21/23, & 9/28/23, and MSW visits 7/21/23, 8/21/23 & 9/21/23. During interview with ADON on 2/8/24 at 11:26 am, she was asked why there were no POCs for patient #7. ADON stated acknowledged that there were no POCs for the patient. ADON added that she had been very busy and was unable to complete the POCs. ADON was asked how she provided care to the patient for two episodes without POCs. ADON stated she just completed nursing care sure as physical and pain assessment and review of the patients medication. Patient #8 Review of Patient #8s CR revealed hospice election date of 4/20/23 and terminal diagnosis of senile degeneration of the brain (a decrease in the ability to think, concentrate, or remember). Review of benefit period 4/20/23 – 7/18/23 showed RN Initial Assessment dated 4/20/23, MSW assessment dated 4/21/23, Chaplain and bereavement assessments dated 4/22/23. Review of the CR showed an incomplete POC dated 4/20/23 and signed by ADON. The POC did not include care issues including care problems identified, frequencies of services to be provided and medications the patient was using. There was no other POC for the episode. Patient #8 was discharged on 7/18/23. Review of visit notes showed the following notes: ADON visits on 4/28/23, 5/4/23, 5/11/23, 5/18/23, 5/25/23, 6/1/23, 6/8/23, 6/15/23, 6/22/23, 6/29/23, 7/6/23 & 7/13/23, and MSW visits on 5/19/23 & 6/16/23. During interview with ADON on 2/7/24 at 2:15 pm, she was asked why she did not complete patient #8s initial POC. ADON stated that she completed the POC, but she probably did not review the document before signing the POC. ADON was asked if the information disappeared after she input the information. ADON stated that she did not know why the POC was incomplete. ADON also stated that if there were no POCs for the patient on the computer and in the designated binder for IDG reports, then the POCs were not completed. ADON was asked how she could provide care to the pt without a POC. ADON stated that during SN visit, she completed head-to-toe assessment of the patient including pain assessment and medication review. During telephone interview with LVN on 2/9/24 at 10:07 am, she was asked how she was communicated information to see a patient. LVN stated that checked her schedule to see what patient had been assigned to her, or the DON or ADON would call to let her know a patient had been assigned to her. LVN was asked how she would know what care to provide for the patient. LVN stated that she reviewed the patients POC to obtain information about the patients care. LVN was asked how she obtained care instructions for patients #5 & #7 when the patients had no POCs. LVN stated that ADON told her what to do for the patients. LVN was asked if she realized that providing care without a POC was providing care that had not been approved by the physician. LVN stated that she was providing care as instructed by the ADON. LVN acknowledged that POC was required to provide care to any patient. During telephone interview with MSW on 2/9/24 at 8:49 am, she was asked why she provided care to patient #7 for two episodes without POC. MSW stated that they initially did not know how to complete the POC. MSW explained that after she assessed the patient, she determined that the patient required once monthly visits for emotional support. MSW stated that the frequency of visit was communicated to the team during IDG meetings. MSW added that MSW should be included in the POC. MSW stated that she found out after the in-service conducted after their survey in January 2024 that she was supposed to develop care plan for any psychosocial problem identified. MSW was asked how she did not know that there was no POC for the patient. MSW stated that nursing was responsible for completing the POC and she did not interfere in what the nurses did. MSW further stated that the above explanations were also the reasons why patients #5 & #8 did not have POCs in their CR. During interview with Adm/DON on 2/9/24 at 1:38 pm, he was asked why POCs were not developed for the patients. Adm/DON stated that the lack of POCs for the patients were issues already identified during the hospice survey in January 2024, and they were in the process of correcting the deficiencies. Adm/DON added that RN CM was the former DON responsible for making sure that POCs were completed, and the staff failed to ensure that was done. Adm/DON stated that RN CM was terminated in January after the survey. Adm/DON acknowledged that he was responsible for making sure that care provided was documented. During telephone interview with MD on 2/9/24 at 3:59 pm, he stated that he had access into the electronic CR and he electronically signed documents or by hand if faxed to him. MD stated that the hospice did not send any POC to him. MD was asked if he reviewed patient records to find out if POCs were developed for the patients. MD stated that lack of POCs for the patients was one of the problems identified during the hospice survey in January 2024. MD stated that they have developed plan to correct the deficient practices identified and they were currently working towards correcting the problems. MD further stated that the patients not having POCs was unacceptable. Review of RN CM PR revealed that the nurse applied and was hired for the position of RN Case Manager on 11/10/20. The PR also showed that the staff signed the job description as RN CM. There was no documentation in the PR that the staff was designated as the DON of the agency. Review of agencys undated policy titled ";Interdisciplinary Group (IDG)", read in part: ";The hospice IDG will develop a POC and specify the hospice care and services necessary to meet the patient and family-specific needs identified in the comprehensive assessment as such needs related to the terminal illness and related conditions." ";The POC (Initial, comprehensive and all updates to the POC) will be filed in the clinical record." Patient #1 Review of patient #1s clinical record revealed patient elected for hospice services on 04/20/2023 with terminal diagnosis of chronic congestive heart failure (Is a long-term medical condition that results when a persons heart cannot pump blood well enough to give the body a normal supply. This usually cause blood and fluids collect in a persons lungs and legs over time). Review of agencys ECR revealed that patient received hospice services for 2 benefit periods from 04/20/2023 to 07/18/2023 and 07/19/2023 to 10/16/2023. Review of patients electronic clinical record (ECR) showed the initial comprehensive nursing assessment was performed by RN CM on 04/20/2023 and incomplete recertification assessment done by ADON on 07/14/2023. The medical social worker (MSW) initial assessment done 04/22/2023 and subsequent MSW monthly assessments were conducted on 05/17/2023, 06/16/2023 and 07/17/2023, and the chaplain initial bereavement assessment dated 04/22/2023. Review of patient #1s clinical records also revealed weekly skilled nursing notes dated 04/27/23, 05/04/23, 05/11/23, 05/18/23, 05/25/23, 06/01/23, 06/08/23, 06/15/23, 06/22/23, 06/29/23, 07/06/23, & 07/13/23 that were conducted by ADON and LVN. Review of patients #1s ECR revealed no plan of care was developed for patient during the first benefit period 04/20/2023 to 07/18/2023. Patient #2 Review of patient #2s clinical record revealed patients hospice election date of 04/19/2023 with terminal diagnosis of chronic obstructive pulmonary disease (COPD) - Is a chronic inflammatory lung disease that causes obstructed airflow from the lungs. Review of patients ECR revealed that the agency provided hospice services to patient for two consecutive benefit periods from 04/19/2023 to 07/17/2023 and from 07/18/2023 to 10/13/2023. Review of the patients ECR showed initial comprehensive Nursing assessment of 04/19/2023, initial bereavement assessment dated 04/20/2023, and MSW initial assessment dated 04/21/2023. Review of the two benefit periods revealed no initial nor updated plans of care was developed for patient #2 during the entire benefit periods. Continued review of patient #2s ECR revealed that monthly MSW notes dated 05/22/23, 06/22/23, & 07/17/23. The review also revealed other weekly skilled nurses visit nots dated 04/26/23, 05/03/23, 05/20/23, 05/10/23, 05/17/23, 05/24/23, 05/31/23, 06/07/23, 06/14/23, 06/21/23, 06/28/23, 07/05/23, and 07/12/23. Review of the patient #2s ECR did not show documentation that the developed any plan of care for this patient for the entire 2 certification periods. Patient #4 Review of patient #4s clinical record revealed patients hospice election date was 04/18/2023 with terminal diagnosis of Cerebral infarct (commonly known as Stroke) - Is a medical condition that is caused by a disruption of blood flow to the brain due to problems with the blood vessels that supply it. A lack of adequate blood supply to brain cells deprives them of oxygen and other vital nutrients which can cause parts of the brain to die off. Review of patients ECR revealed patient received hospice services for two consecutive benefit periods from 04/18/2023 – 06/11/2023 and 06/12/2023 – 09/14/2023 with an initial comprehensive nursing assessment dated 04/18/2023 and two recertification assessment dated 05/29/2023(incomplete) and 09/07/2023. Review of patients ECR also showed patient received chaplain services with chaplains initial assessment dated 04/19/2023 with another visit on 05/19/2023.The review also showed that patient received MSW services with initial assess conducted on 04/21/2023. Review of patient #4s ECR revealed no plans of care for the entire service periods. During interview with the Alternate Director of Nursing (ADON) on 02/07/2024 at 2:30p.m. the Nurse stated that part of the reason for not developing plans was due to having too many things to take care of at the agency and as result she forgot to develop patients plans of care. The Alt. DON further stated that agency was cited with the issues as we were finding by an accreditation organization that came for their certification survey in January 2024. During interview with administrator on 02/12/2024 at 11:42 the administrator stated that he knows that they have not done well because the same deficiencies that surveyors are finding are exactly what the accreditation company found when they came to conduct a recertification at the agency in January 2024.

Based on record review and interview, the hospice IDG failed to review, revise and document in the individualized plan as frequently as patients condition required, but no less frequently than every 15 calendar days for 1 of 8 patients reviewed (#6) in that there was no indication that the patients initial POC was reviewed and updated by the IDG. This failure placed the patients at risk for negative outcome due to the IDG not reviewing patient care to promptly identify and address care problems to ensure symptoms control and comfort. --- Review of Patient #6s CR revealed hospice election date of 7/10/23 and terminal diagnosis of unspecified protein-calorie malnutrition. Review of benefit period 7/10/23 – 10/5/23 showed RN Initial Assessment dated 7/10/23, MSW assessment dated 7/12/23, Chaplain and bereavement assessments dated 7/13/23. Review of CR showed initial POC completed by ADON on 7/10/23. The POC revealed the only problem identified as imbalanced nutrition related to poor dietary intake. Services ordered included SN once weekly, and MSW once a month. Further review of the CR revealed subsequent POCs on 7/12/23, 7/26/23, 8/9/23, 8/23/23, 9/6/23, 9/20/23 & 10/4/23. Review of the POCs showed that the POCs were the same except for the dates, and the POCs were not signed by the MD. Review of visit notes showed the following notes: RN A visits on 7/20/23, 8/3/23, 8/10/23, 8/17/23, 8/24/23, 8/31/23, 9/7/23, 9/14/23, 9/21/23 & 9/28/23, and MSW visits on 8/11/23 & 9/12/23. During telephone interview with MSW on 2/9/24 at 8:49 am, she stated that identified psychosocial problems should be included in the POC. MSW was asked why patient #6s POCs did not include psychosocial issues even though she was making visits monthly to the patient. MSW stated that she was just making monthly visit to provide care to the patient, but she should have developed care plan for the patient. MSW added that going forward she knows what to do. During interview with ADON on 2/8/24 at 1:32 pm, she was asked if patient care issues were discussed during the IDG meetings. ADON stated that each patient care issues were discussed during IDG meetings. ADON was asked why patient #6s POCs looked similar apart from the dates and did not reflect any updates. ADON stated that there were probably no updates to be made to the POCs. ADON was asked why only one care problem was identified on the POCs. ADON stated that she did not know why only one care problem was identified on the POCs. ADON acknowledged that she completed the POCs. ADON also stated that she did not know why the MD did not sign the POCs. During telephone interview with MD on 2/9/24 at 3:59 pm, he was asked how he signed his orders. MD stated that he electronically signed orders/POCs. MD added that he also used handwritten signatures if documents were sent to him. MD acknowledged that he had access into the patients electronic CR. MD was asked why patient #6s POCs were not signed. MD stated that the issue of documents not being signed was one of the problems identified during the hospice survey in January 2024. MD stated that they have developed plan to correct the deficient practices identified. MD stated that these deficient practices were unacceptable, and they were working towards correcting the problems. During interview with Adm/DON on 2/9/24 at 1:38 pm, he was asked why POCs were not signed by the MD. Adm/DON stated that the issue of the doctor not signing documents was one of the issues already identified during the hospice survey in January 2024, and they were in the process of correcting the deficiencies. Adm/DON acknowledged that he was responsible for making sure that CR were completed and signed by clinicians. Review of agencys undated policy titled ";Interdisciplinary Group (IDG)", read in part: ";The IDG members will meet every, at a minimum, every fifteen (15) days to review and update the written POC for each patient." ";The POC (Initial, comprehensive and all updates to the POC) will be filed in the clinical record."

Based on record review and interview, the administrator failed in the responsibility of running the day-to-day operation of the hospice for 8 of 8 patients reviewed (#1 - #8) in that: Administrator did not ensure proper delineation of roles of the Supervising Nurse and Alternate Supervising Nurse Administrator did not make sure that initial RN assessment was completed for discharged patient #3 & #5. Administrator did not make sure that IDG assessments and updates were completed for discharged patients #1 - #8. Administrator did not ensure Initial POC, IDG POC and POC updates were completed for discharged patients #1 - #8. These failures resulted in poor oversight of the hospice program and placed the patients at risk for negative outcome due care delay, care omission or inadequate care being provided to the patients.

Based on record review and interview, the administrator failed in the responsibility of running the day-to-day operation of the hospice for 8 of 8 discharged patients reviewed (#1 - #8) in that: Administrator did not ensure proper delineation of roles of the Supervising Nurse and Alternate Supervising Nurse Administrator did not make sure that initial RN assessment was completed for patient #3 & #5. Administrator did not make sure that IDG assessments and updates were completed for patients #1 - #8. Administrator did not ensure Initial POC, IDG POC and POC updates were completed for patients #1 - #8. These failures resulted in poor oversight of the hospice program and placed the patients at risk for negative outcome due care delay, care omission or inadequate care being provided to the patients. --- Delineation of Roles Review of TULIP (a database utilized by the state to maintain licensing, demographic information, complaints, and self-reported incidents on home health and hospice agencies for the State of Texas) during pre-survey activities revealed Adm/DON listed as the Administrator and Supervising Nurse of the hospice. ADON was listed as the Alternate Supervising Nurse of the hospice. During entrance conference with Adm/DON and Alt Adm on 2/7/24 at 10:12 am, Adm/DON stated that the hospice had a recertification survey in January 2024 and ADON was appointed the DON after the survey. Adm/DON stated that RN CM was the Supervising Nurse before the survey and RN CM was terminated after the survey due to the extent of the deficiencies found. Review of RN CM PR revealed that the nurse applied and was hired for the position of RN Case Manager on 11/10/20. The PR also showed that the staff signed the job description as RN CM. There was no documentation in the PR that the staff was designated as the DON of the agency. During interview with Adm/DON and Alt Adm on 2/12/24 at 10:48 am, Adm/DON was asked why he claimed that RN CM was the DON when the nurse was only hired as a Case Manager. Adm/DON stated that the role of a CM was the same as the DON. The staffs were asked if they realize that the CM was responsible for coordinating the care of patients assigned to her, while the DON was responsible for directing and coordinating the entire clinical aspects of the hospice. Adm/DON stated that they did not know that the roles had different functions. Alt Adm stated that they thought the roles were the same. Adm/DON acknowledged that since he was listed as the Supervising Nurse on TULIP, he was responsible for clinical oversight of the hospice. Initial RN Assessment Review of Patient #5's CR revealed hospice election date of 7/17/23. Review of RN Initial Assessment on the electronic CR showed that the assessment only contained the date of 7/17/23, time of 7/17/23 and 4:00 pm – 5:00 pm, and treatment preference. The document did not reveal assessment of the patient to include vital signs, pain assessment, physical and cognitive ability, mental status, integument (skin), respiratory, cardiovascular, digestive, genitourinary, fall assessment, and review of medications. The document was signed by RN B. During interview with ADON on 2\7\24 at 12:48 pm, ADON stated that she did not know why initial assessment was not completed for the patient. ADON added that RN CM was the DON at the time the patient was admitted. During telephone interview with RN B on 2/9/24 at 9:55 am, she was asked why patient #5s initial assessment was not completed. RN B stated that she was only assigned the weekly visits for the patient. RN B added that she was not working for the agency as at the date patient #5 was admitted. RN B explained that she applied to the agency on 7/26/23 and her first day at the agency was 7/31/23. Patient #3 Review of Patient #3's clinical record revealed that patient elected for hospice services on 10/03/2022. Review of patients electronic clinical record revealed an uncompleted initial assessment document that was conducted and signed by ADON on 10/03/2022. The document revealed that ADON did not assessed patient #3s pain level, functional limitations, Sensory limitations, psychological status, Neurological status, Braden scale for predicting pressure sore risk, Respiratory status, Cardiovascular status, Digestive/Nutritional and fluid intake screening, Genito-Urinary system status, fall assessment, patients need for durable medical equipment, and review of medications. During interview with Adm/DON on 2/9/24 at 1:38 pm, he was asked why RN initial assessment was not completed for patient #5. Adm/DON stated that assessment not being completed for the patients was one of the issues already identified during the hospice survey in January 2024, and they were in the process of correcting the deficiencies. Adm/DON added that they were working towards correcting the deficiencies identified during the last survey. IDG Assessments and POC Patient #1 Review of patient #1s clinical record revealed patient elected for hospice services on 04/20/2023 with terminal diagnosis of chronic congestive heart failure (Is a long-term medical condition that results when a persons heart cannot pump blood well enough to give the body a normal supply. This usually cause blood and fluids collect in a persons lungs and legs over time). Review of patients electronic clinical record (ECR) showed the initial comprehensive nursing assessment dated 04/20/2023 and incomplete recertification assessment dated 07/14/2023. The medical social worker (MSW) initial assessment done 04/22/2023 and subsequent msw monthly assessments were conducted on 05/17/2023, 06/16/2023 and 07/17/2023, and the chaplain initial bereavement assessment dated 04/22/2023. Review of patient #1s ECR for the benefit period 04/20/2023 to 07/18/2023 had no record of hospice agencys interdisciplinary group meetings (IDG) during the entire benefit period to review and update patient #1s healths condition and only one plan of care dated 07/12/2023 that was unsigned by the physician. Review of patient #1s clinical records also revealed weekly skilled nursing notes dated 04/27/23, 05/04/23, 05/11/23, 05/18/23, 05/25/23, 06/01/23, 06/08/23, 06/15/23, 06/22/23, 06/29/23, 07/06/23, & 07/13/23 that were conducted by ADON and LVN. Review of patients #1s ECR revealed no plan of care was developed for patient during the first benefit period 04/20/2023 to 07/18/2023. Patient #2 Review of patient #2s clinical record revealed patients hospice election date of 04/19/2023 with terminal diagnosis of chronic obstructive pulmonary disease (COPD). Review of patients ECR revealed that the agency provided hospice services to patient for two consecutive benefit periods from 04/19/2023 to 07/17/2023 and from 07/18/2023 to 10/13/2023. Review of the patients ECR showed initial comprehensive Nursing assessment of 04/19/2023, initial bereavement assessment dated 04/20/2023, and MSW initial assessment dated 04/21/2023. Further review of the patient #2s ECR showed no record of agencys IDG meetings for the entire 2 benefits to assess patients/caregivers needs and update the services patient was receiving. Review of the two benefit periods revealed no initial nor updated plans of care was developed for patient #2 during the entire benefit periods. Continued review of patient #2s ECR revealed that monthly MSW notes dated 05/22/23, 06/22/23, & 07/17/23. The review also revealed other weekly skilled nurses visit nots dated 04/26/23, 05/03/23, 05/20/23, 05/10/23, 05/17/23, 05/24/23, 05/31/23, 06/07/23, 06/14/23, 06/21/23, 06/28/23, 07/05/23, and 07/12/23. Review of the patient #2s ECR did not show the developed any plan of care for this patient for the entire 2 certification periods. Patient #3 Review of patient #3s clinical records revealed patient elected for hospice service on 10/03/2022 with terminal diagnoses of HIV-AIDS (HIV -human immunodeficiency virus is a virus that attacks the bodys immune system. If HIV is not treated, it can lead to AIDS -acquired immunodeficiency syndrome), Hepatitis C (Is a viral infection that causes inflammation of the liver. Hepatitis C can lead to serious liver damage), disseminated histoplasmosis encapsulate (Is a recurrent life-threatening fungal infection that can quickly spread in a persons body due to the bodys inability to fight of the infection. This disease usually seen in patient with compromised immune system like HIV-AIDS patients or patient suffering from other immunodeficient diseases.), and Toxoplasmosis (This is an infection caused by a single-celled parasite called Toxoplasma gondii). Review of the patients ECR showed that patient received hospice services for three consecutive benefit periods from 10/03/2022 to 12/31/2022, 01/01/2023 – 03/31/2023, and 04/01/2023 to 05/30/2023. Review of patients ECR during these benefit periods revealed a complete initial comprehensive nursing assessment dated 10/03/2023 with two incomplete recertification assessments dated 12/12/2022, and 03/20/2023. Patient #3s ECR review also revealed patient received msw and chaplain services. Further review of the patient #3s ECR showed no record of agencys IDG meetings for the entire 3 benefits to assess patients/caregivers needs and update the services patient was receiving. Patient #4 Review of patient #4s clinical record revealed patients hospice election date of 04/18/2023 with terminal diagnosis of Cerebral infarct (Is a medical condition that is caused by a disruption of blood flow to the brain due to problems with the blood vessels that supply it. A lack of adequate blood supply to brain cells deprives them of oxygen and other vital nutrients which can cause parts of the brain to die off). Review of patients ECR revealed patient received hospice services for two consecutive benefit periods from 04/18/2023 – 06/11/2023 and 06/12/2023 – 09/14/2023 with an initial comprehensive nursing assessment dated 04/18/2023 and two recertification assessment dated 05/29/2023(incomplete) and 09/07/2023. Review of patients ECR also showed that patient chaplain services with initial assessment dated 04/19/2023 with another visit on 05/19/2023 as well as MSW services with initial assess conducted on 04/21/2023. Review of patient #4s ECR revealed no IDG notes for the entire service periods. Review of patients ECR also showed patient received chaplain services with chaplains initial assessment dated 04/19/2023 with another visit on 05/19/2023.The review also showed that patient received MSW services with initial assess conducted on 04/21/2023. Review of patient #4s ECR revealed no plans of care for the entire service periods. Patient #5 Review of Patient #5's CR revealed hospice election date of 7/17/23 and terminal diagnosis of malignant neoplasm (cancer) of unspecified site of unspecified female breast. Review of benefit period 7/17/23 – 10/14/23 showed an incomplete RN Initial Assessment dated 7/17/23, MSW assessment dated 7/17/23, Chaplain and bereavement assessments dated 7/20/23. Further review of the CR showed that there was no IDG assessment and updates for the period. Review of the CR showed that POCs were not developed for the episode. Review of visit notes showed the following notes: RN B visits on 8/9/23, 8/23/23, 9/6/23, 9/20/23 & 10/4/23, LVN visits on 8/2/23, 8/16/23, 8/30/23, 9/23/23 & 9/27/23, and MSW visits on 8/18/23 & 9/18/23. Patient #6 Review of Patient #6s CR revealed hospice election date of 7/10/23 and terminal diagnosis of unspecified protein-calorie malnutrition. Review of benefit period 7/10/23 – 10/5/23 showed RN Initial Assessment dated 7/10/23, MSW assessment dated 7/12/23, Chaplain and bereavement assessments dated 7/13/23. Further review of the CR showed that there was no IDG assessment and updates for the period. Review of CR showed initial POC completed by ADON on 7/10/23. The POC revealed the only problem identified as imbalanced nutrition related to poor dietary intake. Services ordered included SN once weekly, and MSW once a month. Further review of the CR revealed subsequent POCs on 7/12/23, 7/26/23, 8/9/23, 8/23/23, 9/6/23, 9/20/23 & 10/4/23. Review of the POCs showed that the POCs were the same except for the dates, and the POCs were not signed by the MD. Review of visit notes showed the following notes: RN A visits on 7/20/23, 8/3/23, 8/10/23, 8/17/23, 8/24/23, 8/31/23, 9/7/23, 9/14/23, 9/21/23 & 9/28/23, and MSW visits on 8/11/23 & 9/12/23. Patient #7 Review of Patient #7s CR revealed hospice election date of 4/20/23 and terminal diagnosis of chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs). Review of benefit period 4/20/23 – 7/18/23 showed RN Initial Assessment dated 7/10/23, and MSW, Chaplain and bereavement assessments dated 4/24/23. Further review of the CR showed that there was no IDG assessment and updates for the period. Review of the CR showed that POC was not developed for the episode. Further review of the benefit period 4/20/23 – 7/18/23 showed the following visit notes: ADON visits on 4/28/23, 5/11/23, 6/22/23 & 7/14/23, LVN visits on 4/21/23, 5/4/23, 6/15/23, 6/29/23 & 7/6/23, and MSW visits on 5/23/23 & 6/23/23. Patient #8 Review of Patient #8s CR revealed hospice election date of 4/20/23 and terminal diagnosis of senile degeneration of the brain (a decrease in the ability to think, concentrate, or remember). Review of benefit period 4/20/23 – 7/18/23 showed RN Initial Assessment dated 4/20/23, MSW assessment dated 4/21/23, Chaplain and bereavement assessments dated 4/22/23. Further review of the CR showed that there was no IDG assessment and updates for the period. Review of the CR showed an incomplete POC dated 4/20/23 and signed by ADON. The POC did not include care issues including care problems identified, frequencies of services to be provided and medications the patient was using. There was no other POC for the episode. Patient #8 was discharged on 7/18/23. Review of visit notes showed the following notes: ADON visits on 4/28/23, 5/4/23, 5/11/23, 5/18/23, 5/25/23, 6/1/23, 6/8/23, 6/15/23, 6/22/23, 6/29/23, 7/6/23 & 7/13/23, and MSW visits on 5/19/23 & 6/16/23. During interview with Adm/DON on 2/9/24 at 1:38 pm, he was asked why there were no IDG notes and POCs in the patients CR. Adm/DON stated that IDG notes and POCs not being completed for the patients was one of the issues already identified during the hospice survey in January 2024, and they were in the process of correcting the deficiencies. Adm/DON added that RN CM was the former DON responsible for making sure that IDG notes and POCs were completed, and the staff failed to ensure that was done. Adm/DON stated that RN CM was terminated in January after the survey. Adm/DON acknowledged that he was responsible for making sure care provided were properly documented. Review of agencys undated policy titled ";Administrator / Alternate Administrator", read in part: ";The hospice administrator will be responsible for: ";7. operations which include: a. Managing, organizing and directing the ongoing operations, functions, structure and systems to assure the availability and provision of interdisciplinary care and services." ";15. Services as related to: c. Ensuring delivery of comprehensive care by: Ensuring interdisciplinary quality care is provided."

Based on record review and interview, the MD failed to review the clinical information for each hospice patient and provide written certification that it is anticipated that the patients life expectancy is 6 months or less if the illness runs its normal course for 3 of 8 patients reviewed (#3, #5 & #7) in that there was no documentation of the clinical information reviewed by the MD to determine that the patients were terminally ill. This failure placed the patients at risk for negative outcome due to the patient receiving care that was not needed and could be potentially harmful to their health. Refer to L0667 Based on record review and interview, the MD failed in the responsibility for the medical component of the hospices patient care program for 8 of 8 patients reviewed (#1 - #8) in that the MD did not provide medical oversight to ensure that: IDG assessments and updates were completed for patients #1 - #8 Initial POC and IDG POC and POC updates were not completed for patients #1 - #8 This failure placed the patients at risk for negative outcome due lack of medical oversight resulting in patients not receiving appropriate and adequate care, or receiving care that was unnecessary and/or dangerous to their health. Refer to L0669

Based on record review and interview, the MD failed to review the clinical information for each hospice patient to provide written certification that it is anticipated that the patients life expectancy is 6 months or less if the illness runs its normal course for 3 of 8 patients reviewed (#3,#5 & #7) in that there was no documentation of the clinical information reviewed by the MD to determine that the patients were terminally ill. This failure placed the patients at risk for negative outcome due to the patient receiving care that was not needed and could be potentially harmful to their health. --- Patient #5 Review of patient #5s CR showed SOC on 7/17/23. Review of the written certification dated 7/17/23 for the benefit period 7/17/23 – 10/14/23 and signed by the MD revealed that the MD documented that he reviewed patient #5s clinical circumstances and obtained the medical information to provide the clinical justification for certification for hospice services. Further review of the written certification showed an attestation by the MD his decision was based on review of the patients CR and/or examination of the patient. Review of RN Initial Assessment on the electronic CR showed that the assessment only contained the date of 7/17/23 and time from 4:00 pm – 5:00 pm, terminal diagnosis and treatment preference. The document did not reveal assessment of the patient to include vital signs, pain assessment, physical and cognitive ability, mental status, neurological status, integument, respiratory, cardiovascular, digestive, genitourinary, fall assessment, and review of medications. The document was signed by RN B. During telephone interview with RN B on 2/9/24 at 9:55 am, she stated that she was only assigned the weekly visits for the patient. RN B added that she was not working for the agency as at the date patient #5 was admitted. RN B explained that she applied to the agency on 7/26/23 and her first day at the agency was 7/31/23. Patient #7 Review of patient #7s CR showed SOC on 7/17/23. Review of the written certification dated 7/13/23 for the benefit period 7/19/23 – 10/16/23 and signed by the MD revealed that the MD documented that he reviewed patient #5s clinical circumstances and obtained the medical information to provide the clinical justification for certification for hospice services. Further review of the written certification showed an attestation by the MD his decision was based on review of the patients CR and/or examination of the patient. Review of CR showed initial RN comprehensive assessment was completed on 4/20/23 and initial MSW, Chaplain and bereavement assessments were completed on 4/24/23. The CR did not include IDG comprehensive assessment updates. Review of RN recertification assessment on the electronic CR showed that the assessment only contained the date of 7/14/23, and time from 8:00 am – 9:00 am, and terminal diagnosis of chronic obstructive pulmonary disease. The document did not reveal assessment of the patient to include treatment preference, vital signs, pain assessment, physical and cognitive ability, mental status, neurological status, integument, respiratory, cardiovascular, digestive, genitourinary, fall assessment, and review of medications. The document was signed by ADON. During telephone interview with MD on 2/9/24 at 3:59 pm, he was asked what CR he reviewed to determine that the patients were terminally ill. MD stated that his decision was based on the clinical information provided by the nurses about the patients such diagnoses, PPS (a validated and reliable tool used to assess a patients functional performance and to determine progression towards end of life), FAST (a tool frequently used to evaluate the active status of dementia in patients). and pain. DM was asked if he reviewed any documentation the patients medical conditions since no assessments were on record for the patients. MD stated that he did not review any CR of the patients. MD acknowledged that his decisions were based solely on verbal information given by the clinicians during IDGs. MD stated that the IDG team meetings were held every other Wednesday via zoom. MD further stated that he did not refer any of the patient to the agency, and he had never been the PCP any of the hospice patients. During interview with Adm/DON and Alt Adm on 2/12/24 at 10:48 am, he was asked why MD certified patients as terminally ill when the patients assessments were not done. Adm/DON stated that all the deficient practices that surveyors found had been identified during their recertification in January and they were in the process of correcting the deficient practices. Adm/DON acknowledged that he had not been providing the proper oversight of the hospice. Review of agencys undated policy titled ";Certification of Terminal Illness", read in part: ";A. The hospice will provide all patient information related to the eligibility assessment to the hospice MD." ";B. The physician(s) will reach a decision to certify, or not certify, the patient is terminally ill. The factors to be considered are: terminal diagnosis, secondary conditions, if any, comorbidities and medical management, current subjective and objective medical findings, current medication and treatment orders." Review of agencys undated policy titled ";Medical Director and Physician Services", read in part: ";The MD or physician designee: Reviews the clinical information for each hospice patient and provides written certification that it is anticipated that the patients 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 diagnoses; current subjective and objective medical findings; current medication and treatment orders; and information about the medical management of any of the patients conditions unrelated to the terminal illness." Patient #3 Review of Patient #3's clinical record revealed that patient elected for hospice services on 10/03/2022. Review of patients electronic clinical record revealed an uncompleted initial assessment document that was conducted and signed by ADON on 10/03/2022. The document revealed that ADON did not assessed patient #3s pain level, functional limitations, Sensory limitations, psychological status, Neurological status, Braden scale for predicting pressure sore risk, Respiratory status, Cardiovascular status, Digestive/Nutritional and fluid intake screening, Genito-Urinary system status, fall assessment, patients need for durable medical equipment, and review of medications. Review of patients written certification of terminal illness for certification period 10/03/2022 – 12/31/2022 signed and dated 10/03/2022 by MD reads in part, ";I certify that patient #3 is terminally ill with a life expectancy of six months or less if the terminal illness runs its normal course...Review the individuals clinical circumstances and obtained the medical information to provide the clinical justification for certification to hospice services..." Further review of the written certification revealed and attestation that reads: ";I confirm that I composed this narrative based on my review of the patients medical record and/or examination of the patient..."

Based on record review and interview, the MD failed in the responsibility for the medical component of the hospices patient care program for 8 of 8 patients reviewed (#1 - #8) in that the MD did not provide medical oversight to ensure that: IDG assessments and updates were completed for patients #1 - #8 Initial POC and IDG POC and POC updates were not completed for patients #1 - #8 This failure placed the patients at risk for negative outcome due lack of medical oversight resulting in patients not receiving appropriate and adequate care, or receiving care that was unnecessary and/or dangerous to their health. --- Patient #5 Review of Patient #5's CR revealed hospice election date of 7/17/23 and terminal diagnosis of malignant neoplasm of unspecified site of unspecified female breast. Review of benefit period 7/17/23 – 10/14/23 showed an incomplete RN Initial Assessment dated 7/17/23, MSW assessment dated 7/17/23, Chaplain and bereavement assessments dated 7/20/23. Further review of the CR showed that there was no IDG assessment and updates for the period. Review of the CR showed that POC was not developed for the episode. Review of visit notes showed the following notes: RN B visits on 8/9/23, 8/23/23, 9/6/23, 9/20/23 & 10/4/23, LVN visits on 8/2/23, 8/16/23, 8/30/23, 9/23/23 & 9/27/23, and MSW visits on 8/18/23 & 9/18/23. Patient #6 Review of Patient #6s CR revealed hospice election date of 7/10/23 and terminal diagnosis of unspecified protein-calorie malnutrition. Review of benefit period 7/10/23 – 10/5/23 showed RN Initial Assessment dated 7/10/23, MSW assessment dated 7/12/23, Chaplain and bereavement assessments dated 7/13/23. Further review of the CR showed that there was no IDG assessment and updates for the period. Patient #7 Review of Patient #7s CR revealed hospice election date of 4/20/23 and terminal diagnosis of chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs). Review of benefit period 4/20/23 – 7/18/23 showed RN Initial Assessment dated 7/10/23, and MSW, Chaplain and bereavement assessments dated 4/24/23. Further review of the CR showed that there was no IDG assessment and updates for the period. Review of the CR showed that POC was not developed for the episode. Further review of the benefit period 4/20/23 – 7/18/23 showed the following visit notes: ADON visits on 4/28/23, 5/11/23, 6/22/23 & 7/14/23, LVN visits on 4/21/23, 5/4/23, 6/15/23, 6/29/23 & 7/6/23, and MSW visits on 5/23/23 & 6/23/23. Review of visit notes showed the following notes: ADON visits on 7/20/23, 7/27/23, 8/3/23, 8/10/23, 8/17/23, 8/24/23, 8/31/23, 9/7/23, 9/14/23, 9/21/23, & 9/28/23, and MSW visits 7/21/23, 8/21/23 & 9/21/23. Patient #8 Review of Patient #8s CR revealed hospice election date of 4/20/23 and terminal diagnosis of senile degeneration of the brain (a decrease in the ability to think, concentrate, or remember). Review of benefit period 4/20/23 – 7/18/23 showed RN Initial Assessment dated 4/20/23, MSW assessment dated 4/21/23, Chaplain and bereavement assessments dated 4/22/23. Further review of the CR showed that there was no IDG assessment and updates for the period. Review of the CR showed an incomplete POC dated 4/20/23 and signed by ADON. The POC did not include care issues including care problems identified, frequencies of services to be provided and medications the patient was using. There was no other POC for the episode. Patient #8 was discharged on 7/18/23. Review of visit notes showed the following notes: ADON visits on 4/28/23, 5/4/23, 5/11/23, 5/18/23, 5/25/23, 6/1/23, 6/8/23, 6/15/23, 6/22/23, 6/29/23, 7/6/23 & 7/13/23, and MSW visits on 5/19/23 & 6/16/23. During interview with Adm/DON on 2/9/24 at 1:38 pm, he was asked why there were no IDG notes and POCs in the patients CR. Adm/DON stated that IDG notes and POCs not being completed for the patients was one of the issues already identified during the hospice survey in January 2024, and they were in the process of correcting the deficiencies. Adm/DON added that RN CM was the former DON responsible for making sure that IDG notes and POCs were completed, and the staff failed to ensure that was done. Adm/DON stated that RN CM was terminated in January after the survey. Adm/DON acknowledged that he was responsible for making sure care provided were properly documented. During telephone interview with MD on 2/9/24 at 3:59 pm, he stated that the IDG meetings were held via zoom every other Wednesday. MD was asked why there were no POCs and IDG notes in the patients CR. MD stated IDG POCs and assessment updates not being completed were problems identified during the hospice survey in January 2024. MD stated that they have developed plan to correct the deficient practices identified. MD stated that these deficient practices were unacceptable, and they were working towards correcting the problems. MD acknowledged that he was responsible for providing medical oversight for the hospice services provided to the patients. Review of agencys undated policy titled ";Medical Director and Physician Services", read in part: ";The MD or physician designee: Has the responsibility for the medical component of the hospices patient care program. Collaborating with IDG to ensure the medical needs of the patient are met and providing oversight of the POC." Patient#1 Review of patient #1s clinical record revealed patient elected for hospice services on 04/20/2023 with terminal diagnosis of chronic congestive heart failure (Is a long-term medical condition that results when a persons heart cannot pump blood well enough to give the body a normal supply. This usually cause blood and fluids collect in a persons lungs and legs over time). Review of patients electronic clinical record (ECR) showed the initial comprehensive nursing assessment dated 04/20/2023 and incomplete recertification assessment dated 07/14/2023. The MSW initial assessment done 04/22/2023 and subsequent MSW monthly assessments were conducted on 05/17/2023, 06/16/2023 and 07/17/2023, and the chaplain initial bereavement assessment dated 04/22/2023. Review of patient #1s ECR for the benefit period 04/20/2023 to 07/18/2023 had no record of hospice agencys interdisciplinary group meetings (IDG) during the entire benefit period to review and update patient #1s healths condition and only one plan of care dated 07/12/2023 that was unsigned by the physician. Review of patient #1s clinical records also revealed weekly skilled nursing notes dated 04/27/23, 05/04/23, 05/11/23, 05/18/23, 05/25/23, 06/01/23, 06/08/23, 06/15/23, 06/22/23, 06/29/23, 07/06/23, & 07/13/23 that were conducted by ADON and LVN. Review of patients #1s ECR revealed no plan of care was developed for patient during the first benefit period 04/20/2023 to 07/18/2023. Patient #2 Review of patient #2s clinical record revealed patients hospice election date of 04/19/2023 with terminal diagnosis of chronic obstructive pulmonary disease (COPD) - Is a chronic inflammatory lung disease that causes obstructed airflow from the lungs. Review of patients ECR revealed that the agency provided hospice services to patient for two consecutive benefit periods from 04/19/2023 to 07/17/2023 and from 07/18/2023 to 10/13/2023. Review of the patients ECR showed initial comprehensive Nursing assessment of 04/19/2023, initial bereavement assessment dated 04/20/2023, and MSW initial assessment dated 04/21/2023. Further review of the patient #2s ECR showed no record of agencys IDG meetings for the entire 2 benefits to assess patients/caregivers needs and update the services patient was receiving. Review of the two benefit periods revealed no initial nor updated plans of care was developed for patient #2 during the entire benefit periods. Continued review of patient #2s ECR revealed that monthly MSW notes dated 05/22/23, 06/22/23, & 07/17/23. The review also revealed other weekly skilled nurses visit nots dated 04/26/23, 05/03/23, 05/20/23, 05/10/23, 05/17/23, 05/24/23, 05/31/23, 06/07/23, 06/14/23, 06/21/23, 06/28/23, 07/05/23, and 07/12/23. Review of the patient #2s ECR did not show the developed any plan of care for this patient for the entire 2 certification periods. Patient #3 Review of patient #3s clinical records revealed patient elected for hospice service on 10/03/2022 with terminal diagnoses of HIV-AIDS (HIV -human immunodeficiency virus is a virus that attacks the bodys immune system. If HIV is not treated, it can lead to AIDS -acquired immunodeficiency syndrome), Hepatitis C (Is a viral infection that causes inflammation of the liver. Hepatitis C can lead to serious liver damage), disseminated histoplasmosis encapsulate (Is a recurrent life-threatening fungal infection that can quickly spread in a persons body due to the bodys inability to fight of the infection. This disease usually seen in patient with compromised immune system like HIV-AIDS patients or patient suffering from other immunodeficient diseases.), and Toxoplasmosis (This is an infection caused by a single-celled parasite called Toxoplasma gondii). Review of the patients ECR showed that patient received hospice services for three consecutive benefit periods from 10/03/2022 to 12/31/2022, 01/01/2023 – 03/31/2023, and 04/01/2023 to 05/30/2023. Review of patients ECR during these benefit periods revealed a complete initial comprehensive nursing assessment dated 10/03/2023 with two incomplete recertification assessments dated 12/12/2022, and 03/20/2023. Patient #3s ECR review also revealed patient received MSW and chaplain services. Further review of the patient #3s ECR showed no record of agencys IDG meetings for the entire 3 benefits to assess patients/caregivers needs and update the services patient was receiving. Patient #4 Review of patient #4s clinical record revealed patients hospice election date of 04/18/2023 with terminal diagnosis of Cerebral infarct. Review of patients ECR revealed patient received hospice services for two consecutive benefit periods from 04/18/2023 – 06/11/2023 and 06/12/2023 – 09/14/2023 with an initial comprehensive nursing assessment dated 04/18/2023 and two recertification assessment dated 05/29/2023(incomplete) and 09/07/2023. Review of patients ECR also showed that patient chaplain services with initial assessment dated 04/19/2023 with another visit on 05/19/2023 as well as MSW services with initial assess conducted on 04/21/2023. Review of patient #4s ECR revealed no IDG notes for the entire service periods. Review of patients ECR also showed patient received chaplain services with chaplains initial assessment dated 04/19/2023 with another visit on 05/19/2023.The review also showed that patient received MSW services with initial assess conducted on 04/21/2023. Review of patient #4s ECR revealed no plans of care for the entire service periods.

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 demonstration of staff knowledge of emergency procedures and EP training of all hospice employees and individuals providing services under arrangement at least every two (2) years. This standard was not met as evidenced by clinical record review, document review, interview and observation. THIS IS A CONTINUING REQUIRED ACTION This standard was not met as evidenced by review of the agency's action plan during this site visit on 02/08/2024 which revealed the agency did not implement the action plan items that were described in their plan of correction with an effective implementation date of 2/26/2024. Previous Evidence: In 3 of 3 (100%) personnel records reviewed, the agency did not ensure employees received emergency preparedness (EP) training every two (2) years and could demonstrate knowledge of emergency procedures. Personnel Record 2: The Hospice Aide documented the completion of the emergency preparedness (EP) training upon hire on 11/15/21. A personnel record review revealed no documented evidence that the Hospice Aide completed EP training in 2023. During an interview and the home visit observed on 1/19/24, the Hospice Aide reported the patient's water was frozen from the recent extreme temperatures in the area, and she did not know what to do in this situation or other emergencies. Personnel Record 5: The Medical Director documented the completion of the EP training upon hire on 8/10/20. A personnel record review revealed no documented evidence that the Medical Director completed EP training in 2022. Personnel Record 6: The Director of Nursing (DON) documented the completion of the EP training upon hire on 11/10/2020. A personnel record review revealed no documented evidence that the DON completed EP training in 2022. On 1/17/24, a joint personnel record review and interview were conducted with the Director of Nursing (DON), who verified the personnel records did not contain documentation of completed EP training of staff at least every two years. The DON stated she would obtain the documentation of completed EP staff training every two years from an electronic file; however, original documentation of staff completion of EP training was not presented before the exit conference.

The hospice registered nurse must complete an initial assessment within 48 hours after the election of hospice care in accordance with 418.24 is complete (unless the physician, patient, or representative requests that the initial assessment be completed in less than 48 hours. THIS IS A CONTINUING REQUIRED ACTION This standard was not met as evidenced by review of the agency's action plan during this site visit on 02/08/2024 which revealed the agency did not implement the action plan items that were described in their plan of correction with an effective implementation date of 2/26/2024. Previous Evidence: This standard was not met as evidenced by clinical record review and personnel record review. 2 of 11 (18%) clinical records reviewed revealed that the agency did not ensure the hospice Registered Nurse (RN) completed and documented an initial assessment within 48 hours of the patient electing hospice care. Clinical Record 6: An initial nursing visit was completed on 10/3/22. The documentation did not include evidence that an initial assessment, including an assessment of pain, functional status, sleep/rest pattern, fall risk, and body systems including integumentary, respiratory, cardiovascular, digestive, nutrition, and genitourinary, was provided. Clinical Record 14: The patient elected the hospice benefit on 9/27/23, and an initial nursing assessment was completed on 9/27/23. The patient elected the hospice benefit on 10/3/22, and an initial nursing assessment was completed on 10/3/22. An initial nursing visit was completed on 9/27/23. The documentation did not include evidence that an initial assessment, including an assessment of pain, functional status, sleep/rest pattern, fall risk, and body systems including integumentary, respiratory, cardiovascular, digestive, nutrition, and genitourinary, was provided. On 1/19/24 joint record reviews and interviews were conducted with the Director of Nursing (DON), who confirmed that the clinical records identified did not contain documentation of an assessment completed by the RN within 48 hours of the patient electing hospice care.

It is required that the patient’s pain is assessed as part of a comprehensive assessment. Assessment of pain in children and adolescents is conducted with consideration of age and neurocognitive development. The documented assessment of the patient’s pain includes a history of pain and its treatment, both pharmacological and non-pharmacological, use of a standardized pain assessment tool appropriate to the patient’s developmental and cognitive status, characteristics of the pain, including location, frequency, and intensity, how pain impacts the patient’s ability to engage in usual activities and function (e.g., appetite, sleeping), and the patient’s/family’s goals for pain management and their satisfaction with the current level of pain control. THIS IS A CONTINUING REQUIRED ACTION This standard was not met as evidenced by review of the agency's action plan during this site visit on 02/08/2024 which revealed the agency did not implement the action plan items that were described in their plan of correction with an effective implementation date of 2/07/2024. Previous Evidence: This standard was not met as evidenced by clinical record review and interview. 6 of 11 (55%) clinical records reviewed revealed that the agency did not ensure a pain assessment, using a standardized pain assessment tool and including characteristics, impact, and goals for management, was a part of each comprehensive assessment. Clinical Record 3: The patient elected the hospice benefit on 11/6/23. The initial nursing assessment completed on 11/6/23 documented that the patient’s caregiver reported the patient was having low back pain, and it was documented that the caregiver rated the pain a seven (7) out of ten (10). The clinical record did not contain documentation of a comprehensive pain assessment, using a pain assessment tool appropriate for the patient’s documented cognitive status, that included the patient’s history of pain and treatment. Clinical Record 4: The patient elected hospice care on 6/22/23 with a diagnosis of COPD. The initial comprehensive assessment documented the patient's reported chest pain with shortness of breath. The comprehensive assessment (9/14/23), used specifically to consider the ongoing nature and condition of the patient and to identify the continued need for hospice services, did not include documentation of a comprehensive pain assessment. Clinical Record 6: The patient elected hospice on 10/3/22. The initial nursing visit completed on 10/3/22 provided documentation of all Hospice Item Set (HIS) questions, including confirmation of evaluation of the patient’s pain. The comprehensive assessment did not include documentation of the patient’s history of pain and treatment, pain assessment tool used, and characteristics of pain including location, frequency, intensity, impact of pain on activity and function, and the patient’s and family’s goal for pain management and current satisfaction with pain management. Clinical Record 10: The patient elected hospice care on 7/24/23 with a diagnosis of COPD. The initial comprehensive assessment documented the patient's reported pain score of one (1) out of ten (10) and the use of Tylenol. The comprehensive assessment (10/16/23), used specifically to consider the ongoing nature and condition of the patient and to identify the continued need for hospice services, did not include documentation of a comprehensive pain assessment. Clinical Record 11: The patient elected hospice on 7/24/23. The initial nursing visit completed on 7/24/23 provided documentation of all Hospice Item Set (HIS) questions, including confirmation that a comprehensive pain assessment was performed. A review of the nursing assessment revealed that it did not include documentation of the patient’s history of pain and treatment, pain assessment tool used, and characteristics of pain including location, frequency, intensity, impact of pain on activity and function, and the patient’s and family’s goal for pain management and current satisfaction with pain management. Clinical Record 14: The patient elected hospice on 9/27/23. The initial nursing visit completed on 9/27/23 provided documentation of all Hospice Item Set (HIS) questions, including confirmation that a comprehensive pain assessment was performed. A review of the nursing assessment revealed that it did not include documentation of the patient’s history of pain and treatment, pain assessment tool used, and characteristics of pain including location, frequency, intensity, impact of pain on activity and function, and the patient’s and family’s goal for pain management and current satisfaction with pain management. On 1/19/24 joint record reviews and interviews were conducted with the Director of Nursing (DON) who confirmed that the identified medical records and comprehensive assessment did not include documentation of a pain assessment utilizing a standardized pain assessment tool and addressing the history, treatment, characteristics, impact, and patient and family goals for pain.

It is required that the comprehensive assessment includes consideration of the nature and condition causing admission, including the presence, or lack of, objective data and subjective complaints. THIS IS A CONTINUING REQUIRED ACTION This standard was not met as evidenced by review of the agency's action plan during this site visit on 02/08/2024 which revealed the agency did not implement the action plan items that were described in their plan of correction with an effective implementation date of 2/07/2024. Previous Evidence: This standard was not met as evidenced by clinical record review and interview. 5 of 11 (45%) clinical records reviewed revealed that the agency did not ensure that the comprehensive assessment included consideration of the patient’s condition and the objective and subjective data leading to hospice admission. Clinical Record 6: The patient elected hospice on 10/3/22. The initial nursing visit completed on 10/3/22 provided documentation of all Hospice Item Set (HIS) questions. The visit did not include documentation of comprehensive assessment findings in the following areas: pain, activities of daily living (ADLs), functional status, sleep/rest patterns, integumentary, respiratory, cardiovascular, digestive, genitourinary, and fall risk. Clinical Record 10: The patient elected hospice care on 7/24/23. The comprehensive assessment used specifically to consider the ongoing nature and condition of the patient and to identify the continued need for hospice services was documented as complete on 10/16/23. A review of the document revealed it was blank and did not contain documentation of a comprehensive physical assessment, including the patient’s condition and continued need for hospice service, objective data, and subjective complaints. Clinical Record 11: The patient elected hospice care on 7/24/23, and the current benefit period ends on 1/19/24. The comprehensive assessment used specifically to consider the ongoing nature and condition of the patient and to identify the continued need for hospice services was scheduled for 1/10/24 and documented as “not started,” limiting access to objective and subjective data needed by the medical director to determine terminality. Clinical Record 12: The patient elected hospice on 7/24/23 with a terminal diagnosis of Alzheimer’s Disease, unspecified. The initial nursing visit completed on 7/24/23 identified in the Hospice Item Set (HIS) an admitting diagnosis of cancer. The psychological status of the patient was documented as “non-responsive;” however, the nursing narrative documented the patient as alert and oriented to self only. In addition to contradictory documentation related to the condition causing admission, the visit did not include documentation of comprehensive assessment findings in the following areas: digestive and genitourinary systems and fall risk. Clinical Record 14: The patient elected hospice on 9/27/23. The initial nursing visit completed on 9/27/23 provided documentation of all Hospice Item Set (HIS) questions. The visit did not include documentation of comprehensive assessment findings in the following areas: pain, activities of daily living (ADLs), functional status, sleep/rest patterns, integumentary, respiratory, cardiovascular, digestive, genitourinary, and fall risk. On 1/19/24 joint record reviews and interviews were conducted with the Director of Nursing (DON), who confirmed that the clinical records identified did not contain documentation of objective and subjective data associated with the patient’s condition to support hospice admission and recertification.

It is required that the comprehensive assessment includes consideration of functional status and cognitive status, including the patient’s ability to understand and participate in her or his own care. THIS IS A CONTINUING REQUIRED ACTION This standard was not met as evidenced by review of the agency's action plan during this site visit on 02/08/2024 which revealed the agency did not implement the action plan items that were described in their plan of correction with an effective implementation date of 2/07/2024. Previous Evidence: This standard was not met as evidenced by clinical record review and interview. 4 of 11 (36%) clinical records reviewed revealed that the agency did not ensure that the comprehensive assessment included consideration of the patient’s functional and cognitive status and ability to understand and participate in her or his care. Clinical Record 6: The patient elected hospice on 10/3/22. The initial nursing visit completed on 10/3/22 provided documentation of all Hospice Item Set (HIS) questions. The visit did not include documentation of comprehensive assessment findings regarding the patient’s functional status or if the patient could participate in his care. Clinical Record 10: The patient elected hospice care on 7/24/23. The comprehensive assessment used specifically to consider the ongoing nature and condition of the patient and to identify the continued need for hospice services was documented as complete on 10/16/23. A review of the document revealed it was blank and did not contain documentation regarding the patient’s functional and cognitive status and whether the patient was able to understand and participate in his care. Clinical Record 11: The patient elected hospice care on 7/24/23, and the current benefit period ends on 1/19/24. The comprehensive assessment used specifically to consider the ongoing nature and condition of the patient and to identify the continued need for hospice services was scheduled for 1/10/24 and documented as “not started,” limiting access to data regarding functional and cognitive changes associated with disease (COPD) progression to support terminality. Clinical Record 14: The patient elected hospice on 9/27/23. The initial nursing visit completed on 9/27/23 provided documentation of all Hospice Item Set (HIS) questions. The visit did not include documentation of comprehensive assessment findings regarding the patient’s functional and cognitive status and whether the patient was able to understand and participate in his care. On 1/19/24 joint record reviews and interviews were conducted with the Director of Nursing (DON), who confirmed that the clinical records identified did not contain a documented assessment of patients' functional and cognitive status and ability to understand and participate in care.

It is required that the comprehensive assessment includes consideration of the following symptoms: symptoms and symptom severity, including dyspnea, nausea, vomiting, constipation, restlessness, anxiety, emotional distress, sleep disorders, skin integrity, and confusion. THIS IS A CONTINUING REQUIRED ACTION This standard was not met as evidenced by review of the agency's action plan during this site visit on 02/08/2024 which revealed the agency did not implement the action plan items that were described in their plan of correction with an effective implementation date of 2/07/2024. Previous Evidence: This standard was not met as evidenced by clinical record review and interview. 7 of 11 (64%) clinical records reviewed revealed that the agency did not ensure that the comprehensive assessment included consideration of the patient’s symptoms and symptom severity. Clinical Record 1: The patient elected hospice care on 11/6/23. The initial Medical Social Worker (MSW) visit was marked as completed in the electronic medical record (EMR) on 11/9/2023. A review of the document revealed it was blank and did not contain documentation of a comprehensive assessment to identify psychosocial concerns and emotional distress affecting symptoms and symptom severity. Clinical Record 3: The patient elected hospice care on 11/6/23. The initial Medical Social Worker (MSW) visit was marked as completed in the electronic medical record (EMR) on 11/10/2023. A review of the document revealed it was blank and did not contain documentation of a comprehensive assessment to identify psychosocial concerns and emotional distress affecting symptoms and symptom severity. Clinical Record 6: The patient elected hospice on 10/3/22. The initial nursing visit completed on 10/3/22 provided documentation of all Hospice Item Set (HIS) questions. A review of the document revealed it did not contain documented assessment findings or symptoms and symptom severity associated with pain, activities of daily living (ADLs), functional status, sleep/rest patterns, skin integrity, fall risk, and the respiratory, cardiovascular, digestive, and genitourinary systems. Clinical Record 10: The patient elected hospice care on 7/24/23. The comprehensive assessment used specifically to consider the ongoing nature and condition of the patient and to identify the continued need for hospice services was documented as complete on 10/16/23. A review of the document revealed it was blank and did not contain documented assessment findings or symptoms and symptom severity associated with pain, activities of daily living (ADLs), functional status, sleep/rest patterns, skin integrity, fall risk, and the respiratory, cardiovascular, digestive, and genitourinary systems. Clinical Record 11: The patient elected hospice care on 7/24/23, and the current benefit period ends on 1/19/24. The comprehensive assessment used specifically to consider the ongoing nature and condition of the patient and to identify the continued need for hospice services was scheduled for 1/10/24 and documented as “not started,” limiting access to data regarding symptoms and symptom severity associated with pain, activities of daily living (ADLs), functional status, sleep/rest patterns, skin integrity, fall risk, and the respiratory, cardiovascular, digestive, and genitourinary systems. Clinical Record 12: The patient elected hospice on 7/24/23 with a terminal diagnosis of Alzheimer’s Disease, unspecified. The initial nursing visit completed on 7/24/23 identified in the Hospice Item Set (HIS) an admitting diagnosis of cancer. The psychological status of the patient was documented as “non-responsive;” however, the nursing narrative documented the patient as alert and oriented to self only. In addition to contradictory documentation related to the condition causing admission, the visit did not include documentation of comprehensive assessment findings in the following areas: digestive and genitourinary systems and fall risk. Clinical Record 14: The patient elected hospice on 9/27/23. The initial nursing visit completed on 9/27/23 provided documentation of all Hospice Item Set (HIS) questions. A review of the document revealed it did not contain documented assessment findings or symptoms and symptom severity associated with pain, activities of daily living (ADLs), functional status, sleep/rest patterns, skin integrity, fall risk, and the respiratory, cardiovascular, digestive, and genitourinary systems. On 1/19/24 joint record reviews and interviews were conducted with the Director of Nursing (DON), who confirmed that the clinical records identified did not contain documented assessments of symptoms and symptom severity associated with pain, ADLs, sleep/rest patterns, fall risks, and body systems.

It is required that the hospice designates a registered nurse member of the IDG to ensure the implementation of the interdisciplinary plan of care. Hospice care and services provided to patients and families follow the individualized plan of care established by the hospice IDG 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 IS A CONTINUING REQUIRED ACTION This standard was not met as evidenced by review of the agency's action plan during this site visit on 02/08/2024 which revealed the agency did not implement the action plan items that were described in their plan of correction with an effective implementation date of 2/26/2024. Previous Evidence: This standard was not met as evidenced by clinical record review and interview. In 12 of 12 (100%) clinical records reviewed, the agency did not ensure that all hospice care and services furnished to patients and their families followed an individualized written plan of care established by the hospice interdisciplinary group (IDG). Clinical Record 1: The patient elected the hospice benefit on 11/6/23. A clinical record review revealed that visits, including nursing, medical social services, and spiritual counseling, were documented as completed within five days of the election. The clinical record did not contain an implemented interdisciplinary plan of care. Clinical Record 2: The patient elected the hospice benefit on 8/1/23. A clinical record review revealed that visits, including nursing, medical social services, and spiritual counseling, were documented as completed within five days of the election. The clinical record did not contain an implemented interdisciplinary plan of care. Clinical Record 3: The patient elected the hospice benefit on 11/6/23. A clinical record review revealed that visits, including nursing, medical social services, and spiritual counseling, were documented as completed within five days of the election. The clinical record did not contain an implemented interdisciplinary plan of care. Clinical Record 4: The patient elected the hospice benefit on 6/22/23. A clinical record review revealed that visits, including nursing, medical social services, and spiritual counseling, were documented as completed within five days of the election. The clinical record did not contain an implemented interdisciplinary plan of care. Clinical Record 6: The patient elected the hospice benefit on 10/3/22. A clinical record review revealed that visits, including nursing, medical social services, and spiritual counseling, were documented as completed within five days of the election. The clinical record did not contain an implemented interdisciplinary plan of care. Clinical Record 8: The patient elected the hospice benefit on 7/10/23. A clinical record review revealed that visits, including nursing, medical social services, and spiritual counseling, were documented as completed within five days of the election. The clinical record did not contain an implemented interdisciplinary plan of care. Clinical Record 9: The patient elected the hospice benefit on 8/1/23. A clinical record review revealed that visits, including nursing, medical social services, and spiritual counseling, were documented as completed within five days of the election. The clinical record did not contain an implemented interdisciplinary plan of care. Clinical Record 10: The patient elected the hospice benefit on 7/24/23. A clinical record review revealed that visits, including nursing, medical social services, and spiritual counseling, were documented as completed within five days of the election. The clinical record did not contain an implemented interdisciplinary plan of care. Clinical Record 11: The patient elected the hospice benefit on 7/24/23. A clinical record review revealed that visits, including nursing, medical social services, and spiritual counseling, were documented as completed within five days of the election. The clinical record did not contain an implemented interdisciplinary plan of care. Clinical Record 12: The patient elected the hospice benefit on 7/24/23. A clinical record review revealed that visits, including nursing, medical social services, and spiritual counseling, were documented as completed within five days of the election. The clinical record did not contain an implemented interdisciplinary plan of care. Clinical Record 13: The patient elected the hospice benefit on 9/28/23. A clinical record review revealed that visits, including nursing, medical social services, and spiritual counseling, were documented as completed within five days of the election. The clinical record did not contain an implemented interdisciplinary plan of care. Clinical Record 14: The patient elected the hospice benefit on 11/6/23. A clinical record review revealed that visits, including nursing, medical social services, and spiritual counseling, were documented as completed within five days of the election. The clinical record did not contain an implemented interdisciplinary plan of care. During joint chart reviews and interviews on 1/19/24, the Director of Nursing (DON) confirmed that the clinical records did not contain an implemented interdisciplinary POC. The DON stated that she and other RNs entered POCs on 1/17/24, 1/18/24, and 1/19/24 with authenticated physician signatures. She presented the POC Work Log in the electronic medical record (EMR) that maintained a time stamp of changes made to the POC. The POC Work Log maintained documentation of the date, time, and type of change made to the POC, including the name of the clinician making the change. Types of changes documented by the Work Log included changes to and creation of orders (problem or visit frequency), changes to and creation of staff responsibilities, changes to the narrative summary, and when the RN signed a POC.

It is required that a hospice aide provides services: ordered by the Interdisciplinary Group; included in the plan of care; permitted to be performed under state law and regulation; consistent with the hospice aide training. THIS IS A CMS CONDITION LEVEL DEFICIENCY. THIS IS A CONTINUING REQUIRED ACTION This standard was not met as evidenced by review of the agency's action plan during this site visit on 02/08/2024 which revealed the agency did not implement the action plan items that were described in their plan of correction with an effective implementation date of 2/07/2024. Previous Evidence: This CONDITION of participation was not met as evidenced review of clinical records and interviews revealed the following: Failure of the hospice to ensure that the Hospice Aide received written patient care instructions prepared by a Registered Nurse (RN) responsible for supervision of the Hospice Aide [HCDT.15.I/L625]; Failure of the hospice to ensure that the hospice aide provided services as instructed in the aide care plan [HCDT.16.I/L626]; and Failure of the hospice to ensure that the hospice aide completed a competency evaluation program [HSRM.9.I/L615]. The cumulative effect of these deficiencies has resulted in the hospice agency’s ability to ensure the provision of quality hospice care for the condition of participation CFR 418.76, Hospice Aide and Homemaker Services. The collective deficient practice illustrated systemic process failures that had the potential to affect all patients receiving hospice aide services from the agency.

It is required that a qualified hospice aide has successfully completed a competency evaluation program that evaluates the aide’s competency in the following subject areas by observation of the aide’s performance with a patient or a pseudo patient: 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; and appropriate and safe techniques in performing personal hygiene and grooming tasks, including items on the following basic checklist: bed bath; sponge, tub, and shower bath; hair shampoo (sink, tub, and bed); nail and skin care; oral hygiene; toileting and elimination; safe transfer techniques and ambulation; and normal range of motion and positioning. THIS IS A CONTINUING REQUIRED ACTION This standard was not met as evidenced by review of the agency's action plan during this site visit on 02/08/2024 which revealed the agency did not implement the action plan items that were described in their plan of correction with an effective implementation date of 2/07/2024. Previous Evidence: This standard was not met as evidenced by interview and personnel record review. In 1 of 1 (100%) aide personnel records reviewed of hospice aides, the hospice did not ensure that the hospice aide successfully completed a competency evaluation program. Personnel Record 2: The hospice aide was hired on 11/15/21. A review of the hospice aide personnel record revealed no evidence that the hospice aide completed a competency evaluation at the time of hire and before providing patient care. On 1/17/24, a joint record review and interview were conducted with the Director of Nursing (DON), who verified the personnel record did not contain documentation of completed aide competencies. The DON stated she would obtain the completed documentation from an electronic file; however, the original documentation of the aide's completed competency assessments was not presented before the exit conference.

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 IS A CONTINUING REQUIRED ACTION This standard was not met as evidenced by review of the agency's action plan during this site visit on 02/08/2024 which revealed the agency did not implement the action plan items that were described in their plan of correction with an effective implementation date of 2/07/2024. Previous Evidence: This standard was not met as evidenced by clinical record review and interview. In 2 of 3 (67%) clinical records reviewed in which Hospice Aide services were accepted, the agency did not ensure the Hospice Aide received written patient care instructions prepared by a Registered Nurse (RN) responsible for supervision of the Hospice Aide. Clinical Record 1: The Hospice Aide care plan effective 11/6/23, documented the following tasks to be completed by the Aide: foot care every visit, shampooing hair as needed (PRN), skin care every visit, nail care every visit, shaving PRN, and incontinence care every visit. The Hospice Aide care plan did not provide specific instructions on the type of foot, skin, shave, and incontinence care to be provided. The Hospice Aide care plan did not provide the Aide specific frequencies on when the shampoo and shave were to be completed. The nursing assessment dated 11/6/23 documented the patient was unsteady and a fall risk. The Hospice Aide care plan did not alert the aide to the patient's risk of falls. Clinical Record 14: The Hospice Aide care plan effective 10/2/23 through 11/24/23, documented the following tasks to be completed by the Aide: foot care every visit, shampooing hair as needed (PRN), skin care every visit, nail care every visit, shave PRN, and incontinence care every visit. The Hospice Aide care plan did not provide specific instructions on the type of foot, skin, shave, and incontinence care to be provided. The Hospice Aide care plan did not provide the aide specific frequencies on when the shampoo and shave were to be completed. On 1/19/24 joint record reviews and interviews were conducted with the Director of Nursing (DON) who agreed that care instructions for the Aide did not provide the Aide with specific instructions on the type of care to be provided and how often shaving and shampooing needed to occur to meet patients’ needs.

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 review of the agency's action plan during this site visit on 02/08/2024 which revealed the agency did not implement the action plan items that were described in their plan of correction with an effective implementation date of 2/07/2024. Previous Evidence: This standard was not met as evidenced by clinical record review, observation, and interview. 2 of 3 (67%) clinical records reviewed, in which Hospice Aide (HA) services were accepted, the agency did not ensure the HA provided services ordered by the Interdisciplinary Group and included in the plan of care. Clinical Record 1/Home Visit 1: The Registered Nurse (RN) created a hospice aide care plan on 11/6/23 with instructions for the aide to perform a shave as needed (PRN) and three (3) visits per week. Hospice Aide [Personnel Record 2] visits were documented as completed three (3) times per week from 1/1/24 to the current date with all tasks except shampoo and shave marked as completed. During the home visit with the Hospice Aide (HA) [Personnel Record 2] on 1/19/24, the patient had a full-facial beard. The patient stated during the interview that it was the first time the HA [Personnel Record 2] had visited and confirmed that he did want a full-facial shave. In an interview with the HA on 1/19/24, the HA confirmed that this was the first day she had been able to see the patient. There was a 19 day period that aide visits were documented without any evidence of completion. There was no evidence the RN was notified the care plan was not followed. Clinical Record 14: The hospice aide care plan effective on 9/27/23 ordered tasks each visit and as needed that included bathing, shampooing hair, shaving, and nail, foot, and incontinence care. The aide notes for the completed visit on 9/29/23 did not document any care was provided, or the reason why the care tasks were not provided. There was no evidence the RN was notified the care plan was not followed. On 1/19/24 joint record reviews and interviews were conducted with the Director of Nursing (DON), who confirmed the findings. The DON did not speak to the HA for Record 1 about documenting visits that the patient and HA claimed were not made.

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 demonstration of staff knowledge of emergency procedures and EP training of all hospice employees and individuals providing services under arrangement at least every two (2) years. This standard was not met as evidenced by clinical record review, document review, interview and observation. In 3 of 3 (100%) personnel records reviewed, the agency did not ensure employees received emergency preparedness (EP) training every two (2) years and could demonstrate knowledge of emergency procedures. Personnel Record 2: The Hospice Aide documented the completion of the emergency preparedness (EP) training upon hire on 11/15/21. A personnel record review revealed no documented evidence that the Hospice Aide completed EP training in 2023. During an interview and the home visit observed on 1/19/24, the Hospice Aide reported the patient's water was frozen from the recent extreme temperatures in the area, and she did not know what to do in this situation or other emergencies. Personnel Record 5: The Medical Director documented the completion of the EP training upon hire on 8/10/20. A personnel record review revealed no documented evidence that the Medical Director completed EP training in 2022. Personnel Record 6: The Director of Nursing (DON) documented the completion of the EP training upon hire on 11/10/2020. A personnel record review revealed no documented evidence that the DON completed EP training in 2022. On 1/17/24, a joint personnel record review and interview were conducted with the Director of Nursing (DON), who verified the personnel records did not contain documentation of completed EP training of staff at least every two years. The DON stated she would obtain the documentation of completed EP staff training every two years from an electronic file; however, original documentation of staff completion of EP training was not presented before the exit conference.

It is required that the hospice conducts and documents a patient-specific comprehensive assessment that identifies the patient’s need for hospice care and services, and the patient’s need for physical, psychosocial, emotional, and spiritual care. The assessment includes all areas of hospice care related to the palliation and management of the terminal illness and related conditions. THIS IS A CMS CONDITION LEVEL DEFICIENCY CITED AS IMMEDIATE JEOPARDY. This CONDITION of participation, which was also cited as an Immediate Jeopardy, was not met as evidenced by review of clinical records and interview which revealed issues with completion of initial and comprehensive assessments of patients in the following areas: Failure of the hospice Interdisciplinary Group to demonstrate completion of the psychosocial, spiritual and bereavement assessment, as part of the initial comprehensive assessment, within five (5) calendar days after the election of hospice care [HCPC.9.I/L523]; Failure of the hospice Interdisciplinary Group to ensure the initial comprehensive assessment included a review of all of the patient's medications for adverse effects, significant side effects and contraindications [HCPC.15.I/L530]; Failure of the hospice to ensure the hospice Registered Nurse (RN) completed and documented an initial assessment within 48 hours of the patient electing hospice care [HCPC.8.I/L522]; Failure of the hospice to ensure that the comprehensive assessment identified and addressed the physical, psychosocial, emotional, and spiritual needs of the patient to promote the patient's well-being, comfort, and dignity [HCPC.10.I/L524]; Failure of the hospice to ensure that the comprehensive assessment included consideration of the patient’s functional and cognitive status and ability to understand and participate in her or his care [HCPC.11.I/L527]; Failure of the hospice to ensure that the comprehensive assessment included consideration of the patient’s symptoms and symptom severity [HCPC.11.I/L529]; Failure of the hospice to ensure the comprehensive assessment included consideration of the patient’s condition and the objective and subjective data leading to hospice admission [HCPC.11.I/L525]; and Failure to ensure that a pain assessment, using a standardized pain assessment tool and including characteristics, impact, and goals for management, was a part of each comprehensive assessment [HCPC.12.I/L524]. The cumulative effect and scope of these deficiencies could negatively impact the organization’s ability to identify and meet the care needs of the patients and ensure continuity of care and service coordination.

It is required that the hospice registered nurse completes an initial assessment within 48 hours of the patient’s election of hospice care, in accordance with CMS §418.24 (the elements of the hospice care election statement). The physician, patient, or representative may request that the initial hospice assessment be completed in less than 48 hours. This standard was not met as evidenced by clinical record review and personnel record review. 2 of 11 (18%) clinical records reviewed revealed that the agency did not ensure the hospice Registered Nurse (RN) completed and documented an initial assessment within 48 hours of the patient electing hospice care. Clinical Record 6: An initial nursing visit was completed on 10/3/22. The documentation did not include evidence that an initial assessment, including an assessment of pain, functional status, sleep/rest pattern, fall risk, and body systems including integumentary, respiratory, cardiovascular, digestive, nutrition, and genitourinary, was provided. Clinical Record 14: The patient elected the hospice benefit on 9/27/23, and an initial nursing assessment was completed on 9/27/23. The patient elected the hospice benefit on 10/3/22, and an initial nursing assessment was completed on 10/3/22. An initial nursing visit was completed on 9/27/23. The documentation did not include evidence that an initial assessment, including an assessment of pain, functional status, sleep/rest pattern, fall risk, and body systems including integumentary, respiratory, cardiovascular, digestive, nutrition, and genitourinary, was provided. On 1/19/24 joint record reviews and interviews were conducted with the Director of Nursing (DON), who confirmed that the clinical records identified did not contain documentation of an assessment completed by the RN within 48 hours of the patient electing hospice care.

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. 2 of 11 (18%) clinical records reviewed revealed that the agency did not ensure the Interdisciplinary Group completed the initial comprehensive assessment no later than five (5) calendar days after the election of hospice care. Clinical Record 1: The patient elected the Hospice benefit on 11/6/23. The initial Medical Social Worker (MSW) assessment dated 11/9/23 was marked as completed in the electronic medical record (EMR); however, a review of the assessment form found it to be blank and did not contain documentation of a comprehensive psychosocial and emotional assessment. Clinical Record 3: The patient elected the Hospice benefit on 11/6/23. The initial Medical Social Worker (MSW) assessment dated 11/10/23 was marked as completed in the electronic medical record (EMR), however, a review of the assessment form found it to be blank and did not contain documentation of a comprehensive psychosocial and emotional assessment. On 1/19/24, joint record reviews and interviews were conducted with the Director of Nursing, who confirmed that the initial MSW assessments were not completed. Therefore, the Interdisciplinary Group did not complete the comprehensive assessment including psychosocial assessment within five calendar days of the hospice election.

It is required that the patient’s pain is assessed as part of a comprehensive assessment. Assessment of pain in children and adolescents is conducted with consideration of age and neurocognitive development. The documented assessment of the patient’s pain includes a history of pain and its treatment, both pharmacological and non-pharmacological, use of a standardized pain assessment tool appropriate to the patient’s developmental and cognitive status, characteristics of the pain, including location, frequency, and intensity, how pain impacts the patient’s ability to engage in usual activities and function (e.g., appetite, sleeping), and the patient’s/family’s goals for pain management and their satisfaction with the current level of pain control. This standard was not met as evidenced by clinical record review and interview. 6 of 11 (55%) clinical records reviewed revealed that the agency did not ensure a pain assessment, using a standardized pain assessment tool and including characteristics, impact, and goals for management, was a part of each comprehensive assessment. Clinical Record 3: The patient elected the hospice benefit on 11/6/23. The initial nursing assessment completed on 11/6/23 documented that the patient’s caregiver reported the patient was having low back pain, and it was documented that the caregiver rated the pain a seven (7) out of ten (10). The clinical record did not contain documentation of a comprehensive pain assessment, using a pain assessment tool appropriate for the patient’s documented cognitive status, that included the patient’s history of pain and treatment. Clinical Record 4: The patient elected hospice care on 6/22/23 with a diagnosis of COPD. The initial comprehensive assessment documented the patient's reported chest pain with shortness of breath. The comprehensive assessment (9/14/23), used specifically to consider the ongoing nature and condition of the patient and to identify the continued need for hospice services, did not include documentation of a comprehensive pain assessment. Clinical Record 6: The patient elected hospice on 10/3/22. The initial nursing visit completed on 10/3/22 provided documentation of all Hospice Item Set (HIS) questions, including confirmation of evaluation of the patient’s pain. The comprehensive assessment did not include documentation of the patient’s history of pain and treatment, pain assessment tool used, and characteristics of pain including location, frequency, intensity, impact of pain on activity and function, and the patient’s and family’s goal for pain management and current satisfaction with pain management. Clinical Record 10: The patient elected hospice care on 7/24/23 with a diagnosis of COPD. The initial comprehensive assessment documented the patient's reported pain score of one (1) out of ten (10) and the use of Tylenol. The comprehensive assessment (10/16/23), used specifically to consider the ongoing nature and condition of the patient and to identify the continued need for hospice services, did not include documentation of a comprehensive pain assessment. Clinical Record 11: The patient elected hospice on 7/24/23. The initial nursing visit completed on 7/24/23 provided documentation of all Hospice Item Set (HIS) questions, including confirmation that a comprehensive pain assessment was performed. A review of the nursing assessment revealed that it did not include documentation of the patient’s history of pain and treatment, pain assessment tool used, and characteristics of pain including location, frequency, intensity, impact of pain on activity and function, and the patient’s and family’s goal for pain management and current satisfaction with pain management. Clinical Record 14: The patient elected hospice on 9/27/23. The initial nursing visit completed on 9/27/23 provided documentation of all Hospice Item Set (HIS) questions, including confirmation that a comprehensive pain assessment was performed. A review of the nursing assessment revealed that it did not include documentation of the patient’s history of pain and treatment, pain assessment tool used, and characteristics of pain including location, frequency, intensity, impact of pain on activity and function, and the patient’s and family’s goal for pain management and current satisfaction with pain management. On 1/19/24 joint record reviews and interviews were conducted with the Director of Nursing (DON) who confirmed that the identified medical records and comprehensive assessment did not include documentation of a pain assessment utilizing a standardized pain assessment tool and addressing the history, treatment, characteristics, impact, and patient and family goals for pain.

It is required that the comprehensive assessment includes consideration of the nature and condition causing admission, including the presence, or lack of, objective data and subjective complaints. This standard was not met as evidenced by clinical record review and interview. 5 of 11 (45%) clinical records reviewed revealed that the agency did not ensure that the comprehensive assessment included consideration of the patient’s condition and the objective and subjective data leading to hospice admission. Clinical Record 6: The patient elected hospice on 10/3/22. The initial nursing visit completed on 10/3/22 provided documentation of all Hospice Item Set (HIS) questions. The visit did not include documentation of comprehensive assessment findings in the following areas: pain, activities of daily living (ADLs), functional status, sleep/rest patterns, integumentary, respiratory, cardiovascular, digestive, genitourinary, and fall risk. Clinical Record 10: The patient elected hospice care on 7/24/23. The comprehensive assessment used specifically to consider the ongoing nature and condition of the patient and to identify the continued need for hospice services was documented as complete on 10/16/23. A review of the document revealed it was blank and did not contain documentation of a comprehensive physical assessment, including the patient’s condition and continued need for hospice service, objective data, and subjective complaints. Clinical Record 11: The patient elected hospice care on 7/24/23, and the current benefit period ends on 1/19/24. The comprehensive assessment used specifically to consider the ongoing nature and condition of the patient and to identify the continued need for hospice services was scheduled for 1/10/24 and documented as “not started,” limiting access to objective and subjective data needed by the medical director to determine terminality. Clinical Record 12: The patient elected hospice on 7/24/23 with a terminal diagnosis of Alzheimer’s Disease, unspecified. The initial nursing visit completed on 7/24/23 identified in the Hospice Item Set (HIS) an admitting diagnosis of cancer. The psychological status of the patient was documented as “non-responsive;” however, the nursing narrative documented the patient as alert and oriented to self only. In addition to contradictory documentation related to the condition causing admission, the visit did not include documentation of comprehensive assessment findings in the following areas: digestive and genitourinary systems and fall risk. Clinical Record 14: The patient elected hospice on 9/27/23. The initial nursing visit completed on 9/27/23 provided documentation of all Hospice Item Set (HIS) questions. The visit did not include documentation of comprehensive assessment findings in the following areas: pain, activities of daily living (ADLs), functional status, sleep/rest patterns, integumentary, respiratory, cardiovascular, digestive, genitourinary, and fall risk. On 1/19/24 joint record reviews and interviews were conducted with the Director of Nursing (DON), who confirmed that the clinical records identified did not contain documentation of objective and subjective data associated with the patient’s condition to support hospice admission and recertification.

It is required that the comprehensive assessment includes consideration of functional status and cognitive status, including the patient’s ability to understand and participate in her or his own care. This standard was not met as evidenced by clinical record review and interview. 4 of 11 (36%) clinical records reviewed revealed that the agency did not ensure that the comprehensive assessment included consideration of the patient’s functional and cognitive status and ability to understand and participate in her or his care. Clinical Record 6: The patient elected hospice on 10/3/22. The initial nursing visit completed on 10/3/22 provided documentation of all Hospice Item Set (HIS) questions. The visit did not include documentation of comprehensive assessment findings regarding the patient’s functional status or if the patient could participate in his care. Clinical Record 10: The patient elected hospice care on 7/24/23. The comprehensive assessment used specifically to consider the ongoing nature and condition of the patient and to identify the continued need for hospice services was documented as complete on 10/16/23. A review of the document revealed it was blank and did not contain documentation regarding the patient’s functional and cognitive status and whether the patient was able to understand and participate in his care. Clinical Record 11: The patient elected hospice care on 7/24/23, and the current benefit period ends on 1/19/24. The comprehensive assessment used specifically to consider the ongoing nature and condition of the patient and to identify the continued need for hospice services was scheduled for 1/10/24 and documented as “not started,” limiting access to data regarding functional and cognitive changes associated with disease (COPD) progression to support terminality. Clinical Record 14: The patient elected hospice on 9/27/23. The initial nursing visit completed on 9/27/23 provided documentation of all Hospice Item Set (HIS) questions. The visit did not include documentation of comprehensive assessment findings regarding the patient’s functional and cognitive status and whether the patient was able to understand and participate in his care. On 1/19/24 joint record reviews and interviews were conducted with the Director of Nursing (DON), who confirmed that the clinical records identified did not contain a documented assessment of patients' functional and cognitive status and ability to understand and participate in care.

It is required that the comprehensive assessment includes consideration of the following symptoms: symptoms and symptom severity, including dyspnea, nausea, vomiting, constipation, restlessness, anxiety, emotional distress, sleep disorders, skin integrity, and confusion. This standard was not met as evidenced by clinical record review and interview. 7 of 11 (64%) clinical records reviewed revealed that the agency did not ensure that the comprehensive assessment included consideration of the patient’s symptoms and symptom severity. Clinical Record 1: The patient elected hospice care on 11/6/23. The initial Medical Social Worker (MSW) visit was marked as completed in the electronic medical record (EMR) on 11/9/2023. A review of the document revealed it was blank and did not contain documentation of a comprehensive assessment to identify psychosocial concerns and emotional distress affecting symptoms and symptom severity. Clinical Record 3: The patient elected hospice care on 11/6/23. The initial Medical Social Worker (MSW) visit was marked as completed in the electronic medical record (EMR) on 11/10/2023. A review of the document revealed it was blank and did not contain documentation of a comprehensive assessment to identify psychosocial concerns and emotional distress affecting symptoms and symptom severity. Clinical Record 6: The patient elected hospice on 10/3/22. The initial nursing visit completed on 10/3/22 provided documentation of all Hospice Item Set (HIS) questions. A review of the document revealed it did not contain documented assessment findings or symptoms and symptom severity associated with pain, activities of daily living (ADLs), functional status, sleep/rest patterns, skin integrity, fall risk, and the respiratory, cardiovascular, digestive, and genitourinary systems. Clinical Record 10: The patient elected hospice care on 7/24/23. The comprehensive assessment used specifically to consider the ongoing nature and condition of the patient and to identify the continued need for hospice services was documented as complete on 10/16/23. A review of the document revealed it was blank and did not contain documented assessment findings or symptoms and symptom severity associated with pain, activities of daily living (ADLs), functional status, sleep/rest patterns, skin integrity, fall risk, and the respiratory, cardiovascular, digestive, and genitourinary systems. Clinical Record 11: The patient elected hospice care on 7/24/23, and the current benefit period ends on 1/19/24. The comprehensive assessment used specifically to consider the ongoing nature and condition of the patient and to identify the continued need for hospice services was scheduled for 1/10/24 and documented as “not started,” limiting access to data regarding symptoms and symptom severity associated with pain, activities of daily living (ADLs), functional status, sleep/rest patterns, skin integrity, fall risk, and the respiratory, cardiovascular, digestive, and genitourinary systems. Clinical Record 12: The patient elected hospice on 7/24/23 with a terminal diagnosis of Alzheimer’s Disease, unspecified. The initial nursing visit completed on 7/24/23 identified in the Hospice Item Set (HIS) an admitting diagnosis of cancer. The psychological status of the patient was documented as “non-responsive;” however, the nursing narrative documented the patient as alert and oriented to self only. In addition to contradictory documentation related to the condition causing admission, the visit did not include documentation of comprehensive assessment findings in the following areas: digestive and genitourinary systems and fall risk. Clinical Record 14: The patient elected hospice on 9/27/23. The initial nursing visit completed on 9/27/23 provided documentation of all Hospice Item Set (HIS) questions. A review of the document revealed it did not contain documented assessment findings or symptoms and symptom severity associated with pain, activities of daily living (ADLs), functional status, sleep/rest patterns, skin integrity, fall risk, and the respiratory, cardiovascular, digestive, and genitourinary systems. On 1/19/24 joint record reviews and interviews were conducted with the Director of Nursing (DON), who confirmed that the clinical records identified did not contain documented assessments of symptoms and symptom severity associated with pain, ADLs, sleep/rest patterns, fall risks, and body systems.

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, supplements, herbal remedies, and other alternative treatments that could affect drug therapy. The medication review process includes the identification of the effectiveness of drug therapy, drug side effects, actual or potential drug interactions, and duplicate drug therapy. The assessment includes evidence that common side effects of medication in hospice populations are anticipated, and as appropriate, preventive measures are implemented to manage the side effects. 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 clinical record review and interview. 13 of 13 (100%) clinical records reviewed revealed that the agency did not ensure the initial comprehensive assessment included documentation of a drug profile and medication review, assessing for effectiveness, interactions, side effects, or duplications of medications. Clinical Record 1: The initial comprehensive assessment was completed on 11/6/23. This comprehensive assessment did not include documentation of prescription or over-the-counter drugs, supplements, herbal remedies, and other alternative treatments the patient may have been taking. There was no evidence of a medication profile. The clinical record did not contain documentation of a medication review assessing for effectiveness, interactions, side effects, or duplications of medications. Clinical Record 2: The initial comprehensive assessment was completed on 8/1/23. This comprehensive assessment did not include documentation of prescription or over-the-counter drugs, supplements, herbal remedies, and other alternative treatments the patient may have been taking or documentation that the patient did not have items to create a drug profile. There was no evidence of a medication profile. The clinical record did not contain documentation of a medication review assessing for effectiveness, interactions, side effects, or duplications of medications. Clinical Record 3: The initial comprehensive assessment was completed on 11/6/23. This comprehensive assessment did not include documentation of prescription or over-the-counter drugs, supplements, herbal remedies, and other alternative treatments the patient may have been taking or documentation that the patient did not have items to create a drug profile. There was no evidence of a medication profile. The clinical record did not contain documentation of a medication review assessing for effectiveness, interactions, side effects, or duplications of medications. Clinical Record 4: The initial comprehensive assessment was completed on 6/22/23. This comprehensive assessment did not include documentation of prescription or over-the-counter drugs, supplements, herbal remedies, and other alternative treatments the patient may have been taking or documentation that the patient did not have items to create a drug profile. The clinical record did not contain documentation of a medication review assessing for effectiveness, interactions, side effects, or duplications of medications. Clinical Record 5: The initial comprehensive assessment was completed on 7/17/23. This comprehensive assessment did not include documentation of prescription or over-the-counter drugs, supplements, herbal remedies, and other alternative treatments the patient may have been taking or documentation that the patient did not have items to create a drug profile. Clinical Record 6: The initial comprehensive assessment was completed on 10/3/22. This comprehensive assessment did not include documentation of prescription or over-the-counter drugs, supplements, herbal remedies, and other alternative treatments the patient may have been taking or documentation that the patient did not have items to create a drug profile. Clinical Record 8: The initial nursing assessment was completed on 7/10/23. This comprehensive assessment did not include documentation of prescription or over-the-counter drugs, supplements, herbal remedies, and other alternative treatments the patient may have been taking or documentation that the patient did not have items to create a drug profile. On 1/19/24 an interview was conducted with the RN Case Manager, who stated she entered a drug profile into this clinical record on 1/19/24 from notes she had kept on her person since 7/10/23. There was no documentation of physician contact to support her EMR entry of the medications. The clinical record did not contain documentation of a medication review assessing for effectiveness, interactions, side effects, or duplications of medications. Clinical Record 9: The initial comprehensive assessment was completed on 8/1/23. This comprehensive assessment did not include documentation of prescription or over-the-counter drugs, supplements, herbal remedies, and other alternative treatments the patient may have been taking or documentation that the patient did not have items to create a drug profile. Clinical Record 10: The initial comprehensive assessment was completed on 7/24/23. This comprehensive assessment did not include documentation of prescription or over-the-counter drugs, supplements, herbal remedies, and other alternative treatments the patient may have been taking or documentation that the patient did not have items to create a drug profile. Clinical Record 11: The initial comprehensive assessment was completed on 7/24/23. This comprehensive assessment did not include documentation of prescription or over-the-counter drugs, supplements, herbal remedies, and other alternative treatments the patient may have been taking or documentation that the patient did not have items to create a drug profile. Clinical Record 12: The initial comprehensive assessment was completed on 7/24/23. This comprehensive assessment did not include documentation of prescription or over-the-counter drugs, supplements, herbal remedies, and other alternative treatments the patient may have been taking or documentation that the patient did not have items to create a drug profile. The POC for BP 10/22/23 to 1/19/23 included medications that started on 1/10/24. The clinical record did not contain documentation of a medication review assessing for effectiveness, interactions, side effects, or duplications of medications. Clinical Record 13: The initial comprehensive assessment was completed on 9/28/23. This comprehensive assessment did not include documentation of prescription or over-the-counter drugs, supplements, herbal remedies, and other alternative treatments the patient may have been taking or documentation that the patient did not have items to create a drug profile. Clinical Record 14: The initial comprehensive assessment was completed on 9/27/23. This comprehensive assessment did not include documentation of prescription or over-the-counter drugs, supplements, herbal remedies, and other alternative treatments the patient may have been taking or documentation that the patient did not have items to create a drug profile. A comprehensive nursing assessment on 10/5/23 documented that the patient’s pain was managed with a “pain pump” and oral pain medications; however, the documentation did not include a drug profile with pain medications. On 1/19/24 an interview was conducted with the RN Case Manager, who stated she entered a drug profile into this clinical record on 1/19/24 from notes she had kept on her person since 9/27/23. signed the plan of care (POC). The clinical record did not contain documentation of a medication review assessing effectiveness, interactions, side effects, or duplications of medications entered into the drug profile on 1/19/24. On 1/19/24 joint record reviews and interviews were conducted with the Director of Nursing (DON), who confirmed the initial comprehensive assessments did not include drug profiles or documentation of medication reviews, assessing for effectiveness, interactions, side effects, or duplications of medications. The DON stated that she had created the drug profiles for Clinical Record 1, Clinical Record 2, and Clinical Record 3 on 1/17/23 without physician contact or a prior order.

It is required that the hospice designates an Interdisciplinary Group or groups who, in consultation with the patient's attending physician, prepare a written plan of care (POC) for each patient. The plan of care specifies the hospice care and services necessary to meet the specific needs of the patient and family identified in the comprehensive assessment, relative to the terminal illness and associated conditions. THIS IS A CMS CONDITION LEVEL DEFICIENCY CITED AS IMMEDIATE JEOPARDY. This CONDITION of participation, which was also cited as an Immediate Jeopardy, was not met as evidenced by clinical record review, document review, and interview, which revealed the following issues with the development and implementation of the patient’s interdisciplinary care plan: Failure to ensure that the designated RN member of the IDG provided coordination of care, ensured continuous assessment of each patient's and family's needs, and ensured the implementation of an interdisciplinary plan of care (POC) [HCPC.19.I/L540]; Failure to ensure that the Interdisciplinary Group (IDG) members provided care and services offered by the hospice and supervised the care and services provided to the patient and the family [HCPC. 1. I/L539]: Failure to ensure that all hospice care and services furnished to patients and their families followed an individualized written plan of care established by the hospice interdisciplinary group (IDG) [HCPC.21. I/L543]; and Failure to ensure the hospice Interdisciplinary Group (IDG) documented the review and revision of the patient's individualized plan of care no less frequently than every 15 calendar days [HCPC.22. I/L552]. The cumulative effect of these deficiencies has resulted in the hospice organization's inability to ensure the provision of quality of care for the Condition of Participation CFR 418.56: Interdisciplinary group, care planning, and coordination of services. The collective deficient practice illustrated systemic process failures that had the potential to affect all patients receiving hospice care and services from the agency.

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. The IDG, in its entirety, supervises the care and services provided to the patient and family. This standard was not met as evidenced by clinical record review and interview. 12 of 12 (100%) clinical records reviewed, the organization did not ensure the IDG, in its entirety, provided and documented evidence of supervision of hospice care and services provided to the patient and family. Clinical Record 1: The patient elected the hospice benefit on 11/6/23. The initial nursing assessment was completed on 11/6/23, followed by medical social services and spiritual counseling services within five (5) days of the election. A review of the clinical record revealed no documented evidence of an implemented interdisciplinary plan of care that was reviewed and signed by the physician for the benefit period dated 11/6/23 through 2/3/24. Clinical Record 2: The patient elected the hospice benefit on 8/1/23. The initial nursing assessment was completed on 8/1/23, followed by medical social services and spiritual counseling services within five (5) days of the election. A review of the clinical record revealed no documented evidence of an implemented interdisciplinary plan of care that was reviewed and signed by the physician for the benefit period dated 8/1/23 through 10/29/23. Clinical Record 3: The patient elected the hospice benefit on 11/6/23. The initial nursing assessment was completed on 11/6/23, followed by medical social services and spiritual counseling services within five (5) days of the election. A review of the clinical record revealed no documented evidence of an implemented interdisciplinary plan of care that was reviewed and signed by the physician for the benefit period dated 11/6/23 through 2/3/24. Clinical Record 4: The patient elected the hospice benefit on 6/22/23. The initial nursing assessment was completed on 6/22/23, followed by medical social services and spiritual counseling services within five (5) days of the election. A review of the clinical record revealed no documented evidence of an implemented interdisciplinary plan of care that was reviewed and signed by the physician for the benefit period dated 6/22/23 through 9/19/23. Clinical Record 6: The patient elected the hospice benefit on 10/3/22. The initial nursing assessment was completed on 10/3/22, followed by medical social services and spiritual counseling services within five (5) days of the election. A review of the clinical record revealed no documented evidence of an implemented interdisciplinary plan of care that was reviewed and signed by the physician for the benefit period dated 10/3/22 through 1/1/23. Clinical Record 8: The patient elected the hospice benefit on 7/10/23. The initial nursing assessment was completed on 7/10/23, followed by medical social services and spiritual counseling services within five (5) days of the election. A review of the clinical record revealed no documented evidence of an implemented interdisciplinary plan of care that was reviewed and signed by the physician for the benefit period dated 7/10/23 through 10/8/23. Clinical Record 9: The patient elected the hospice benefit on 8/1/23. The initial nursing assessment was completed on 8/1/23, followed by medical social services and spiritual counseling services within five (5) days of the election. A review of the clinical record revealed no documented evidence of an implemented interdisciplinary plan of care that was reviewed and signed by the physician for the benefit period dated 8/1/23 through 10/29/23. Clinical Record 10: The patient elected the hospice benefit on 7/24/23. The initial nursing assessment was completed on 7/24/23, followed by medical social services and spiritual counseling services within five (5) days of the election. A review of the clinical record revealed no documented evidence of an implemented interdisciplinary plan of care that was reviewed and signed by the physician for the benefit period dated 7/24/23 through 10/21/23. Clinical Record 11: The patient elected the hospice benefit on 7/24/23. The initial nursing assessment was completed on 7/24/23, followed by medical social services and spiritual counseling services within five (5) days of the election. A review of the clinical record revealed no documented evidence of an implemented interdisciplinary plan of care that was reviewed and signed by the physician for the benefit period dated 7/24/23 through 10/21/23. Clinical Record 12: The patient elected the hospice benefit on 7/24/23. The initial nursing assessment was completed on 7/24/23, followed by medical social services and spiritual counseling services within five (5) days of the election. A review of the clinical record revealed no documented evidence of an implemented interdisciplinary plan of care that was reviewed and signed by the physician for the benefit period dated 7/24/23 through 10/21/23. Clinical Record 13: The patient elected the hospice benefit on 9/28/23. The initial nursing assessment was completed on 9/28/23, followed by medical social services and spiritual counseling services within five (5) days of the election. A review of the clinical record revealed no documented evidence of an implemented interdisciplinary plan of care that was reviewed and signed by the physician for the benefit period dated 9/28/23 through 12/26/23. Clinical Record 14: The patient elected the hospice benefit on 9/27/23. The initial nursing assessment was completed on 9/27/23, followed by medical social services and spiritual counseling services within five (5) days of the election. A review of the clinical record revealed no documented evidence of an implemented interdisciplinary plan of care that was reviewed and signed by the physician for the benefit period dated 9/27/23 through 12/25/23. During joint record reviews and interviews on 1/19/24, the Director of Nursing (DON) confirmed plans of care were not developed. Therefore, care and services were being provided without the physician-signed plans of care and orders. On day two (2) of the survey, the electronic medical record (EMR) identified plans of care and physician orders with an annotated date, Change Date of 1/17/24 and 1/18/24. The signatures in the EMR on the plans of Care and orders were not authenticated. The DON confirmed the IDG had not been supervising the care and direction of services provided.

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 ensure the implementation of the interdisciplinary plan of care. This standard was not met as evidenced by clinical record review and interview. 12 of 12 (100%) clinical records reviewed the hospice did not ensure a Registered Nurse (RN) was designated to coordinate patient care and ensure the development and implementation of the interdisciplinary plan of care. Clinical Record 1: The patient elected the hospice benefit on 11/6/23. The initial nursing assessment was completed on 11/6/23. A clinical record review revealed no evidence of an initial plan of care documented for the benefit period dated 11/6/23 through 2/3/24. Clinical Record 2: The patient elected the hospice benefit on 8/1/23. The initial nursing assessment was completed on 8/1/23. A clinical record review revealed no evidence of an initial plan of care documented for the benefit period dated 8/1/23 through 10/29/23. Clinical Record 3: The patient elected the hospice benefit on 11/6/23. The initial nursing assessment was completed on 11/6/23. A clinical record review revealed no evidence of an initial plan of care documented for the benefit period dated 11/6/23 through 2/3/24. Clinical Record 4: The patient elected the hospice benefit on 6/22/23. The initial nursing assessment was completed on 6/22/23. A clinical record review revealed no evidence of an initial plan of care documented for the benefit period dated 6/22/23 through 9/19/23. Clinical Record 9: The patient elected the hospice benefit on 8/1/23. The initial nursing assessment was completed on 8/1/23. A clinical record review revealed no evidence of an initial plan of care documented for the benefit period dated 8/1/23 through 10/29/23. Clinical Record 10: The patient elected the hospice benefit on 7/24/23. The initial nursing assessment was completed on 7/24/23. A clinical record review revealed no evidence of an initial plan of care documented for the benefit period dated 7/24/23 through 10/21/23. Clinical Record 11: The patient elected the hospice benefit on 7/24/23. The initial nursing assessment was completed on 7/24/23. A clinical record review revealed no evidence of an initial plan of care documented for the benefit period dated 7/24/23 through 10/21/23. Clinical Record 12: The patient elected the hospice benefit on 7/24/23. The initial nursing assessment was completed on 7/24/23. A clinical record review revealed no evidence of an initial plan of care documented for the benefit period dated 7/24/23 through 10/21/23. Clinical Record 13: The patient elected the hospice benefit on 9/28/23. The initial nursing assessment was completed on 9/28/23. A clinical record review revealed no evidence of an initial plan of care documented for the benefit period dated 9/28/23 through 12/26/23. Clinical Record 14: The patient elected the hospice benefit on 9/27/23. The initial nursing assessment was completed on 9/27/23. A clinical record review revealed no evidence of an initial plan of care documented for the benefit period dated 9/27/23 through 12/25/23. During joint chart reviews and interviews on 1/19/24, the Director of Nursing (DON) confirmed that the clinical records did not contain POCs developed initially at the start of care. The DON stated that she and other RNs entered POCs on 1/17/24, 1/18/24, and 1/19/24, and she presented the POC Work Log in the electronic medical record (EMR) that maintained a time stamp of changes made to the POC. The POC Work Log maintained documentation of the date, time, and type of change made to the POC, including the name of the clinician making the change. Types of changes documented by the Work Log included changes to and creation of orders (problem or visit frequency), changes to and creation of staff responsibilities, changes to the narrative summary, and when the RN signed a POC.

It is required that the hospice designates a registered nurse member of the IDG to ensure the implementation of the interdisciplinary plan of care. Hospice care and services provided to patients and families follow the individualized plan of care established by the hospice IDG 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 12 of 12 (100%) clinical records reviewed, the agency did not ensure that all hospice care and services furnished to patients and their families followed an individualized written plan of care established by the hospice interdisciplinary group (IDG). Clinical Record 1: The patient elected the hospice benefit on 11/6/23. A clinical record review revealed that visits, including nursing, medical social services, and spiritual counseling, were documented as completed within five days of the election. The clinical record did not contain an implemented interdisciplinary plan of care. Clinical Record 2: The patient elected the hospice benefit on 8/1/23. A clinical record review revealed that visits, including nursing, medical social services, and spiritual counseling, were documented as completed within five days of the election. The clinical record did not contain an implemented interdisciplinary plan of care. Clinical Record 3: The patient elected the hospice benefit on 11/6/23. A clinical record review revealed that visits, including nursing, medical social services, and spiritual counseling, were documented as completed within five days of the election. The clinical record did not contain an implemented interdisciplinary plan of care. Clinical Record 4: The patient elected the hospice benefit on 6/22/23. A clinical record review revealed that visits, including nursing, medical social services, and spiritual counseling, were documented as completed within five days of the election. The clinical record did not contain an implemented interdisciplinary plan of care. Clinical Record 6: The patient elected the hospice benefit on 10/3/22. A clinical record review revealed that visits, including nursing, medical social services, and spiritual counseling, were documented as completed within five days of the election. The clinical record did not contain an implemented interdisciplinary plan of care. Clinical Record 8: The patient elected the hospice benefit on 7/10/23. A clinical record review revealed that visits, including nursing, medical social services, and spiritual counseling, were documented as completed within five days of the election. The clinical record did not contain an implemented interdisciplinary plan of care. Clinical Record 9: The patient elected the hospice benefit on 8/1/23. A clinical record review revealed that visits, including nursing, medical social services, and spiritual counseling, were documented as completed within five days of the election. The clinical record did not contain an implemented interdisciplinary plan of care. Clinical Record 10: The patient elected the hospice benefit on 7/24/23. A clinical record review revealed that visits, including nursing, medical social services, and spiritual counseling, were documented as completed within five days of the election. The clinical record did not contain an implemented interdisciplinary plan of care. Clinical Record 11: The patient elected the hospice benefit on 7/24/23. A clinical record review revealed that visits, including nursing, medical social services, and spiritual counseling, were documented as completed within five days of the election. The clinical record did not contain an implemented interdisciplinary plan of care. Clinical Record 12: The patient elected the hospice benefit on 7/24/23. A clinical record review revealed that visits, including nursing, medical social services, and spiritual counseling, were documented as completed within five days of the election. The clinical record did not contain an implemented interdisciplinary plan of care. Clinical Record 13: The patient elected the hospice benefit on 9/28/23. A clinical record review revealed that visits, including nursing, medical social services, and spiritual counseling, were documented as completed within five days of the election. The clinical record did not contain an implemented interdisciplinary plan of care. Clinical Record 14: The patient elected the hospice benefit on 11/6/23. A clinical record review revealed that visits, including nursing, medical social services, and spiritual counseling, were documented as completed within five days of the election. The clinical record did not contain an implemented interdisciplinary plan of care. During joint chart reviews and interviews on 1/19/24, the Director of Nursing (DON) confirmed that the clinical records did not contain an implemented interdisciplinary POC. The DON stated that she and other RNs entered POCs on 1/17/24, 1/18/24, and 1/19/24 with authenticated physician signatures. She presented the POC Work Log in the electronic medical record (EMR) that maintained a time stamp of changes made to the POC. The POC Work Log maintained documentation of the date, time, and type of change made to the POC, including the name of the clinician making the change. Types of changes documented by the Work Log included changes to and creation of orders (problem or visit frequency), changes to and creation of staff responsibilities, changes to the narrative summary, and when the RN signed a POC.

It is required that the Interdisciplinary Group, in collaboration with the individual's attending physician (if any), reviews, revises, and documents the individualized care plan as frequently as the patient's condition requires; but no less frequently than every 15 calendar days. This standard was not met as evidenced by clinical record review and interview. In 12 of 12 (100%) clinical records reviewed, the agency did not ensure the hospice Interdisciplinary Group (IDG) documented the review and revision of the patient's individualized plan of care no less frequently than every 15 calendar days. Clinical Record 1: The patient elected the hospice benefit on 11/6/23. The initial nursing assessment was completed on 11/6/23. A clinical record review revealed no documented evidence of an initial plan of care reviewed and signed by the physician for the benefit period dated 11/6/23 through 2/3/24. There was no documented evidence that the Interdisciplinary Group reviewed and revised the patient's plan of care no less frequently than every 15 calendar days. Clinical Record 2: The patient elected the hospice benefit on 8/1/23. The initial nursing assessment was completed on 8/1/23. A clinical record review revealed no documented evidence of an initial plan of care reviewed and signed by the physician for the benefit period dated 8/1/23 through 10/29/23. There was no documented evidence that the Interdisciplinary Group reviewed and revised the patient's plan of care no less frequently than every 15 calendar days. Clinical Record 3: The patient elected the hospice benefit on 11/6/23. The initial nursing assessment was completed on 11/6/23. A clinical record review revealed no documented evidence of an initial plan of care reviewed and signed by the physician for the benefit period dated 11/6/23 through 2/3/24. There was no documented evidence that the Interdisciplinary Group reviewed and revised the patient's plan of care no less frequently than every 15 calendar days. Clinical Record 4: The patient elected the hospice benefit on 6/22/23. The initial nursing assessment was completed on 6/22/23. A clinical record review revealed no documented evidence of an initial plan of care reviewed and signed by the physician for the benefit period dated 6/22/23 through 9/19/23. There was no documented evidence that the Interdisciplinary Group reviewed and revised the patient's plan of care no less frequently than every 15 calendar days. Clinical Record 6: The patient elected the hospice benefit on 10/3/22. The initial nursing assessment was completed on 10/3/23. A clinical record review revealed no documented evidence of an initial plan of care reviewed and signed by the physician for the benefit period dated 10/3/22 through 1/1/23. There was no documented evidence that the Interdisciplinary Group reviewed and revised the patient's plan of care no less frequently than every 15 calendar days. Clinical Record 8: The patient elected the hospice benefit on 7/10/23. The initial nursing assessment was completed on 7/10/23. A clinical record review revealed no documented evidence of an initial plan of care reviewed and signed by the physician for the benefit period dated 7/10/23 through 10/8/23. There was no documented evidence that the Interdisciplinary Group reviewed and revised the patient's plan of care no less frequently than every 15 calendar days. Clinical Record 9: The patient elected the hospice benefit on 8/1/23. The initial nursing assessment was completed on 8/1/23. A clinical record review revealed no documented evidence of an initial plan of care reviewed and signed by the physician for the benefit period dated 8/1/23 through 10/29/23. There was no documented evidence that the Interdisciplinary Group reviewed and revised the patient's plan of care no less frequently than every 15 calendar days. Clinical Record 10: The patient elected the hospice benefit on 7/24/23. The initial nursing assessment was completed on 7/24/23. A clinical record review revealed no documented evidence of an initial plan of care reviewed and signed by the physician for the benefit period dated 7/24/23 through 10/21/23. There was no documented evidence that the Interdisciplinary Group reviewed and revised the patient's plan of care no less frequently than every 15 calendar days. Clinical Record 11: The patient elected the hospice benefit on 7/24/23. The initial nursing assessment was completed on 7/24/23. A clinical record review revealed no documented evidence of an initial plan of care reviewed and signed by the physician for the benefit period dated 7/24/23 through 10/21/23. There was no documented evidence that the Interdisciplinary Group reviewed and revised the patient's plan of care no less frequently than every 15 calendar days. Clinical Record 12: The patient elected the hospice benefit on 7/24/23. The initial nursing assessment was completed on 7/24/23. A clinical record review revealed no documented evidence of an initial plan of care reviewed and signed by the physician for the benefit period dated 7/24/23 through 10/21/23. There was no documented evidence that the Interdisciplinary Group reviewed and revised the patient's plan of care no less frequently than every 15 calendar days. Clinical Record 13: The patient elected the hospice benefit on 9/28/23. The initial nursing assessment was completed on 9/28/23. A clinical record review revealed no documented evidence of an initial plan of care reviewed and signed by the physician for the benefit period dated 9/28/23 through 12/26/23. There was no documented evidence that the Interdisciplinary Group reviewed and revised the patient's plan of care no less frequently than every 15 calendar days. Clinical Record 14: The patient elected the hospice benefit on 9/27/23. The initial nursing assessment was completed on 9/27/23. A clinical record review revealed no documented evidence of an initial plan of care reviewed and signed by the physician for the benefit period dated 9/27/23 through 12/25/23. There was no documented evidence that the Interdisciplinary Group reviewed and revised the patient's plan of care no less frequently than every 15 calendar days. During joint chart reviews and interviews on 1/19/24, the Director of Nursing (DON) confirmed that the clinical records did not contain an implemented interdisciplinary POC. The DON stated that she and other RNs entered POCs on 1/17/24, 1/18/24, and 1/19/24 with authenticated physician signatures. She presented the POC Work Log in the electronic medical record (EMR) that maintained a time stamp of changes made to the POC. The POC Work Log maintained documentation of the date, time, and type of change made to the POC, including the name of the clinician making the change. Types of changes documented by the Work Log included changes to and creation of orders (problem or visit frequency), changes to and creation of staff responsibilities, changes to the narrative summary, and when the RN signed a POC.

It is required that licensed professionals participate in hospice sponsored in-service training. This standard was not met as evidenced by interview and personnel record review. 1 of 2 (50%) personnel records reviewed revealed that the agency did not ensure that licensed professionals participated in hospice in-service training. Personnel Record 6: The Director of Nursing (DON) was hired on 11/10/2020. The personnel record did not contain documentation that the DON participated in hospice in-service training in 2021, 2022, and 2023. On 1/17/24 a joint record review and interview were conducted with the Director of Nursing (DON), who verified the personnel record did not contain documentation of licensed employees attending hospice in-service training. The DON stated she would obtain the documentation of completed in-service training for each employee from an electronic file; however, original documentation of in-service training for employees was not presented before the exit conference.

It is required that a hospice aide provides services: ordered by the Interdisciplinary Group; included in the plan of care; permitted to be performed under state law and regulation; consistent with the hospice aide training. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This CONDITION of participation was not met as evidenced review of clinical records and interviews revealed the following: Failure of the hospice to ensure that the Hospice Aide received written patient care instructions prepared by a Registered Nurse (RN) responsible for supervision of the Hospice Aide [HCDT.15.I/L625]; Failure of the hospice to ensure that the hospice aide provided services as instructed in the aide care plan [HCDT.16.I/L626]; and Failure of the hospice to ensure that the hospice aide completed a competency evaluation program [HSRM.9.I/L615]. The cumulative effect of these deficiencies has resulted in the hospice agency’s ability to ensure the provision of quality hospice care for the condition of participation CFR 418.76, Hospice Aide and Homemaker Services. The collective deficient practice illustrated systemic process failures that had the potential to affect all patients receiving hospice aide services from the agency.

It is required that a qualified hospice aide has successfully completed a competency evaluation program that evaluates the aide’s competency in the following subject areas by observation of the aide’s performance with a patient or a pseudo patient: 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; and appropriate and safe techniques in performing personal hygiene and grooming tasks, including items on the following basic checklist: bed bath; sponge, tub, and shower bath; hair shampoo (sink, tub, and bed); nail and skin care; oral hygiene; toileting and elimination; safe transfer techniques and ambulation; and normal range of motion and positioning. This standard was not met as evidenced by interview and personnel record review. In 1 of 1 (100%) aide personnel records reviewed of hospice aides, the hospice did not ensure that the hospice aide successfully completed a competency evaluation program. Personnel Record 2: The hospice aide was hired on 11/15/21. A review of the hospice aide personnel record revealed no evidence that the hospice aide completed a competency evaluation at the time of hire and before providing patient care. On 1/17/24, a joint record review and interview were conducted with the Director of Nursing (DON), who verified the personnel record did not contain documentation of completed aide competencies. The DON stated she would obtain the completed documentation from an electronic file; however, the original documentation of the aide's completed competency assessments was not presented before the exit conference.

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 clinical record review and interview. In 2 of 3 (67%) clinical records reviewed in which Hospice Aide services were accepted, the agency did not ensure the Hospice Aide received written patient care instructions prepared by a Registered Nurse (RN) responsible for supervision of the Hospice Aide. Clinical Record 1: The Hospice Aide care plan effective 11/6/23, documented the following tasks to be completed by the Aide: foot care every visit, shampooing hair as needed (PRN), skin care every visit, nail care every visit, shaving PRN, and incontinence care every visit. The Hospice Aide care plan did not provide specific instructions on the type of foot, skin, shave, and incontinence care to be provided. The Hospice Aide care plan did not provide the Aide specific frequencies on when the shampoo and shave were to be completed. The nursing assessment dated 11/6/23 documented the patient was unsteady and a fall risk. The Hospice Aide care plan did not alert the aide to the patient's risk of falls. Clinical Record 14: The Hospice Aide care plan effective 10/2/23 through 11/24/23, documented the following tasks to be completed by the Aide: foot care every visit, shampooing hair as needed (PRN), skin care every visit, nail care every visit, shave PRN, and incontinence care every visit. The Hospice Aide care plan did not provide specific instructions on the type of foot, skin, shave, and incontinence care to be provided. The Hospice Aide care plan did not provide the aide specific frequencies on when the shampoo and shave were to be completed. On 1/19/24 joint record reviews and interviews were conducted with the Director of Nursing (DON) who agreed that care instructions for the Aide did not provide the Aide with specific instructions on the type of care to be provided and how often shaving and shampooing needed to occur to meet patients’ needs.

It is required that a hospice aide provides services ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by clinical record review, observation, and interview. 2 of 3 (67%) clinical records reviewed, in which Hospice Aide (HA) services were accepted, the agency did not ensure the HA provided services ordered by the Interdisciplinary Group and included in the plan of care. Clinical Record 1/Home Visit 1: The Registered Nurse (RN) created a hospice aide care plan on 11/6/23 with instructions for the aide to perform a shave as needed (PRN) and three (3) visits per week. Hospice Aide [Personnel Record 2] visits were documented as completed three (3) times per week from 1/1/24 to the current date with all tasks except shampoo and shave marked as completed. During the home visit with the Hospice Aide (HA) [Personnel Record 2] on 1/19/24, the patient had a full-facial beard. The patient stated during the interview that it was the first time the HA [Personnel Record 2] had visited and confirmed that he did want a full-facial shave. In an interview with the HA on 1/19/24, the HA confirmed that this was the first day she had been able to see the patient. There was a 19 day period that aide visits were documented without any evidence of completion. There was no evidence the RN was notified the care plan was not followed. Clinical Record 14: The hospice aide care plan effective on 9/27/23 ordered tasks each visit and as needed that included bathing, shampooing hair, shaving, and nail, foot, and incontinence care. The aide notes for the completed visit on 9/29/23 did not document any care was provided, or the reason why the care tasks were not provided. There was no evidence the RN was notified the care plan was not followed. On 1/19/24 joint record reviews and interviews were conducted with the Director of Nursing (DON), who confirmed the findings. The DON did not speak to the HA for Record 1 about documenting visits that the patient and HA claimed were not made.

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 CONDITION LEVEL DEFICIENCY CITED AS IMMEDIATE JEOPARDY. This CONDITION of participation, which was also cited as an Immediate Jeopardy, was not met as evidenced by review of clinical records and interviews which revealed failure by the Governing Body to ensure that the management and oversight of the clinical operations of the hospice were occurring on a day-to-day basis, and that the individuals charged with providing oversight of the provision of care and services were completing the duties associated with their roles [HSLG.2.I/L651]; and Failure of the hospice to designate a registered nurse member of the interdisciplinary group to provide coordination of care and ensure continuous assessment of the patient's and family's needs and implementation of the interdisciplinary plan of care (HCPC.19.I/L540). The cumulative effect of these deficiencies has resulted in the hospice organization's inability to ensure the provision of quality of care for the Condition of Participation CFR 418.100: Organization and administration of services. The collective deficient practice illustrated systemic process failures that had the potential to affect all patients receiving hospice care and services from the agency.

It is required that the hospice’s governance (or designated person(s) so functioning) assumes full legal authority and responsibility for the organization’s overall management and operation, provision of care and services. fiscal operations, and ongoing performance improvement and patient safety program that is defined, implemented, maintained, and evaluated annually. This standard was not met, as evidenced by clinical record review, document review, and interview. The governing body did not provide oversight of the organizational operations to ensure the hospice interdisciplinary group (IDG) delivered services to patients, caregivers, and families that provided palliation and management of their terminal illness and related conditions. There was no documented evidence that the governing body provided oversight and management of hospice operations to ensure the provision of care and services. The clinical records were missing initial hospice plans of care and updated plans of care (POC), verbal orders, plans of care signed by the physician or health care practitioner, medication orders, drug regime reviews, and medication profiles. The Administrator could not provide documentation to support that the hospice's overall status of operations and provision of care and services had been reviewed in 2022 or 2023. No documented evidence included information about the ongoing operations of the organization, including no information pertaining to patient care coordination and issues such as missed comprehensive assessments, plans of care and updated plans of care, Interdisciplinary Group (IDG) review of plans of care, verbal orders and signed physician orders, and drug regime reviews and medication profiles. During an interview on 1/19/24, the Director of Nursing (DON) confirmed that care and services were being provided without verbal orders and physician-signed plans of care, treatment, and medication orders. DON stated that “we did not know how to enter orders and the plans of care” into their electronic medical record (EMR). The DON also confirmed that she and other RNs entered POCs for patients being reviewed during the previous night and into the morning to correct the charting deficiencies from July 2023 to current records identified during the survey.

It is required that the hospice medical director, physician employees, and contracted physician(s), in conjunction with the patient’s attending physician, are responsible for the palliation and management of the terminal illness as well as conditions related to the terminal illness. THIS IS A CMS CONDITION LEVEL DEFICIENCY CITED AS IMMEDIATE JEOPARDY. This CONDITION of participation, which was also cited as an Immediate Jeopardy, was not met as evidenced by clinical record review and interviews which revealed that the Medical Director had not considered current medications and treatments when providing written certification of patients' life expectancy [HCPC.4.I/L667]; failure of the Medical Director to review the patient’s clinical information when providing written recertification of the patient's terminal illness [HCPC.6.I/L668]; and failure of the Medical Director to assume responsibility for the medical component of the hospice care program [HCPC.4.I/L669]. The cumulative effect of these deficiencies has resulted in the hospice organization's inability to ensure the provision of quality of care for the Condition of Participation CFR 418.102: Medical Director. The collective deficient practice illustrated systemic process failures that had the potential to affect all patients receiving hospice care and services from the agency.

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 current subjective and objective medical findings and current medication and treatment orders. This standard was not met as evidenced by clinical record review and interview. In 13 of 13 (100%) clinical records reviewed, the agency did not ensure that the Medical Director considered current medications and treatments when providing written certification of patients' life expectancy. Clinical Record 1: The patient elected the hospice benefit on 11/6/23. The medical record did not contain a comprehensive assessment that included a drug profile obtained on admission for review by the Medical Director, limiting data needed to determine the patient's anticipated life expectancy. Clinical Record 2: The patient elected the hospice benefit on 8/1/23. The medical record did not contain a comprehensive assessment that included a drug profile obtained on admission for review by the Medical Director, limiting data needed to determine the patient's anticipated life expectancy. Clinical Record 3: The patient elected the hospice benefit on 11/6/23. The medical record did not contain a comprehensive assessment that included a drug profile obtained on admission for review by the Medical Director, limiting data needed to determine the patient's anticipated life expectancy. Clinical Record 4: The patient elected the hospice benefit on 6/22/23. The medical record did not contain a comprehensive assessment that included a drug profile obtained on admission for review by the Medical Director, limiting data needed to determine the patient's anticipated life expectancy. Clinical Record 5: The patient elected the hospice benefit on 7/17/23. The medical record did not contain a comprehensive assessment that included a drug profile obtained on admission for review by the Medical Director, limiting data needed to determine the patient's anticipated life expectancy. Clinical Record 6: The patient elected the hospice benefit on 10/3/22. The medical record did not contain a comprehensive assessment that included a drug profile obtained on admission for review by the Medical Director, limiting data needed to determine the patient's anticipated life expectancy. Clinical Record 8: The patient elected the hospice benefit on 7/10/23. The medical record did not contain a comprehensive assessment that included a drug profile obtained on admission for review by the Medical Director, limiting data needed to determine the patient's anticipated life expectancy. On 1/19/24 an interview was conducted with the RN Case Manager documented as completing the plan of care (POC) for admission, who confirmed that the initial POC, including the drug profile, was not created until the morning of 1/19/24. Clinical Record 9: The patient elected the hospice benefit on 8/1/23. The medical record did not contain a comprehensive assessment that included a drug profile obtained on admission for review by the Medical Director, limiting data needed to determine the patient's anticipated life expectancy. Clinical Record 10: The patient elected the hospice benefit on 7/24/23. The medical record did not contain a comprehensive assessment that included a drug profile obtained on admission for review by the Medical Director, limiting data needed to determine the patient's anticipated life expectancy. Clinical Record 11: The patient elected the hospice benefit on 7/24/23. The medical record did not contain a comprehensive assessment that included a drug profile obtained on admission for review by the Medical Director, limiting data needed to determine the patient's anticipated life expectancy. Clinical Record 12: The patient elected the hospice benefit on 7/24/23. The medical record did not contain a comprehensive assessment that included a drug profile obtained on admission for review by the Medical Director, limiting data needed to determine the patient's anticipated life expectancy. Clinical Record 13: The patient elected the hospice benefit on 11/6/23. The medical record did not contain a comprehensive assessment that included a drug profile obtained on admission for review by the Medical Director, limiting data needed to determine the patient's anticipated life expectancy. Clinical Record 14: The patient elected the hospice benefit on 9/27/23. The medical record did not contain a comprehensive assessment that included a drug profile obtained on admission for review by the Medical Director, limiting data needed to determine the patient's anticipated life expectancy. On 1/19/24 an interview was conducted with the RN Case Manager documented as completing the POC order for 9/27/23, who confirmed that the POC for the benefit period 9/27/23 - 12/26/23, including the drug profile, was not created until the morning of 1/19/24. On 1/19/24 joint record reviews and interviews were conducted with the Director of Nursing (DON), who confirmed that initial comprehensive assessments did not include drug profiles. The DON also stated that "they" did not know how to correctly enter information into the electronic medical record (EMR), and that agency leadership did not ensure all data was collected and relayed to the physician.

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 for the hospice care benefit is informed by the medical director or physician designee’s review of the patient’s clinical information. This standard was not met as evidenced by clinical record review and interview. In 7 of 9 (78%) clinical records reviewed for patients recertified for another benefit period, the agency did not ensure the Medical Director considered subjective and objective medical findings and current medications and treatments when providing written recertification of the patient's terminal illness. Clinical Record 2: The Medical Director electronically signed and verified the written narrative recertifying the patient's terminal illness for the benefit period 10/30/23 to 1/27/24. The clinical record did not contain updated comprehensive assessments that identified the drug profile and the patient's response to medications provided in the palliation of symptoms. Clinical Record 4: The Medical Director electronically signed and verified the written narrative recertifying the patient's terminal illness for the benefit period 9/20/23 to 12/18/23. The clinical record did not contain updated comprehensive assessments that identified the drug profile and the patient's response to medications provided in the palliation of symptoms. Clinical Record 9: The Medical Director electronically signed and verified the written narrative recertifying the patient's terminal illness for the benefit period 10/30/23 to 2/3/24. The clinical record did not contain updated comprehensive assessments that identified the drug profile and the patient's response to medications provided in the palliation of symptoms. Clinical Record 10: The Medical Director electronically signed and verified the written narrative recertifying the patient's terminal illness for the benefit period 9/20/23 to 12/18/23. The clinical record did not contain updated comprehensive assessments that identified the drug profile and the patient's response to medications provided in the palliation of symptoms. The RN recertification assessment dated 10/16/23 did not include documentation of assessment findings for the Medical Director to review for determining the recertification of terminal illness. Clinical Record 11: The Medical Director electronically signed and verified the written narrative recertifying the patient's terminal illness for the benefit period 10/22/23 to 1/19/24. The clinical record did not contain updated comprehensive assessments that identified the drug profile and the patient's response to medications provided in the palliation of symptoms. Clinical Record 12: The Medical Director electronically signed and verified the written narrative recertifying the patient's terminal illness for the benefit period 10/22/23 to 1/19/24. The clinical record did not contain updated comprehensive assessments that identified the drug profile and the patient's response to medications provided in the palliation of symptoms. Clinical Record 13: The Medical Director electronically signed and verified the written narrative recertifying the patient's terminal illness for the benefit period 12/27/23 to 3/25/24. The clinical record did not contain updated comprehensive assessments that identified the drug profile and the patient's response to medications provided in the palliation of symptoms. On 1/19/23 joint record reviews and interviews were conducted with the Director of Nursing (DON) who confirmed that the clinical records did not include initial and updated drug profiles before 1/17/24. The DON stated that she and other RNs worked to enter drug profiles with plans of care on 1/17/24, 1/18/24, and 1/19/24.

It is required that the medical director or physician designee has responsibility for the medical component of the hospice's patient care program. This standard was not met as evidenced by clinical record review and interview. In 13 of 13 (100%) clinical records reviewed, the agency did not ensure that the Medical Director took responsibility for the medical component of the hospice care program. Clinical Record 1: The patient elected the hospice benefit on 11/6/23, and the Medical Director documented, electronically signed, and electronically verified the Certification of Terminal Illness (CTI) on 11/6/23. The clinical record did not contain a signed plan of care order or physician orders for care and services provided to the patient. Clinical Record 2: The patient elected the hospice benefit on 11/6/23. The Medical Director documented, electronically signed, and electronically verified the CTI for benefit periods (BP) 8/1/23 to 10/29/23 and 10/30/23 to 1/27/24. The clinical record did not contain signed plans of care orders or physician orders for care and services provided to the patient. Clinical Record 3: The patient elected the hospice benefit on 11/6/23, and the Medical Director documented, electronically signed, and electronically verified the CTI for the BP from 11/6/23 to 2/3/24. The clinical record did not contain a signed plan of care order or physician orders for care and services provided to the patient. Clinical Record 4: The patient elected the hospice benefit on 6/22/23 and was discharged from services on 12/18/23 due to no longer being terminally ill. The Medical Director documented, electronically signed, and electronically verified the CTI for benefit periods 6/22/23 to 9/19/23 and 9/20/23 to 12/18/23. The clinical record did not contain signed plans of care orders or physician orders for care and services provided to the patient, discharge orders, and documentation from the Medical Director confirming the patient was no longer considered terminally ill. Clinical Record 5: The patient elected the hospice benefit on 11/6/23, and the Medical Director documented, electronically signed, and electronically verified the Certification of Terminal Illness on 11/6/23. The clinical record did not contain a signed plan of care order or physician orders for care and services provided to the patient. Clinical Record 6: The patient elected the hospice benefit on 7/17/23 and per documentation was discharged on 9/1/23 for cause (i.e. patient/staff safety.) The Medical Director documented, electronically signed, and electronically verified the CTI for the BP from 7/17/23 to 10/15/23. The clinical record did not contain a signed plan of care order or physician orders for care and services provided to the patient or for discharge of the patient from services. Clinical Record 8: The patient elected the hospice benefit on 7/10/23, and the Medical Director documented, electronically signed, and electronically verified the CTI for the BP from 7/10/23 to 10/8/23. The clinical record did not contain a signed plan of care order or physician orders for care and services provided to the patient. Clinical Record 9: The patient elected the hospice benefit on 8/1/23, and the Medical Director documented, electronically signed, and electronically verified the CTI for benefit periods 8/1/23 to 10/29/23 and 10/30/23 to 2/3/24. The clinical record did not contain signed plans of care orders or physician orders for care and services provided to the patient. Clinical Record 10: The patient elected the hospice benefit on 7/24/23, and the Medical Director documented, electronically signed, and electronically verified the CTI for benefit periods 7/24/23 to 10/21/23 and 10/22/23 to 1/19/24. The clinical record did not contain signed plans of care orders or physician orders for care and services provided to the patient. Clinical Record 11: The patient elected the hospice benefit on 7/24/23, and the Medical Director documented, electronically signed, and electronically verified the CTI for benefit periods 7/24/23 to 10/21/23 and 10/22/23 to 1/19/24. The medical record does not contain a signed plan of care order or physician orders for care and services provided to the patient. Clinical Record 12: The patient elected the hospice benefit on 7/24/23, and the Medical Director documented, electronically signed, and electronically verified the CTI for benefit periods 7/24/23 to 10/21/23 and 10/22/23 to 1/19/24. The medical record does not contain a signed plan of care order or physician orders for care and services provided to the patient. Clinical Record 13: The patient elected the hospice benefit on 9/28/23, and the Medical Director documented, electronically signed, and electronically verified the CTI for benefit periods 9/28/23 to 12/26/23 and 12/27/23 to 3/25/24. The medical record does not contain a signed plan of care order or physician orders for care and services provided to the patient. Clinical Record 14: The patient elected the hospice benefit on 9/27/23, and the Medical Director documented, electronically signed, and electronically verified the CTI for benefit periods 9/27/23 to 12/25/23 to 3/24/24. The medical record does not contain a signed plan of care order or physician orders for care and services provided to the patient. On 1/19/24 chart record reviews and interviews were conducted with the DON, who confirmed that plans of care, for patients chosen for clinical record review, were not created until 1/17/24, 1/18/24, and 1/19/24. The DON stated that she and other RNs had entered the POCs during the survey site visit. On 1/19/24 an interview was conducted with the Medical Director who stated that part of his responsibilities was to complete initial and recertification CTIs and provide physician orders when needed. He confirmed that he participated in the scheduled IDG meetings every other Wednesday via Zoom. He stated that orders were typically signed through the agency’s EMR or when faxed to him. He did not recall signing any orders in the previous days or weeks before the interview.

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. THIS IS A CMS CONDITION LEVEL DEFICIENCY CITED AS IMMEDIATE JEOPARDY. This CONDITION of participation, which was also cited as an Immediate Jeopardy, was not met as evidenced review of clinical records and interviews with the Director of Nursing, Registered Nurse Case Manager and Medical Director, which revealed issues with the development and maintenance of the clinical record that contained past and current findings for each hospice patient in the following areas: Failure to ensure the patient's clinical record included plan of care, initial assessment, comprehensive assessment, updated comprehensive assessments, and clinical notes including the care and services provided [HSIM.3.I/L672]; Failure to ensure that entries in the patient record were appropriately authenticated and dated by the physician [HSIM.4.I/L679]; Failure to ensure the prevention of physical or electronic altering of the patient record [HSIM.5.I/L680]; and Failure to ensure that the patient's clinical record included physician orders [HSIM.3.I/L678]. The cumulative effect of these deficiencies has resulted in the hospice organization's inability to ensure the provision of quality of care for the Condition of Participation CFR 418.104: Clinical Records. The collective deficient practice illustrated systemic process failures that had the potential to affect all patients receiving hospice care and services from the agency.

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 the initial plan of care, updated plans of care, and clinical notes including the care and services provided. This standard was not met as evidenced by clinical record review and interview. In 10 of 10 (100%) clinical records reviewed, the agency did not ensure that the clinical records contained an initial and updated plan of care for hospice care and services being provided. Clinical Record 1: The patient elected hospice services on 11/6/23. A review of the clinical record revealed weekly SN, Hospice Aide (HA), monthly MSW services, and monthly Chaplain services documented as provided to the patient. The clinical record did not include documentation of an initial and updated POC including visit frequencies for the SN, HA, Chaplain and the MSW. A POC Work Log documented that an order identifying pain and fall risk as problems was added on 1/10/24, an order identifying spiritual care as a problem was added on 1/11/24, and changes to the status of team members were entered on 1/17/24. There was no evidence of physician contact and consultation to support the addition orders added on 1/10/24, 1/11/24 and 1/17/24. Clinical Record 2/Home Visit 1: The patient elected hospice services on 8/1/23. A review of the clinical record revealed weekly Skilled Nursing (SN) services and monthly Medical Social Worker (MSW) services were documented as provided to the patient. There was a documented Chaplain visit note dated 8/3/23. During the home visit on 1/18/24, the Chaplain stated they visited the patient every month. The clinical record did not include initial POC orders created at the start of care. The electronic medical record (EMR) plan of care (POC) Work Logs dated 1/17/24 and 1/19/24 documented changes made to the plans of care for the benefit periods (BP) dated 8/1/23 through 10/29/23 and 10/30/23 through 1/27/24 including the documented addition of visit frequency orders for the SN, MSW, and Chaplain. The plan of care did not include an update for psychosocial interventions provided by the MSW. Clinical Record 3: The patient elected hospice services on 11/6/23. A review of the clinical record revealed weekly SN and monthly MSW services were documented as provided to the patient. The clinical record did not include initial POC orders created at the start of care. The POC Work Log dated 1/17/24 documented changes made by the Registered Nurse (RN) to the POC dated 11/6/23 through 2/3/24 which included the orders for problems identified during the comprehensive assessment dated 11/6/23: Neurological/Fall Risk, Pain, and Nutrition and Spiritual as of 1/4/23. The plan of care did not include an update for psychosocial interventions provided by the MSW. Clinical Record 4: The patient elected hospice services on 6/22/23. A review of the clinical record revealed weekly SN, monthly MSW services, and monthly Chaplain services documented as provided to the patient. The clinical record did not include initial POC orders created at the start of care. The POC Work Log dated 1/19/24 documented changes to the POC dated 6/22/23 through 9/19/23 which included the orders for SN problems identified during the comprehensive assessments dated 8/3/23, 9/15/23, and 11/29/23. Neurological/Fall Risk, Pain, and Nutrition and Spiritual as of 1/4/23. The plan of care did not include an update for psychosocial interventions provided by the MSW. During an interview 1/19/24, the RN Case Manager, who signed the POC confirmed that the plans of care for the benefit periods dated 6/22/23 through 9/19/23 and 9/20/23 through 12/18/23 were developed and documented on 1/19/24. Clinical Record 6: The patient elected hospice services on 10/3/22 and was discharged from hospice care on 5/30/23 as no longer terminal. A review of the clinical record revealed weekly SN, monthly MSW services, and monthly Chaplain services documented as provided to the patient. The clinical record did not include initial POC orders created at the start of care. The POC Work Logs dated 10/29/22, 1/18/24, and 1/19/24 documented changes to the POC which included the orders for problems identified during the comprehensive assessments and changes to the patient summary. The plan of care did not include an update for psychosocial interventions provided by the MSW. Clinical Record 10: The patient elected hospice services on 7/24/23. A review of the clinical record revealed weekly SN and monthly MSW services documented as provided to the patient. The initial nursing assessment dated 7/24/23 documented symptoms associated with terminal illness and related conditions including dyspnea, wheezes, edema, and the need for oxygen and nebulizer treatments. The clinical record did not include initial POC orders created at the start of care. A review of the clinical record revealed the recertification comprehensive assessment dated 10/16/23 was incomplete. The clinical record did not contain documentation of a completed, updated comprehensive assessment. The POC Work Logs dated 1/18/24 documented changes to the POC for the BP dated 10/22/23 through 1/19/24 including the documented addition of visit frequency orders: one (1) time per week for SN, MSW, and Chaplain. The documented changes to the POC did not include documentation of psychosocial and spiritual interventions. Clinical Record 11: The patient elected hospice services on 7/24/23. A review of the clinical record revealed weekly SN and monthly MSW services documented as provided to the patient. The clinical record did not include initial POC orders created at the start of care. The POC Work Logs dated 12/27/23, 1/9/23, 1/18/24, and 1/19/24 documented changes to the POC for the BP dated 10/22/23 through 1/19/24. The documented changes to the POC did not include documentation of medications provided and the frequency of visits for the SN and MSW. Clinical Record 12: The patient elected hospice services on 7/24/23. A review of the clinical record revealed weekly SN, initial MSW, and initial Chaplain services were documented as being provided to the patient. The clinical record did not include initial POC orders created at the start of care. The POC Work Log documented changes to the POC for the BP dated 10/22/23 through 1/19/24 which included the orders for a visit frequency of one visit per month for the MSW and Chaplain. The documented changes to the POC did not include documentation of psychosocial and spiritual interventions and medications to be provided. Clinical Record 13: The patient elected hospice services on 9/28/23. A review of the clinical record revealed weekly SN, monthly MSW services, and monthly Chaplain services documented as provided to the patient. The clinical record did not include initial POC orders created at the start of care. The POC Work Log dated 1/19/24 documented changes to the POC for the BP dated 9/28/23 through 12/25/23 on 1/19/24 which included the orders for visit frequencies for the SN, MSW, and Chaplain, and documentation of SN and Chaplain interventions. The plan of care did not include an update for psychosocial interventions provided by the MSW. Clinical Record 14: The patient elected hospice services on 9/27/23. A review of the clinical record revealed weekly SN, monthly MSW services, and monthly Chaplain services documented as provided to the patient. The clinical record did not include initial POC orders created at the start of care. The POC Work Log dated 1/19/24 documented changes to the POC for the BP dated 12/26/23 through 3/24/24 on 1/19/24 which included the orders for visit frequencies for the SN, MSW, and Chaplain, documentation of SN and Chaplain interventions, and medications with a start date of 10/26/23. The plan of care did not include an update for psychosocial interventions provided by the MSW. On 1/19/24 an interview was conducted with the RN Case Manager, who signed the POC. The RN confirmed that POCs for the benefit periods of 9/27/23 to 12/25/23 and 12/26/23 to 3/24/24 were not developed until she entered them on 1/19/24. On 1/19/24 joint chart reviews and interviews were conducted with the Director of Nursing (DON), who confirmed that the clinical records did not contain POCs developed initially, at the start of care, and POCs updated as patient conditions warranted and new benefit periods entered. The DON stated that she and other RNs entered POCs on 1/17/24, 1/18/24, and 1/19/24, and they presented the POC Work Log in the EMR. The POC Work Log maintained documentation of the date, time, and type of change made to the POC, including the name of the clinician making the change. The types of changes documented by the POC Work Log included changes to, and creation of orders (problem or visit frequency), changes to and creation of staff responsibilities, changes to the narrative summary, and when a POC was signed by the RN. On 1/19/24, an interview was conducted with an RN Case Manager, who confirmed that on 1/18/24 and 1/19/24 entered initial and updated POCs for current and discharged patients. The RN stated that she entered the initial Plans of Care from patient assessments dated 7/10/23 and 9/17/23. The RN stated that the drug profiles for these initial POCs were based on “notes” she had kept on each patient. She did not respond when asked to describe how the information in her paper notes was stored and kept confidential.

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 physician orders. This standard was not met as evidenced by clinical record review, interview, and observation. In 10 of 10 (100%) clinical records reviewed, the agency did not ensure the clinical records included physician orders for the hospice care and services provided. Clinical Record 1: The patient elected hospice services on 11/6/23. A review of the clinical record revealed weekly SN, Hospice Aide (HA), monthly MSW services, and monthly Chaplain services documented as provided to the patient. The clinical record did not include documented physician orders for visits made by each discipline. Clinical Record 2/Home Visit 1: The patient elected hospice services on 8/1/23. A review of the clinical record revealed weekly Skilled Nursing (SN) services and monthly Medical Social Worker (MSW) services were documented as provided to the patient. There was a documented Chaplain visit note dated 8/3/23. During the home visit on 1/18/24, the Chaplain stated they visited the patient every month. The clinical record did not include documented physician orders for visits made by each discipline. In addition, during the home visit, a medication review was performed with the patient's caregiver. The caregiver reported that the patient was taking carvedilol, amlodipine, and docusate sodium. The clinical record did not include documented physician orders for the medications. Clinical Record 3/Home Visit 2: The patient elected hospice services on 11/6/23. A review of the clinical record revealed weekly SN and monthly MSW services were documented as provided to the patient. The clinical record did not contain physician orders for visits made by each discipline. A Hospice Aide care plan created on 1/8/24 assigned Hospice Aide (HA) services for personal care three (3) days per week. The clinical record did not contain physician orders for the HA visits. During the home visit on 1/18/24, the patient’s caregiver confirmed that the HA was visiting three (3) days per week. In addition, during the home visit, a medication review was performed with the patient's caregiver. The caregiver reported that the patient was taking acetaminophen with codeine as needed for pain. The clinical record did not contain physician orders for the acetaminophen with codeine as needed for pain. Clinical Record 4: The patient elected hospice services on 6/22/23. A review of the clinical record revealed weekly SN, monthly MSW services, and monthly Chaplain services documented as provided to the patient 6/22/23 through 9/19/23. The clinical record did not contain physician orders for visits made by each discipline. The initial nursing assessment completed on 6/22/23 documented the patient's use of oxygen at two (2) liters per minute (LPM). The clinical record did not contain physician orders for oxygen. Clinical Record 6: The patient elected hospice services on 10/3/22 and was discharged from hospice care on 5/30/23 as no longer terminal. A review of the clinical record revealed weekly SN, monthly MSW services, and monthly Chaplain services documented as provided to the patient. The clinical record did not contain physician orders for visits made by each discipline. Additionally, there were no documented physician orders to discharge the patient from hospice services. Clinical Record 10: The patient elected hospice services on 7/24/23. A review of the clinical record revealed weekly SN and monthly MSW services documented as provided to the patient. The initial nursing assessment dated 7/24/23 documented symptoms associated with terminal illness and related conditions including dyspnea, wheezes, edema, and the need for oxygen and nebulizer treatments. Additionally, the assessment documented that the patient was taking Tylenol for pain and using oxygen at three (3) LPM. The clinical record did not contain physician orders for visits made by each discipline, the Tylenol, and the oxygen. Clinical Record 11: The patient elected hospice services on 7/24/23. A review of the clinical record revealed weekly SN and monthly MSW services documented as provided to the patient. The Chaplain completed an initial visit on 7/28/23. The clinical record did not contain physician orders for visits made by each discipline. The initial nursing assessment dated 7/24/23 documented the patient's use of oxygen at 3 LPM. The clinical record did not contain physician orders for oxygen. Clinical Record 12: The patient elected hospice services on 7/24/23. A review of the clinical record revealed weekly SN, initial MSW (7/26/23), and initial Chaplain (7/25/23) services were documented as being provided to the patient. The clinical record did not contain physician orders for visits made by each discipline. Clinical Record 13: The patient elected hospice services on 9/28/23. A review of the clinical record revealed weekly SN, monthly MSW services, and monthly Chaplain services documented as provided to the patient. The clinical record did not contain physician orders for visits made by each discipline. Clinical Record 14: The patient elected hospice services on 9/27/23. A review of the clinical record revealed weekly SN, monthly MSW, HA, and monthly Chaplain services documented as provided to the patient. The clinical record did not contain physician orders for visits made by each discipline. The initial nursing assessment dated 9/27/23 documented that the patient was using oxygen at two (2) LPM via nasal cannula (NC). The clinical record did not contain physician orders for the oxygen. The nursing assessment dated 10/5/23 documented, “pain pump and PO (by mouth) meds (medications) for pain management.” The clinical record did not contain physician orders for pain medications administered by a pump or by mouth. During a joint record review and interviews on 1/19/24, the Director of Nursing (DON) confirmed the clinical records did not contain physician orders for all visits completed, medications identified in the assessments and home, and oxygen provided. The DON stated that she and other Registered Nurses (RN) entered POCs on 1/17/24, 1/18/24, and 1/19/24 which included visit frequencies and medications. The DON presented the POC Work Log in the electronic medical record (EMR) that maintained a time stamp of changes made to the POC. The POC Work Log maintained documentation of the date, time, and type of change made to the POC, including the name of the clinician making the change. Types of changes documented by the Work Log included changes to and creation of orders (visit frequency) and when a POC was signed by the RN.

It is required that all entries in the patient record are legible, complete, appropriately authenticated, and dated by the person performing the care/service in accordance with hospice policy and with currently acceptable standards of practice. The hospice has a means to authenticate entries or to identify the author of each entry. If the hospice uses electronic records, electronic authentication utilizes a user ID and password protection. This standard was not met as evidenced by clinical record review, document review, and interview. In 10 of 10 (100%) clinical records reviewed, the agency did not ensure that entries in the patient record were appropriately authenticated and dated by the physician. Document 2: The agency could not present a policy addressing the authentication of records, electronic signatures, and documentation standards. The agency could not produce a signature log to verify the computerized signature that lacked the digitally signed date stamp. Clinical Record 1: The patient elected hospice services on 11/6/23. A clinical record review revealed weekly SN, Hospice Aide (HA) services three (3) times per week, monthly MSW services, and monthly Chaplain services documented as provided to the patient. The POC Work Log documented that an order identifying pain and fall risk as problems was added on 1/10/24, an order identifying spiritual care as a problem was added on 1/11/24, and changes to the status of team members were entered on 1/17/24. The physician signatures on the plans of care and orders were not appropriately authenticated signatures. The physician signatures were computer-generated without authentication. There was no evidence during the clinical record review and interview with the Medical Director that the plans of care and orders were reviewed and approved by a physician. Clinical Record 2/Home Visit 1: The patient elected hospice services on 8/1/23. A clinical record review revealed weekly Skilled Nursing (SN) services and monthly Medical Social Worker (MSW) services were documented as provided to the patient. There was a documented Chaplain visit note dated 8/3/23. During the home visit on 1/18/24, the Chaplain stated they visited the patient every month. The clinical record did not include initial POC orders created at the start of care. The electronic medical record (EMR) plan of care (POC) Work Logs dated 1/17/24 and 1/19/24 documented changes made to the plans of care for the benefit periods (BP) dated 8/1/23 through 10/29/23 and 10/30/23 through 1/27/24 including the documented addition of visit frequency orders for the SN, MSW, and Chaplain. The physician signatures on the plans of care and orders were not appropriately authenticated signatures. The physician signatures were computer-generated. There was no evidence during the clinical record review and interview with the Medical Director that the plans of care and orders were reviewed and approved by a physician. Clinical Record 3: The patient elected hospice services on 11/6/23. A clinical record review revealed weekly SN and monthly MSW services were documented as provided to the patient. The clinical record did not include initial or updated POC orders. The POC Work Log dated 1/17/24 documented changes made by the Registered Nurse (RN) to the POC dated 11/6/23 through 2/3/24, which included the orders for problems identified during the comprehensive assessment dated 11/6/23: Neurological/Fall Risk, Pain, and Nutrition and Spiritual as of 1/4/23. The physician signatures on the plans of care and orders were not appropriately authenticated signatures. The physician signatures were computer-generated. There was no evidence during the clinical record review and interview with the Medical Director that the plans of care and orders were reviewed and approved by a physician. Clinical Record 4: The patient elected hospice services on 6/22/23. A clinical record review revealed weekly SN, monthly MSW services, and monthly Chaplain services documented as provided to the patient. The clinical record did not include initial or updated POC orders. The POC Work Log dated 1/19/24 documented changes to the POC dated 6/22/23 through 9/19/23, including the orders for SN problems identified during the comprehensive assessments dated 8/3/23, 9/15/23, and 11/29/23. Neurological/Fall Risk, Pain, and Nutrition and Spiritual as of 1/4/23. The plan of care did not include an update for psychosocial interventions provided by the MSW. During an interview on 1/19/24, the RN Case Manager, who signed the POC, confirmed that the plans of care for the benefit periods dated 6/22/23 through 9/19/23 and 9/20/23 through 12/18/23 were developed and documented on 1/19/24. The physician signatures on the plans of care and orders were not appropriately authenticated signatures. The physician signatures were computer-generated. There was no evidence during the clinical record review and interview with the Medical Director that the plans of care and orders were reviewed and approved by a physician. Clinical Record 6: The patient elected hospice services on 10/3/22 and was discharged from hospice care on 5/30/23 as no longer terminal. A clinical record review revealed weekly SN, monthly MSW services, and monthly Chaplain services documented as provided to the patient. The clinical record did not include initial POC orders created at the start of care. The POC Work Logs dated 10/29/22, 1/18/24, and 1/19/24 documented POC changes, including the orders for problems identified during the comprehensive assessments and changes to the patient summary. The physician signatures on the plans of care and orders were not appropriately authenticated signatures. The physician signatures were computer-generated. There was no evidence during the clinical record review and interview with the Medical Director that the plans of care and orders were reviewed and approved by a physician. Clinical Record 10: The patient elected hospice services on 7/24/23. A clinical record review revealed weekly SN and monthly MSW services documented as provided to the patient. The initial nursing assessment dated 7/24/23 documented symptoms associated with terminal illness and related conditions, including dyspnea, wheezes, edema, and the need for oxygen and nebulizer treatments. The clinical record did not include initial POC orders created at the start of care. A clinical record review revealed the recertification comprehensive assessment dated 10/16/23 was incomplete. The clinical record did not contain documentation of a completed, updated comprehensive assessment. The POC Work Logs dated 1/18/24 documented changes to the POC for the BP dated 10/22/23 through 1/19/24, including the documented addition of visit frequency orders: one (1) time per week for SN, MSW, and Chaplain. The physician signatures on the plans of care and orders were not appropriately authenticated signatures. The physician signatures were computer-generated. There was no evidence during the clinical record review and interview with the Medical Director that the plans of care and orders were reviewed and approved by a physician. Clinical Record 11: The patient elected hospice services on 7/24/23. A clinical record review revealed weekly SN and monthly MSW services documented as provided to the patient. The clinical record did not include initial POC orders created at the start of care. The POC Work Logs dated 12/27/23, 1/9/23, 1/18/24, and 1/19/24 documented changes to the POC for the BP dated 10/22/23 through 1/19/24. The documented changes to the POC did not include documentation of medications provided and the frequency of visits for the SN and MSW. The physician signatures on the plans of care and orders were not appropriately authenticated signatures. The physician signatures were computer-generated. There was no evidence during the clinical record review and interview with the Medical Director that the plans of care and orders were reviewed and approved by a physician. Clinical Record 12: The patient elected hospice services on 7/24/23. A clinical record review revealed weekly SN, initial MSW, and initial Chaplain services were documented as being provided to the patient. The clinical record did not include initial POC orders created at the start of care. The POC Work Log documented changes to the POC for the BP dated 10/22/23 through 1/19/24, which included the orders for a visit frequency of one visit per month for the MSW and Chaplain. The documented changes to the POC did not include documentation of psychosocial and spiritual interventions and medications to be provided. The physician signatures on the plans of care and orders were not appropriately authenticated signatures. The physician signatures were computer-generated. There was no evidence during the clinical record review and interview with the Medical Director that the plans of care and orders were reviewed and approved by a physician. Clinical Record 13: The patient elected hospice services on 9/28/23. A clinical record review revealed weekly SN, monthly MSW services, and monthly Chaplain services documented as provided to the patient. The clinical record did not include initial POC orders created at the start of care. The POC Work Log dated 1/19/24 documented changes to the POC for the BP dated 9/28/23 through 12/25/23 on 1/19/24, which included the orders for visit frequencies for the SN, MSW, and Chaplain, and documentation of SN and Chaplain interventions. The physician signatures on the plans of care and orders were not appropriately authenticated signatures. The physician signatures were computer-generated. There was no evidence during the clinical record review and interview with the Medical Director that the plans of care and orders were reviewed and approved by a physician. Clinical Record 14: The patient elected hospice services on 9/27/23. A clinical record review revealed weekly SN, monthly MSW services, and monthly Chaplain services documented as provided to the patient. The clinical record did not include initial POC orders created at the start of care. The POC Work Log dated 1/19/24 documented changes to the POC for the BP dated 12/26/23 through 3/24/24 on 1/19/24, which included the orders for visit frequencies for the SN, MSW, and Chaplain, documentation of SN and Chaplain interventions, and medications with a start date of 10/26/23. The plan of care did not include an update for psychosocial interventions provided by the MSW. On 1/19/24, an interview was conducted with the RN Case Manager, who signed the POC. The RN confirmed that POCs for the benefit periods 9/27/23 to 12/25/23 and 12/26/23 to 3/24/24 were developed when she entered them on 1/19/24. The physician signatures on the plans of care and orders were not appropriately authenticated signatures. The physician signatures were computer-generated. There was no evidence during the clinical record review and interview with the Medical Director that the plans of care and orders were reviewed and approved by a physician. During joint chart reviews and interviews on 1/19/23, the Director of Nurses (DON) confirmed that she and other RNs had been entering POCs throughout the night before and the morning of the interview during the survey. The DON confirmed plans of care were not developed, and physician orders were only completed after the surveyor arrived. On day 2 of the survey, plans of care and physician orders were identified in the electronic medical record (EMR) with an annotated date, change date of 1/17/24 and 1/18/24. During an interview on 1/19/23, the Medical Director confirmed that orders were typically signed through the agency's EMR or faxed for signature. He stated that he did not recall signing any orders in the previous days or weeks prior to the interview.

It is required that the clinical patient record, its content, and the information it contains is safeguarded against loss or unauthorized use. The hospice addresses leaving and protecting patient record information in the home and prevention of physical or electronic altering of the patient record. The hospice complies with state and federal laws and regulations addressing privacy, including the Health Insurance and Portability and Accountability Act (HIPAA) and the Health Information Technology for Economic and Clinical Health Act (HITECH). This standard was not met as evidenced by clinical record review and interview. 10 of 10 (100%) clinical records reviewed, the agency did not ensure the prevention of physical or electronic altering of the patient record. Clinical Record 1/Home Visit 1: The patient elected hospice services on 11/6/23. A clinical record review revealed weekly SN, Hospice Aide (HA), monthly MSW services, and monthly Chaplain services documented as provided to the patient. The clinical record did not include initial POC orders created at the start of care with visit frequencies for the SN, HA, MSW, and Chaplain services provided. The plan of care (POC) Work Log documented that an order identifying pain and fall risk as problems was added on 1/10/24, an order identifying spiritual care as a problem was added on 1/11/24, and changes to the status of team members were entered on 1/17/24. The initial plan of care orders and updated plans of care orders were developed on 1/17/24 and 1/18/24 without evidence of consultation, review, and approval by the Medical Director. There was no evidence that the updated plan of care orders dated 1/10/24, 1/11/24, and 1/17/24 were developed, reviewed, and approved by the Medical Director. Additionally, the Registered Nurse (RN) created a Hospice Aide (HA) care plan on 11/6/23 with instructions for the HA to perform a shave as needed (PRN) and three (3) visits per week. Visits made by the HA {Personnel Record 2] were documented as completed three (3) times per week from 1/1/24 to the current date with all tasks except shampoo and shave marked as completed. During the home visit on 1/19/24 with the HA {Personnel Record 2], the patient had a full-facial beard. The patient stated during the interview that it was the first time HA [Personnel Record 2] had visited and confirmed that he did want a full-facial shave. In an interview with the aide on 1/19/24, the HA {Personnel Record 2] confirmed that this was the first day she had been able to see the patient. There was a 19 day period that HA visits were documented without any evidence of completion. There was no evidence the RN was notified the care plan was not followed. Clinical Record 2/Home Visit 1: The patient elected hospice services on 8/1/23. A clinical record review revealed weekly Skilled Nursing (SN) services and monthly Medical Social Worker (MSW) services were documented as provided to the patient. There was a documented Chaplain visit note dated 8/3/23. During the home visit on 1/18/24, the Chaplain stated they visited the patient every month. The clinical record did not include initial POC orders created at the start of care with visit frequencies for the SN, MSW, and Chaplain services provided. The electronic medical record (EMR) plan of care (POC) Work Logs dated 1/17/24 and 1/19/24 documented changes made to the plans of care for the benefit periods (BP) dated 8/1/23 through 10/29/23 and 10/30/23 through 1/27/24 including the documented addition of visit frequency orders for the SN, MSW, and Chaplain. The initial plan of care orders and updated plans of care orders were developed on 1/17/24 and 1/18/24 without evidence of consultation, review, and approval by the Medical Director. Clinical Record 3: The patient elected hospice services on 11/6/23. A clinical record review revealed weekly SN and monthly MSW services were documented as provided to the patient. The clinical record did not include initial POC orders created at the start of care with visit frequencies for the SN and MSW services provided. The POC Work Log dated 1/17/24 documented changes made by the Registered Nurse (RN) to the POC dated 11/6/23 through 2/3/24, which included the orders for problems identified during the comprehensive assessment dated 11/6/23: Neurological/Fall Risk, Pain, and Nutrition and Spiritual as of 1/4/23. The initial plan of care orders and updated plans of care orders were developed on 1/17/24 and 1/18/24 without evidence of consultation, review, and approval by the Medical Director. Clinical Record 4: The patient elected hospice services on 6/22/23. A clinical record review revealed weekly SN, monthly MSW services, and monthly Chaplain services documented as provided to the patient. The clinical record did not include initial POC orders created at the start of care with visit frequencies for the SN, Chaplain, and MSW services provided. The POC Work Log dated 1/19/24 documented changes to the POC dated 6/22/23 through 9/19/23, including the orders for SN problems identified during the comprehensive assessments dated 8/3/23, 9/15/23, and 11/29/23. Neurological/Fall Risk, Pain, and Nutrition and Spiritual as of 1/4/23. During an interview on 1/19/24, the RN Case Manager, who signed the POC, confirmed that the plans of care for the benefit periods dated 6/22/23 through 9/19/23 and 9/20/23 through 12/18/23 were developed and documented on 1/19/24. The initial plan of care orders and updated plans of care orders were developed on 1/17/24, 1/18/24, and 1/19/24 without evidence of consultation, review, and approval by the Medical Director. Clinical Record 6: The patient elected hospice services on 10/3/22 and was discharged from hospice care on 5/30/23 as no longer terminal. A clinical record review revealed weekly SN, monthly MSW services, and monthly Chaplain services documented as provided to the patient. The clinical record did not include initial POC orders created at the start of care with visit frequencies for the SN, Chaplain, and MSW services provided. The POC Work Logs dated 10/29/22, 1/18/24, and 1/19/24 documented POC changes, including the orders for problems identified during the comprehensive assessments and changes to the patient summary. The initial plan of care orders and updated plans of care orders were developed on 1/17/24 and 1/18/24 without evidence of consultation, review, and approval by the Medical Director. Clinical Record 10: The patient elected hospice services on 7/24/23. A clinical record review revealed weekly SN and monthly MSW services documented as provided to the patient. The clinical record did not include initial POC orders created at the start of care with visit frequencies for the SN and MSW services provided. A clinical record review revealed the recertification comprehensive assessment dated 10/16/23 was incomplete. The clinical record did not contain documentation of a completed, updated comprehensive assessment. The POC Work Logs dated 1/18/24 documented changes to the POC for the BP dated 10/22/23 through 1/19/24, including the documented addition of visit frequency orders: one (1) time per week for SN, MSW, and Chaplain. The initial plan of care orders and updated plans of care orders were developed on 1/17/24 and 1/18/24 without evidence of consultation, review, and approval by the Medical Director. Clinical Record 11: The patient elected hospice services on 7/24/23. A clinical record review revealed weekly SN and monthly MSW services documented as provided to the patient. The clinical record did not include initial POC orders created at the start of care with visit frequencies for the SN and MSW services provided. The POC Work Logs dated 12/27/23, 1/9/23, 1/18/24, and 1/19/24 documented changes to the POC for the BP dated 10/22/23 through 1/19/24. The initial plan of care orders and updated plans of care orders were developed on 1/17/24 and 1/18/24 without evidence of consultation, review, and approval by the Medical Director. Clinical Record 12: The patient elected hospice services on 7/24/23. A clinical record review revealed weekly SN, initial MSW, and initial Chaplain services were documented as being provided to the patient. The clinical record did not include initial POC orders created at the start of care with visit frequencies for the SN, Chaplain, and MSW services provided. The POC Work Log documented changes to the POC for the BP dated 10/22/23 through 1/19/24, which included the orders for a visit frequency of one visit per month for the MSW and Chaplain. The initial plan of care orders and updated plans of care orders were developed on 1/17/24 and 1/18/24 without evidence of consultation, review, and approval by the Medical Director. Clinical Record 13: The patient elected hospice services on 9/28/23. A clinical record review revealed weekly SN, monthly MSW services, and monthly Chaplain services documented as provided to the patient. The clinical record did not include initial POC orders created at the start of care with visit frequencies for the SN, Chaplain, and MSW services provided. The POC Work Log dated 1/19/24 documented changes to the POC for the BP dated 9/28/23 through 12/25/23 on 1/19/24, which included the orders for visit frequencies for the SN, MSW, and Chaplain, and documentation of SN and Chaplain interventions. The initial plan of care orders and updated plans of care orders were developed on 1/17/24 and 1/18/24 without evidence of consultation, review, and approval by the Medical Director. Clinical Record 14: The patient elected hospice services on 9/27/23. A clinical record review revealed weekly SN, monthly MSW services, and monthly Chaplain services documented as provided to the patient. The clinical record did not include initial POC orders created at the start of care with visit frequencies for the SN, Chaplain, and MSW services provided. The POC Work Log dated 1/19/24 documented changes to the POC for the BP dated 12/26/23 through 3/24/24 on 1/19/24, which included the orders for visit frequencies for the SN, MSW, and Chaplain, documentation of SN and Chaplain interventions, and medications with a start date of 10/26/23. The initial plan of care orders and updated plans of care orders were developed on 1/17/24 and 1/18/24 without evidence of consultation, review, and approval by the Medical Director. During an interview and joint record reviews on 1/19/24, the Director of Nursing (DON) confirmed that the clinical records did not contain POCs developed initially at the start of care, and POCs updated as patient conditions warranted and new benefit periods entered. The DON stated and confirmed that she and other RNs entered POCs on 1/17/24, 1/18/24, and 1/19/24 without prior consultation or contact with the physician. They presented the POC Work Log in the EMR. The POC Work Log maintained documentation of the date, time, and type of change made to the POC, including the name of the clinician making the change. The types of changes documented by the POC Work Log included changes to and creation of orders (problem or visit frequency), changes to and creation of staff responsibilities, changes to the narrative summary, and when the RN signed a POC. On 1/19/24, an interview was conducted with an RN Case Manager, who confirmed that on 1/18/24 and 1/19/24, entered initial and updated POCs for current and discharged patients. The RN stated that she entered the initial Plans of Care from patient assessments dated 7/10/23 and 9/17/23. The RN stated that the drug profiles for these initial POCs were based on “notes” she had kept on each patient. She did not respond when asked to describe how the information in her paper notes was stored and kept confidential.

It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid certified facility, the hospice forwards to the receiving facility a copy of the hospice discharge summary described in HCDT 40.I This standard was not met as evidenced by clinical record review and interview. 1 of 1 (100%) clinical record reviewed, in which the patient was admitted to a Medicare/Medicaid certified hospital, revealed that the agency did not ensure that a discharge summary was forwarded to the receiving facility. Clinical Record 5: The patient elected hospice care on 7/17/23 with the diagnosis of Chronic Systolic (Congestive) Heart Failure. The Registered Nurse communication note dated 9/1/23 documented "DC (discharge) for cause (i.e. patient/family safety…Patient went to ER (emergency room) and admitted to hospital.” A review of the clinical record revealed no documentation to support a "Discharge for Cause" and no evidence that a discharge summary was documented and sent to the hospital. On 1/19/23 a joint record review and an interview was conducted with the Director of Nursing who confirmed that a discharge summary was not completed and forwarded to the receiving hospital.

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary. This standard was not met as evidenced by clinical record review and interview. 2 of 2 (100%) clinical records reviewed, in which the patient was discharged, revealed that the agency did not ensure that a discharge summary was forwarded to the patient's attending physician. Clinical Record 4: The patient elected hospice care on 6/22/23 and was discharged from hospice care on 12/18/23 as "no longer terminal." A review of the clinical record revealed no discharge summary and no evidence that a discharge summary was forwarded to the patient's attending physician. On 1/19/23 a joint record review and an interview was conducted with the Director of Nursing who confirmed that a discharge summary was not completed and forwarded to the attending physician.

It is required that the hospice discharge summary provided to a facility receiving a hospice patient for care—or to the patient’s community attending physician upon hospice discharge—includes at least a summary of the patient’s hospice stay, including treatments, symptoms, and pain management. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed revealed that the agency did not ensure that a discharge summary was completed for patients discharged from services. Clinical Record 4: The patient was discharged from hospice services on 12/18/23. The medical record did not contain a documented discharge summary. Clinical Record 5: The patient was discharged from hospice services on 9/1/23. The medical record did not contain a documented discharge summary. On 1/19/24 joint record reviews and interviews were conducted with the Director of Nursing (DON), who confirmed that the medical record did not contain discharge summaries for patients discharged from services.