Every finding on record at Advanced Holistic Palliative Care, LLC

It is required that the hospice Interdisciplinary Group, in consultation with the individual's attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by review of clinical records and interview. 2 of 5 (40%) records reviewed revealed the hospice did not ensure the initial comprehensive assessment was completed no later than five (5) calendar days after the election of hospice care. Record #76156 was reviewed and documented the patient elected hospice services on 6/3/2022 with a primary diagnosis of COPD. The initial assessment dated 6/3/2022 was completed by the registered nurse. The clinical record contained evidence of a psycho-social assessment completed by the medical social worker (MSW). The clinical record was missing documented evidence of a bereavement assessment completed within five calendar days after the election of hospice services. Clinical Record #62319 was reviewed and documented the patient elected hospice services on 3/22/2022 with a primary diagnosis of COPD. The initial assessment dated 3/22/2022 was completed by the registered nurse. The patient accepted the services of the MSW and chaplain. The clinical record was missing documented evidence of a psycho-social assessment. During an interview with the administrator on 6/15/2022, the administrator confirmed the initial comprehensive assessments were overlooked.

It is required that the interdisciplinary group determines the ability of the patient and/or family to safely self-administer drugs and biologicals to the patient in their home. The plan of care is to identify the IDG’s finding regarding safe self-administration and/or family administration of drugs and biologicals. If the patient and/or family cannot administer drugs or biologicals, it will be noted in the plan of care, as well as how it is addressed by the IDG. This standard was not met as evidenced by review of clinical records and interview. 1 of 5 (20%) records reviewed revealed the hospice did not ensure the interdisciplinary group determines the ability of the patient and/or family to safely self-administer drugs and biologicals to the patient in their home. Record #76156 was reviewed and documented the patient elected hospice services on 6/3/2022 with a primary diagnosis of COPD. The plan of care did not identify the patient and/or family ability or inability to self-administer drugs and biologicals. During an interview with the administrator on 6/15/202022, the administrator confirmed the record did not address the ability of the patient and/or family to safely self-administer drugs and biologicals.

It is required that the organization defines a process to ensure that nationally recognized infection prevention and control guidelines intended to mitigate the transmission and spread of COVID-19 are implemented and followed. This standard was not met as evidenced by review of clinical records and interview. 2 of 3 (66%) clinical records reviewed revealed the hospice did not ensure guidelines intended to mitigate the transmission and spread of COVID-19 were followed. Clinical Record #39421 was reviewed and documents the patient elected hospice services on 3/25/2022 with a primary diagnosis of COPD. Review of the clinical record revealed the RN made visits on 3/25/2022, 3/28/2022, 4/4/2022, 4/11/2022, 4/18/2022, 4/25/2022, 5/2/2022, 5/11/2022 and 5/16/2022 without documenting the completion of COVID-19 screening of the patient and family prior to the start of these RN visits. Clinical Record #62319 was reviewed and documents the patient elected hospice services on 3/22/2022 with a primary diagnosis of COPD. Review of the clinical record revealed the RN made visits on 3/29/2022, 4/4/2022, 4/13/2022, 4/19/2022, 5/2/2022, 5/9/2022 and 5/18/2022 without documenting the completion of COVID-19 screening of the patient and family prior to the start of these RN visits. During an interview with the administrator on 6/15/202022, the administrator confirmed the RN visit notes did not include the completion of COVID-19 screening of the patient and family prior to the start of RN visits.