Every finding on record at Accord Health Group, LLC

It is required that a hospice aide provides services included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 3 of 5 (60%) clinical records reviewed of patients that received aide services it was revealed that the agency did not ensure the hospice aide provided the services included in the plan of care. THIS IS A CONTINUED PRIOR REQUIRED ACTION Clinical Record 1: The aide visit note dated 07/25/2024, the aide documented in the narrative "...applied barrier cream..." The aide care plan dated 07/25/2024 did not include a task or order to "Apply barrier cream and location". Clinical Record 4: The aide care plan dated 02/24/2024 ordered the bath task of "Shower Chair". The aide visit note dated 02/24/2024 stated "Done" for the task "Shower Chair", but in the narrative the aide documented "Assisted patient with bed bath". The aide did not provide the task "Shower Chair" as ordered on the aide care plan. Clinical Record 5: The aide care plan dated 12/22/2023 ordered the bath task "Shower Chair". The aide visit note dated 12/27/2023 stated "Unable to Document: Not applicable this visit" for the task "Shower Chair". The aide documented in the narrative, "Assisted patient with bed bath". The aide did not provide the task "Shower Chair" as ordered on the aide care plan. The Owner/Director of Nursing, Owner, Executive Director, Registered Nurse Case Manager/Alternate Director of Nursing, and Business Office Manager stated in an interview on 08/02/2024 that the agency did not ensure the hospice aide provided services only as ordered in the plan of care. CONTINUATION OF REQUIRED ACTION

It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. Hospice aide documentation complies with hospice policies and procedures. This standard was not met as evidenced by clinical record review and interview. In 3 of 5 (60%) clinical records reviewed of patients that received hospice aide services it was revealed that the agency did not ensure the hospice aide reported changes in the patient's medical needs to the registered nurse (RN) as the changes related to the plan of care (POC). Clinical Record 1: The aide visit note dated 07/25/2024, the aide documented in the narrative "...applied barrier cream..." The aide care plan dated 07/25/2024 lacked evidence of a task ordered "Apply barrier cream and location", The record lacked evidence of the aide notifying the RN that the aide care plan lacked an ordered task to apply barrier cream and a location". Clinical Record 4: The aide care plan dated 02/24/2024 ordered the bath task "Shower Chair". The aide visit note dated 02/24/2024 stated "Done" for the task "Shower Chair", but in the narrative the aide documented, "Assisted patient with bed bath". The record lacked evidence of the aide reporting changes in the patient's medical needs to the RN as related to the bath task ordered. Clinical Record 5: The aide care plan dated 12/22/2023 ordered the bath task "Shower Chair". The aide visit note dated 12/27/2023 stated "Unable to Document: Not applicable this visit" for the task "Shower Chair", but in the narrative the aide documented, "Assisted patient with bed bath". The record lacked evidence of the aide reporting changes in the patient's medical needs to the RN as related to the bath task ordered. The Owner/Director of Nursing, Owner, Executive Director, Registered Nurse Case Manager/Alternate Director of Nursing, and Business Office Manager stated in an interview on 08/02/2024 that the agency did not ensure the hospice aide reported changes in the patient's medical needs to the registered nurse (RN) as the changes related to the plan of care (POC).

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 and supplements. 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, interview and observation. In 1 of 1 (100%) record of a patient living in a skilled nursing facility (SNF), it was revealed that the hospice did not ensure the SNF had a current list of medications for the patient, which was updated at a minimum, at the time of each comprehensive assessment and/or when new medication was added, or changes were made to existing medication. Clinical Record 1: The facility MAR included the following medications Escitalopram Oxalate oral tablet, one by mouth one time a day for depression ordered 7/9/23 for, Vitamins/Minerals one per day supplement ordered 12/13/22, and Lorazepam (2 GM/ml) 0.25 ml every 4 hours PRN ordered 6/8/23. These mediations were not documented on the hospice medication profile. Phenobarbital 30 mg oral tablet, one tab orally every 3 hours as needed for anxiety/agitation ordered 10/27/22, Phenobarbital 30 mg oral tablet, one tab orally once a day in the morning ordered 10/27/22, and Risperdal 0.25 mg oral tablet, one tab orally 2 times a day ordered 5/4/23. were documented the hospice medication profile, and not documented on the facility MAR. Additionally, the hospice medication profile included "Oxygen via nasal cannula device, 2-3 liters inhaled continuous as needed for shortness of breath" dated 10/27/22 and the facility MAR included, "Oxygen 0-5 liters". The hospice medication profile included an order for, "Hydromorphone 1 mg/ml every 4 hours pain or dyspnea" dated 10/27/22, and the facility MAR included an order for "Hydromorphone one tab every 3 hours PRN". During interview on 8/31/23, the Hospice RN (Record 6) confirmed that the hospice medication profile did not match the facility medication administration record (MAR) During interview 8/31/23, the Hospice RN (Record 6) confirmed the hospice medication orders did not match the SNF orders that the patient was receiving as documented on the facility medication administration record (MAR).

It is required that the hospice designates a registered nurse member of the IDG to ensure continuous assessment of each patient’s and family’s needs. This standard was not met as evidenced by clinical record review and interview. In 3 of 14 (21%) clinical records reviewed, it was revealed that the hospice did not ensure that the RN completed continuous assessments of the patient's needs. Clinical Record 1: The patient elected hospice care on 5/17/18 with a terminal diagnosis of COPD. During the home visit observation on 8/31/23, the patient was on continuous oxygen for dyspnea. The dates of service reviewed were 7/5/23 through 8/5/23. There was no documentation of an assessment of the patient's respiratory status in the nursing visit notes dated 7/7/23, 7/12/23 and 7/14/23. Clinical Record 6: The patient elected hospice care on 6/6/22 with a terminal diagnosis of COPD. The on-call nursing documentation dated 3/8/23 included, "Coffee spill left leg, red" and the nursing visit documentation dated 3/10/23 included "Coffee burn left leg 35 cm x 5 cm x 1 cm, blistered". The nursing visit documentation dated 3/13/23 included, "Patient complaining of excruciating pain, no pain from burn, unable to look at burn due to clothing, instructed wife not to pop blister". The nursing visit dated 3/14/23 included, "Wound care done", and the nursing visit dated 3/16/23 included, "Burn to be cleansed, dried, ointment and bandaged". The nursing visit dated 3/23/23 included the burn was healed. There was no documented nursing assessment of the burn wound visits dated 3/14/23, and 3/16/23. Clinical Record 8: The patient elected hospice care on 6/14/23 with a terminal diagnosis of COPD. The nursing visit note dated 6/14/23 included, "Shortness of breath, oxygen 2-3 liters". During the dates of service reviewed from 7/5/23 through 8/5/23, there was no documented nursing assessment of the patient's respiratory status in the nursing visit note dated 7/12/23. During interview 8/31/23, the Director of Nursing confirmed the missing nursing assessments of the patients in the RN visit note documentation and stated the RN (Record 12) had been counseled due to documentation issues and terminated 7/25/23. During interview 8/31/23, the Director of Nursing confirmed the missing nursing assessment of the patients in the RN visit note documentation and stated the RN (Record 12) had been counseled due to documentation issues and terminated 7/25/23.

It is required that 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). This standard was not met as evidenced by clinical record review and interview. In 2 of 14 (14%) clinical record reviewed, it was revealed that the hospice did not ensure nursing visits followed the visit frequency as included on the plan of care established by the IDG/IDT. Clinical Record 10: The nursing visit frequency was three times a week. During the week of 3/5/23, only one nursing visit was provided. There was no documentation to explain why the ordered visit frequency was not followed. Clinical Record 11: The nursing visit frequency was two times a week. During the week of 6/4/23, only one nursing visit was provided. There was no documentation to explain why the ordered visit frequency was not followed. During interview 8/31/23, the Director of Nursing confirmed the missing nursing visits. During interview 8/31/23, the Director of Nursing confirmed the missing nursing visits.

It is required that counseling services include an organized program for providing bereavement services delivered by or under the supervision of a qualified professional with experience or education in grief or loss counseling. The bereavement services reflect the needs of the bereaved per a bereavement plan of care that includes the types of bereavement services to be offered and the frequency of service delivery. This standard was not met as evidenced by clinical record review, document review and interview. In 2 of 3 (67%) records reviewed of bereaved family/caregivers who were receiving bereavement letters and phone calls, it was revealed that the hospice did not ensure that the bereavement case was discussed at the next IDG/IDT meeting after the death of the patient, as required in agency policy. In 3 of 3 (100%) records reviewed of bereaved family/caregivers who were receiving bereavement letters and phone calls, the hospice did not ensure the bereavement plan of care was initiated after the death of the patient, as required in agency policy. Agency policy, "Bereavement Services", Policy number 4.26, included in part, "A bereavement plan of care will be initiated, which may include: telephone support, letters and cards, referral to other community resources, memorial services, bereavement camps, telephone contacts and individual or family counseling and bereavement groups", "The plan of care will note the kind of bereavement services to be offered and frequency of service delivery", and "After the death has occurred, the case will be discussed at the next IDG meeting, recommendations for bereavement will be made based on the severity of grief and determined by the family member's consent for further services, bereavement services must reflect the needs of the bereaved". Clinical Record 12: The patient expired 5/15/23. There was no documentation at the next IDT/IDG of a discussion of the patient's death and recommendations for bereavement services based on the severity of grief and determined by the family member's consent for further services. The family was receiving the bereavement services of phone calls and bereavement letters, but there was no documented bereavement plan of care initiated after the death of the patient. Clinical Record 13: The patient expired 4/23/23. There was no documented IDT/IDG discussion after the death of the patient on the IDT meeting dated 4/26/23 and recommendations for bereavement services based on the severity of grief and determined by the family member's consent for further services. Although the family received the bereavement services of phone calls and bereavement letters, there was no documented bereavement plan of care initiated after the death of the patient. Clinical Record 14: The patient expired 3/29/23. The IDT/IDG meeting dated 4/12/23 after the death of the patient documented that the bereavement case was discussed, but there was no documented bereavement plan of care initiated that included the types of bereavement services to be offered and the frequency of service delivery. During an interview on 8/31/23, with the Director of Nursing the clinical records were reviewed, and it was confirmed that the IDG/IDT discussion after the death of the patients and the bereavement plan of cares were not initiated after the patient's death. Additionally, the Director of Nursing stated, "The procedure is that the care plan that was established while the patient was on service is to be updated after the death to include the bereavement plan of care for 12 months". Policy, "Bereavement Services", Policy number 4.26, included in part, "A bereavement plan of care will be initiated, which may include: telephone support, letters and cards, referral to other community resources, memorial services, bereavement camps, telephone contacts and individual or family counseling and bereavement groups", "The plan of care will note the kind of bereavement services to be offered and frequency of service delivery", and "After the death has occurred, the case will be discussed at the next IDG meeting, recommendations for bereavement will be made based on the severity of grief and determined by the family member's consent for further services, bereavement services must reflect the needs of the bereaved". During interview 8/31/23, the Director of Nursing reviewed the clinical record and confirmed the missing IDG/IDT discussion after the death of the patients and the bereavement plan of care was not initiated after the death of the patient. Additionally, the Director of Nursing stated, "The procedure is that the care plan that was established while the patient was on service is to be updated after the death to include the bereavement plan of care for 12 months". During interview 8/31/23, the Director of Nursing stated the bereavement coordinator was new to managing the bereavement program and needed more training. The HR/Office coordinator (Staff Record 5) was assigned to do bereavement mailings. During interview 8/31/23, the HR/Office coordinator presented the non-clinical record tracking form she used to identify when bereavement letters are due and stated, "I check next to the due dates on this tracking form when I mailed the letter and the mailings are not documented in the clinical record". The bereavement coordinator (Staff Record 7) was unavailable for interview due to making patient visits.

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 8 (25%) records reviewed of patients with orders for hospice aide services, it was revealed that the agency did not ensure that an aide plan of care was prepared by the RN. Clinical Record 3: The dates of service reviewed were 7/5/23 through 8/5/23. The order for hospice aide services dated 7/17/23 stated, "1 week 2 (7/17/23-7/29/23)". There was one attempted hospice aide visit, documented as a missed visit on 7/20/23. The Director of Nursing presented a paper format aide plan of care dated 7/26/23 and stated the hospice aide had a copy of the care plan for the 7/26/23 visit dated 7/26/23. There was no hospice aide plan of care documented in the clinical record, either EMR or paper form, for the attempted aide visit and missed aide visit on 7/20/23. Clinical Record 8: The dates of service reviewed were 7/5/23 through 8/5/23. The order for hospice aide services dated 7/17/23 stated, "1 week 2 (7/17/23-7/29/23)". 2 attempted and missed aide visits were documented. During interview on 8/30/23, the Director of Nursing stated, "The hospice aide visits were not completed since an aide plan of care was not completed". During interview 8/31/23, the Director of Nursing confirmed there were no documented hospice aide plans of care. During interview 8/31/23, the Director of Nursing confirmed the missing hospice aide plans of care.

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 and interview. In 4 of 8 (50%) applicable clinical records of patients receiving hospice aide services, it was revealed that the hospice did not ensure aide visits and/or tasks were completed as assigned on the plan of care. Clinical Record 1: The hospice aide plan of care assigned a shower and shave each visit. The hospice aide visit note dated 7/9/23 documented "refused shower". The aide visit note dated 7/21/23 documented "refused shower and shave", and the aide visit note 7/25/23 documented "refused shower, bed bath given". There was no documented communication with the RN as to why the hospice aide plan of care was not followed. Clinical Record 7: The hospice aide visit frequency was 3 x week effective 6/29/23. There was one missing aide visit for the week of 6/29/23 and the week of 7/23/23. Clinical Record 13: The hospice aide visit frequency was 2 x week. There was one missing aide visit the week of 4/22/23. Clinical Record 14: The hospice aide visit frequency was 2 x week. There was one missing aide visit the week of 3/22/23. During interview 8/31/23, the Director of Nursing confirmed the missing aide visits and tasks were not performed as assigned on plan of care and stated, "There is no documented communication with the RN to explain why the aide did not follow the aide plan of care". During interview 8/31/23, the Director of Nursing confirmed the missing aide visits and tasks were not performed as assigned on plan of care and stated, "There is no documented communication with RN to explain why the aide did not follow the aide plan of care".

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum physician orders. This standard was not met as evidenced by clinical record review, interview and observation. In 3 of 14 (21%) clinical records reviewed, it was revealed that the hospice did not ensure physician's orders were documented in the clinical record. Clinical Record 2: The patient elected hospice care on 8/12/23 with a terminal diagnosis of Cirrhosis of Liver. During the home visit observation on 8/30/23, the wife stated, the patient fell at approximately 7am on the Monday after admission to hospice (8/14/23). The wife called 911, and the paramedics responded. The nursing visit note dated 8/14/23, documented an assessment of the arm and shoulder wounds and included, "Wound care supplies provided with caregiver instructions". There were no documented orders, in the EMR or paper format, for the wound care for the shoulder. The patient was noted to have a CPAC machine next to the bed. The wife of the patient stated, "He uses that every night". There were no documented orders and/or plan of care for the use of CPAC. Additionally, the nursing visit dated 8/22/23 included, "Instructed to hold coumadin". There were no orders in the electronic medical record dated 8/22/23 to hold the Coumadin. On 8/31/23, the Director of Nursing presented a paper format order dated 8/21/23 and stated, "I took this verbal order, and the date of the verbal order is not correct and should have been dated 8/22/23 to hold the Coumadin". Clinical Record 6: The patient elected hospice care on 6/6/22. The terminal diagnosis was COPD. Documentation revealed the patient had a "red burn to the left leg from coffee spill" on 3/8/23. The nursing visit note dated 3/10/23 included, "Burn 35 cm x 5 x 1, left leg blister". The nursing visit note dated 3/14/23 included, "Wound care done to leg." The nursing visit note dated 3/16/23 included, "Burn to be cleaned, dried, ointment and bandaged". There were no documented orders found for wound care for the burn. Clinical Record 9: The patient elected hospice care on 4/27/20. The terminal diagnosis was Parkinson's Disease. During the dates of service reviewed: 7/5/23 through 8/5/23, the nursing visit note dated 7/26/23 included, "Red leg wound, covered with Optifoam" and the nursing visit note dated 8/3/23 included, "Mepilex" applied. There were no orders found for wound care or orders for the use of Optifoam and Mepilex. During interview 8/31/23, the Director of Nursing confirmed the physician's orders were not documented in the clinical record. During interview 8/31/23, the Director of Nursing confirmed the missing physician's orders in the clinical record.

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. In 1 of 1 (100%) record of a patient that was transferred to another hospice, it was revealed that the hospice did not ensure that the discharge summary was sent to the hospice at time of transfer. Clinical Record 10: The patient was transferred to another hospice on 3/21/23. There was no documentation found that the discharge summary was sent to the new hospice at the time of transfer. During an interview on 8/31/23, the Director of Nursing confirmed there was no documentation that the discharge summary was sent to the new hospice. During interview 8/31/23, the Director of Nursing confirmed there was no documentation that the discharge summary was sent to the new hospice.

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. In 1 of 1 (100%) record of a patient that revoked hospice services, it was revealed that the hospice did not ensure that the discharge summary was sent to the attending physician. Clinical Record 11: The patient revoked hospice services on 6/26/23. There was no documentation that the discharge summary was sent to the attending physician. During an interview on 8/31/23, the Director of Nursing confirmed that there was no documentation that the discharge summary was sent to the attending physician. During interview 8/31/23, the Director of Nursing confirmed the missing documentation that the discharge summary was sent to attending physician and stated, "The patient was in a facility and the the facility physician would be following the patient and is the attending physician".