Every finding on record at Alinea Family Hospice Care LLC

It is required that the hospice develops and maintains an emergency preparedness (EP) plan that is reviewed and updated at least every two (2) years. The plan is based on and includes a documented hospice-based and community-based risk assessment, using an “all-hazards” approach specific to the geography and population served. It includes strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural or man-made disasters, emerging infectious diseases (EIDS) that place the health and safety of patients and employees at risk; and other anticipated emergencies that could affect the hospice’s ability to provide care. This standard was not met as evidenced by document review and interview. In review of the agency emergency preparedness plan, there was no evidence of a documented hospice-based and community-based risk assessment, using an “all-hazards” approach specific to the geography and population served. The Administrator appointee for emergency preparedness was interviewed and confirmed there was not a documented "all hazards" hospice-based and community-based risk assessment. In review of the agency emergency preparedness plan, there was no evidence of a documented hospice-based and community-based risk assessment, using an “all-hazards” approach specific to the geography and population served. The Administrator appointee for emergency preparedness was interviewed and confirmed there was not a documented "all hazards" hospice-based and community-based risk assessment.

It is required that the hospice has a written Patient Bill of Rights and Responsibilities (Bill of Rights). The patient has the right to be informed of his or her rights and responsibilities, and the hospice defines, protects, and promotes the exercise of these rights. This is a CMS CONDITION LEVEL DEFIENCY This CONDITION was not met as evidenced by a review of clinical records, interviews, document review which revealed the hospice: Failed to ensure that the patient was free from mistreatment, neglect, or mental, sexual and physical abuse, injuries unknown source, misappropriate of property HPFC.2.D/L517/ 418.52(c)(6)}. The cumulative effect of these systemic problems resulted in the hospice agency's inability to ensure the provision of quality health care in a safe environment for the condition of participation CFR 418.52: Patient Rights. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the hospice agency.

It is required that the written Patient Bill of Rights includes the right to be free from mistreatment, neglect, or verbal, mental, sexual, or physical abuse. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 19 (5%) clinical record reviews, the agency did not ensure that the patient's right to be free from neglect was protected. DOCUMENT 4: Agency policy Abuse, Neglect and Exploitation Policy PC.15, stated, in part: "Patients have the right to be free from mistreatment, neglect or verbal, mental, sexual and physical abuse....". CLINICAL RECORD 19: This patient elected the hospice benefit on 07/18/2024 with a terminal diagnosis of Alzheimer's Disease and Vitamin B 12 anemia. The Registered Nurse (RN) comprehensive assessment dated 07/18/2024 stated that there were no open wounds at the time of admission to hospice; and documented that the patient was at risk for skin breakdown and the patient was ordered a low air loss mattress. The RN notes on 08/05/2024 and 09/10/2024 identified and documented a left medial proximal inner buttocks coccyx wound stage II and the wound was cleansed with soap and water and covered with a hydrocolloid gauze. On 09/22/2024, there was a call from the family stating that the son was requesting assistance with wound care on the patient's legs. Following the call, the RN made a visit and documented wounds on the left medial distal inner leg knee and right medial distal inner leg knee. The RN contacted the physician and provided wound care as well as received new medication for pain. On 09/25/2024, the patient was transferred to a skilled nursing facility (SNF) for respite. At that time, the receiving RN at the facility notified the on-call Administrator that the patient had several open areas which were not reported to the receiving RN at the facility. During a visit by the agency on-call nurse on 09/25/2024 to oversee the admission of a patient for respite care, the nurse noted open areas on the patient. She contacted the Director of Nursing and reported that the patient had open areas that had not been identified or reported to the receiving RN at the facility. In review of the clinical record for the date of 09/10/2024, the interdisciplinary notes documented there were no active wounds. In review of the IDT notes from 09/12/2024-09/22/2024, there was no documentation of the care of the patient's wounds. The RN documentation for 09/25/2024 included the wounds and treatment orders and a consultation was performed by a wound care physician on 09/26/2024. In review of the documentation by the wound care physician, it included the following open areas: 1. Stage 4 pressure wound sacrum full thickness duration greater than 140 days. 2. Unstageable (due to necrosis) of the left heel full thickness greater than 56 days. 3. Unstageable (due to necrosis) of the right heel full thickness greater than 14 days. 4. Unstageable right lateral foot. 5. End stage skin failure of the right shoulder partial thickness greater than 7 days. 6. End stage skin failure of the left knee full thickness greater than 7 days. 7. Wound of the right knee full thickness greater than 7 days. The physician provided documentation that the patient was at end of life and recommended treatment was palliative. There was no documented evidence that the agency ensured that the patient's right to be free from neglect was protected. During an interview with the Director of Clinical Services on 03/04/2025, it was reported the agency self-reported to the Dept. of HHS and the (State) Board of Nursing on 09/26/2024 and filled out Form 3613 which was sent by certified mail. The Director of Clinical Services stated the Department of Health and Human Services conducted an investigation 09/30/2024-10/2/2024 and submitted preliminary findings, but the agency had not received formal required actions at the time of this site visit. In an interview with the Director of Clinical Services and the Director of Nursing on 03/06/2026, it was confirmed that a performance improvement plan was written 09/26/2024 and executed for "Wounds are not consistently assessed and measured at a minimum of 1XW" The audits for measurement of wounds in 4th quarter 2024 was 50%. In an interview conducted with the Administrator on 03/06/2025, it was confirmed that the documentation provided did not ensure that the patient's right to be free from neglect was protected

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 other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following: the effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy, and drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and as appropriate, preventive measurements 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, document review, and interview. In 1 of 19 (5%) clinical records reviewed, the agency did not ensure that the drug profile was updated as per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when a new medication was added, or changes were made to the existing medication. DOCUMENT 2: : Agency policy Medication Administration, PC. 80, stated in part: "III. The Hospice staff will transcribe written medications orders as soon as possible after they are received and update the POC." CLINICAL RECORD 11: This patient elected the hospice benefit 03/01/2025 with a terminal diagnosis of malignant neoplasm of the ampulla of Vater. In review of the Registered Nurse (RN) comprehensive assessment dated 03/01/2025, the RN documented that the patient used nitroglycerine tabs for chest pain. The drug profile was reviewed for the dates of 03/01/2025-03/07/2025. Nitroglycerine was not listed on the drug profile. There was no documented evidence that the medication profile was updated during the comprehensive assessment. In an interview conducted 03/07/2025 with the Director of Clinical Services, it was confirmed that the drug profile was not updated as per hospice policy.

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. This condition of participation was not met as evidenced by review of clinical records, interviews, and review of findings with the Director of Clinical Services and Director of Nursing which revealed the following issues with the development and implementation of the patients’ interdisciplinary care plans: Failed to ensure that the plan of care reflected the patient and family goals {HCPC.21.I/L545/ 418.56(c)}; Failed to ensure that the written plan of care identified planned interventions based on problems identified in the initial and updated comprehensive assessments {HCPC.21. I/L546/ 418.56(c)(1)}; and Failed to ensure ongoing sharing of information between all disciplines providing care and services in all settings {HCPC.23.D/L557/ 418.56(e)(4)}. 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 each patient’s individualized written plan of care reflects patient and family goals. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed, the agency did not ensure that the plan of care reflected the patient and family goals. CLINICAL RECORD 6: This patient elected the hospice benefit on 02/05/2025 with a diagnosis of Alzheimer's and Down's Syndrome. In review of the Registered Nurse (RN) comprehensive assessment dated 02/05/2025, it was documented that the patient was unable to make wishes known, but family stated the patient cried out and they would give Tylenol which seems to help with the pain. The goal for pain was "pt will be pain free or verbalize an acceptable pain level with the current pain management regimen". In review of the clinical record for dates of 02/05/2025-03/06/2025, there was no documentation that the plan of care reflected the patient and family goal for pain management as the patient was not able to verbalize what was acceptable pain level. In an interview conducted on 03/06/2025, the Director of Clinical Services confirmed that the plan of care did not reflect patient and family goals.

It is required that each patient’s individualized written plan of care identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 3 of 19 (16%) clinical records reviewed, the agency did not ensure that the written plan of care identified planned interventions based on problems identified in the initial and updated comprehensive assessments. CLINICAL RECORD 9: This patient elected the hospice benefit 10/02/2024 with a terminal diagnosis of end stage renal disease. The medication profile reviewed 03/06/2025 documented that Eliquis was started on 02/26/2025. In review of the plan of care for the dates of 02/26/2025-03/06/2025, there were no identified planned interventions for education and care of the patient while on Eliquis. CLINICAL RECORD 11: This patient elected the hospice benefit 03/01/2025 with a terminal diagnosis of malignant neoplasm of the ampulla of Vater. The Registered Nurse (RN) comprehensive assessment dated 03/01/2025 documented the patient was experiencing dyspnea upon admission and morphine and oxygen were ordered. In review of the plan of care for dates of 03/02/3035-03/07/2025, there were no identified planned interventions for dyspnea. CLINICAL RECORD 12: This patient elected the hospice benefit 01/13/2025 with a terminal diagnosis of cirrhosis of the liver. The Registered Nurse (RN) comprehensive assessment documented that the patient experienced pain with movement. In review of the plan of care for the dates of 01/13.2025-03/07/2025, there were no identified planned interventions for pain. In an interview conducted with the Director of Clinical Services on 03/07/2025, it was confirmed that the plans of care did not include planned interventions based on problems identified in the initial and updated comprehensive assessments.

It is required that the hospice’s policies and procedures define a system of communication and integration that sustains coordination of services and provides documentation of exchange of information. The policies and procedures ensure that sharing of information occurs between all disciplines providing care and services in all settings and is ongoing whether or not the care and services are provided directly or under arrangement. This standard was not met as evidenced by clinical record review, document review, and interview. In 1 of 19 (5%) clinical records reviewed, the agency did not ensure ongoing sharing of information between all disciplines providing care and services in all settings. DOCUMENT 3: In complaint statement dated 09/25/2024, the document stated, in part: "Multiple wounds were found on the patient by _______ RN on 09/24/24." "No active wounds were documented by the previous nurse." CLINICAL RECORD 19: This patient elected the hospice benefit 07/18/2024 with a terminal diagnosis of Alzheimer's Disease. In review of the clinical record, the Registered Nurse (RN) visit notes on 08/05/2024 and 09/10/2024 documented a left medial proximal inner buttocks coccyx wound stage II and the wound was cleansed with soap and water and covered with a hydrocolloid gauze. In review of the interdisciplinary team notes for the dates of 07/18/2024-09/24/2024, there was no documentation of coordination of care for the wounds documented in the RN notes. In an interview with the Director of Clinical Services and the Director of Nursing on 03/06/2025, it was confirmed that the interdisciplinary team (IDT) did not ensure that the sharing of information occurred between the members of the team, and did not discuss that wound care orders were missing from the clinical record.

It is required that the hospice’s governing body assumes legal authority and responsibility or the organization’s ongoing performance improvement and patient safety program that is defined, implemented, maintained, and evaluated annually. This standard was not met as evidenced by document review, clinical record review, observation and interview. A review of the clinical records, observation, and interviews with the Administrator, Director of Clinical Services, and Director of Nursing revealed that the governing body did not assume responsibility for the organization’ ongoing performance improvement and patient safety as evidenced by: 1 of 19 (5%) clinical record reviews, the agency did not ensure that the patient's right to be free from neglect was protected. {HPDC.2.D} L571. 3 of 19 (16%) clinical records reviewed, the agency did not ensure that the written plan of care identified planned interventions based on problems identified in the initial and updated comprehensive assessments. {HCPC.21. I} L 546. 1 of 19 (5%) clinical records reviewed, the agency did not ensure ongoing sharing of information between all disciplines providing care and services in all settings. { HCPC.23. D} 557. 2 of 5 (40%) clinical records reviewed, of patients receiving wound care, the agency did not ensure that the nursing needs of the patient were met as identified in the patient’s initial assessment, comprehensive assessment, and any updated assessments. {HCDT.6.I} 591. 1 of 19 (5%) clinical records reviewed, the agency did not ensure that nursing services were provided in a manner consistent with accepted standards of practice. {HCDT.1.I} L652. In an interview conducted with the Administrator (Personnel Record 9) on 03/06/2025, it was confirmed that the documentation provided did not ensure that the patient's right to be free from neglect was protected In an interview with the Director of Clinical Services and the Director of Nursing on 03/06/2025, it was confirmed that the interdisciplinary team (IDT) did not ensure that the sharing of information occurred between the members of the team, and did not discuss that wound care orders were missing from the clinical record. In an interview conducted on 03/07/2025 with the Director of Clinical Services, it was confirmed that the nursing needs of the patient were not met as identified in the patient’s initial assessment, comprehensive assessment, and updated assessments.

It is required that the hospice documents and maintains an effective infection control program that protects patients, families, visitors, and hospice staff by preventing and controlling infections and communicable diseases. The infection control program includes the education of employees, contracted providers, patients, families, and other caregivers in infection control. This standard was not met as evidenced by interview and personnel record review. In 1 of 10 (10%) personnel records reviewed, the agency did not ensure that the infection control program included the education of employees. PERSONNEL RECORD 10: The volunteer was hired 08/16/2022. There was no documentation of infection control education for 2024 in the personnel record. In an interview conducted with the Director of Clinical Services on 03/05/2025, she stated that the agency provided annual education which included infection control, and this education was missing from the personnel record.

It is required that nursing care and services are provided by or under the supervision of a registered nurse and per the patient plan of care. Nursing services ensure that the nursing needs of the patient are met as identified in the patient’s initial assessment, comprehensive assessment, and any updated assessments. This standard was not met as evidenced by clinical record review, document review, interview, and observation. In 2 of 5 (40%) clinical records reviewed, of patients receiving wound care, the agency did not ensure that the nursing needs of the patient were met as identified in the patient’s initial assessment, comprehensive assessment, and any updated assessments. DOCUMENT 1: The agency policy "Skin Assessment/Wound Care Policy stated in part: "The Registered Nurse/Case Manager will complete and document a skin assessment at least once a week on every patient. Upon the discovery of a wound the Registered Nurse/Case Manager will document a complete assessment and institute care/treatment measures until such time as the wound is resolved." "Procedure: A. Upon the discovery of a wound, the Registered Nurse/Case Manager will add a "wound" in the patient chart in _____ noting the following: 4. Measurements-to include length, width, depth; updated weekly. CLINICAL RECORD 1/HOME VISIT 1: CLINICAL RECORD 1: This patient elected the hospice benefit 01/12/2024 with a terminal diagnosis of COPD. In review of the Registered Nurse (RN) comprehensive assessment dated 12/18/2024, it was documented that an open area was discovered on the patient's right heel. In review of the RN visits for 01/22/2024, 01/30/2024, 02/05/2024, 02/11/2024, 02/18/2024 and 03/04,2024, there was no update to the assessment of the wound measurements of the open area. During the home visit (Clinical Record 1) on 03/05/2025 to observe the Registered Nurse (Personnel Record 1), it was confirmed that the patient was receiving wound care for an open area on the right heel. The clinical record was reviewed, and no documented evidence was present for the measurements of the open area on the right heal. The clinical record lacked evidence that the nursing needs were not met. CLINICAL RECORD 19: This patient elected the hospice benefit on 07/18/2024 with a terminal diagnosis of Alzheimer's Disease and Vitamin B 12 anemia. The Registered Nurse (RN) comprehensive assessment dated 07/18/2024 stated that there were no open wounds at the time of admission to hospice. The RN documented that the patient was at risk for skin breakdown and the patient was ordered a low air loss mattress. On 08/05/2024 and 09/10/2024, the RN documented a left medial proximal inner buttocks coccyx wound stage II and documented that the wound was cleansed with soap and water and covered with a hydrocolloid gauze. In review of physician orders from dates of 08/05/2024-09/25/2024, there was no documented evidence that physician orders were received for care of the wounds. The clinical record lacked evidence that the nursing needs were not met. In an interview conducted on 03/07/2025 with the Director of Clinical Services, it was confirmed that the nursing needs of the patient were not met as identified in the patient’s initial assessment, comprehensive assessment, and updated assessments.

It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This standard was not met as evidenced by document review and interview. A review of the documentation of the volunteer hours that were provided for 2024 did not equal five (5%) percent of the total patient care hours of all paid hospice employees and contract staff. The agency documented for 2024 1.95% volunteer hours. In an interview conducted with the Volunteer Coordinator on 03/06/2025, it was confirmed that the volunteer hours did not equal, at a minimum, 5% percent of the total patient care hours of all paid hospice employees and contract staff. (1.95%) A review of the documentation of the volunteer hours that were provided for 2024 did not equal five percent of the total patient care hours of all paid hospice employees and contract staff. In an interview conducted with the Volunteer Coordinator on 03/06/2025, it was confirmed that the volunteer hours did not equal, at a minimum, 5 percent of the total patient care hours of all paid hospice employees and contract staff. (1.95%)

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. This condition of participation was not met as evidenced by document review, observation, personnel record reviews, clinical record reviews, and interviews which revealed issues with the organization's compliance with local, state, and federal law and regulation related to the health and safety of patient in the following areas: Failed to ensure that nursing services were provided in a manner consistent with accepted standards of practice {HCDT.1.I/L652/ 418.100(c)(1)}; and Failed to ensure responsibility for the organization’ ongoing performance improvement and patient safety (HSLG.12. I/L574/ 418.58(e)(1)}. The cumulative effect of these systemic problems resulted in the hospice agency's inability to ensure the provision of quality health care in a safe environment 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 service from the agency.

It is required that the hospice is primarily engaged in providing the following care and services in a manner consistent with accepted standards of practice: nursing services. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed, the agency did not ensure that nursing services were provided in a manner consistent with accepted standards of practice. CLINICAL RECORD 19: This patient elected the hospice benefit on 07/18/2024 with a terminal diagnosis of Alzheimer's Disease and Vitamin B 12 anemia. The Registered Nurse (RN) comprehensive assessment dated 07/18/2024 stated that there were no open wounds at the time of admission to hospice. The RN documented that the patient was at risk for skin breakdown and the patient was ordered a low air loss mattress. On 08/05/2024 and 09/10/2024, the RN documented a left medial proximal inner buttocks coccyx wound stage II and documented that the wound was cleansed with soap and water and covered with a hydrocolloid gauze. In review of physician orders from dates of 08/05/2024-09/25/2024, there was no documented evidence that physician orders were received for care of the wounds. In an interview conducted 03/07/2025 with the Director of Clinical Services, it was confirmed that the Registered Nurse was preforming wound care without a physician order.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: the initial plan of care, updated plans of care, initial assessment, comprehensive assessment, updated comprehensive assessments, and clinical notes including the care and services provided. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed, the agency did not ensure that each's patient's record included documentation of an updated comprehensive assessments. The agency policy "Skin Assessment/Wound Care Policy stated in part: "The Registered Nurse/Case Manager will complete and document a skin assessment at least once a week on every patient. Upon the discovery of a wound the Registered Nurse/Case Manager will document a complete assessment and institute care/treatment measures until such time as the wound is resolved." "Procedure: A. Upon the discovery of a wound, the Registered Nurse/Case Manager will add a "wound" in the patient chart in (_____) noting the following: 4. Measurements-to include length, width, depth; updated weekly. CLINICAL RECORD 1: This patient elected the hospice benefit 01/12/2024 with a terminal diagnosis of COPD. The Registered Nurse (RN) comprehensive assessment dated12/18/2024 included documentation that an open area was discovered on the patient's right heel. In review of the RN visits for 01/22/2024, 01/30/2024, 02/05/2024, 02/11/2024, 02/18/2024 and 03/04,2024, there was no documentation of the measurements of this open area on the right heel in accordance with the agency Skin Assessment/Wound Care Policy. In an interview conducted on 03/05/2025 with the Director of Clinical Services, it was confirmed that the agency did not ensure that each's patient's record included documentation of updated comprehensive assessments of wounds as per the hospice policy.

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. and the patient's record, if requested. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records reviewed in which the patient was discharged from hospice, the agency did not ensure that a hospice discharge summary was forwarded to the attending physician. CLINICAL RECORD 16: This patient elected the hospice benefit 01/13/2025 with a terminal diagnosis of gastrointestinal stromal tumor. The patient revocated services on 02/04/2025 to seek aggressive treatment. In review of the clinical record, there was no documentation that a discharge summary was forwarded to the attending physician. In an interview conducted on 03/06/2025 with the Director of Clinical Services, it was confirmed that there was no documentation that a hospice discharge summary was forwarded to the attending physician.

It is required that hospice care of the patient/resident is stated in a written plan of care established and maintained in consultation with SNF/NF or ICF/IID representatives. The hospice plan of care identifies the care and services that are needed and specifies which provider is responsible for performing the functions that are agreed upon and included in the plan of care. This standard was not met as evidenced by clinical record review, interview, and observation. In 1 of 2 (50%) clinical records reviewed where home visits were conducted in the SNF, the agency did not ensure that the delineation of duties form to identify the care and services that were needed and to specify which provider was responsible for performing the functions that were agreed upon and included in the plan of care was present in the hospice binder. CLINICAL RECORD 4/HOME VISIT 4: The patient elected the hospice benefit on 07/22/2024 with a terminal diagnosis of congestive obstructive pulmonary disease. The patient resided in a skilled nursing facility (SNF). The hospice plan of care did not include documentation to specify which provider was responsible to perform the functions included in the patient’s plan of care. During Home Visit 4 (Clinical Record 4) on 03/05/2025 to observe the Chaplain (Personnel Record 4) in the skilled nursing facility (SNF), the hospice binder was reviewed for the delineation of duties form to identify the care and services that were needed and to specify which provider was responsible for performing the functions that were agreed upon and included in the plan of care. This form was not present in the hospice binder. In an interview conducted on 03/05/2025 with the Director of Clinical Services, it was confirmed that the agency utilized a delineation of duties form for skilled nursing facilities and confirmed that this form should have been present in the hospice binder.

It is required that the hospice designates a Registered Nurse member of the IDG to provide coordination of care and ensure the implementation of the interdisciplinary Plan of Care (POC). Hospice care and services provided to patients and families follow the individualized POC established by the hospice IDG in collaboration with the attending physician. THIS IS A CONTINUING PRIOR REQUIRED ACTION This standard was not met as evidenced by clinical record review and interview. 1 of 6 (17%) clinical records reviewed revealed the agency did not ensure that the skilled disciplines followed the Plan of Care (POC) as ordered by the hospice interdisciplinary group. Record 5: The patient elected hospice care on 8/15/22. The POC effective 2/11/23 through 4/11/23 ordered the Medical Social Worker (MSW visit frequency for two (2) times per month. A clinical record review revealed MSW completed a visit on 2/20/23. There was evidence that a second MSW was completed as of 2/28/23 and no evidence of communication with the physician to change the frequency of MSW visits. During an interview and a joint clinical record review with the Patient Care Coordinator (PCC), it was confirmed that for the month of February, the MSW documented one visit. The PCC agreed that the patient should have had two MSW visits made between 2/11/23 to 2/28/23. THIS IS A CONTINUING PRIOR REQUIRED ACTION

It is required that a hospice aide provides services as ordered by the Interdisciplinary Group. THIS IS A CONTINUING PRIOR REQUIRED ACTION This standard was not met as evidenced by clinical record review and interview. 3 of 5 (60%) records reviewed, in which hospice aide services were accepted, it was revealed the agency did not ensure the aide services provided were consistent with Plan of Care (POC) orders. Record 2: The patient elected hospice care on 9/9/22. The hospice aide care plan, effective as of 2/25/23, ordered the aide visit frequency three (3) times weekly; relevant tasks included shave one (1) time per week and change linen one (1) time per week. For the week starting on 2/26/23, the hospice aide documented both tasks were completed with all three visits (2/27/23, 3/1/23, and 3/3/23). The hospice aides were not providing the tasks at the frequency ordered by the interdisciplinary group. Record 4: The patient elected hospice care on 11/9/22. The hospice aide care plan, effective as of 2/7/23, ordered the aide visit frequency five (5) times weekly; relevant tasks included change linen three (3) times weekly. For the week starting on 3/5/23, the hospice aide documented the task was completed with all five visits (3/6/23, 3/7/23, 3/8/23, 3/9/23, and 3/10/23). The hospice aides were not providing the tasks at the frequency ordered by the interdisciplinary group. Record 5: The patient elected hospice care on 8/15/22. The hospice aide care plan, effective as of 2/11/23, ordered the aide visit frequency three (3) times per week; relevant tasks included shampoo once a week, nail care once a week, shave once a week, and change linen once a week. For the week starting on 3/5/23, the aide documented the tasks were completed with all three visits (3/6/23, 3/8/23, and 3/10/23). The hospice aides were not providing the tasks at the frequency ordered by the interdisciplinary group. During an interview and a joint clinical record review, the Patient Care Coordinator, RN (PCC) reported that the aides were "just marking all tasks as completed" and agreed that by doing so they were not providing services as ordered in the aide care plans. THIS IS A CONTINUING PRIOR 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. This standard was not met as evidenced by clinical record review and interview. 1 of 5 (20%) records reviewed, in which hospice aide services were accepted, revealed the agency did not ensure that the hospice aides reported changes in the patient care needs to the Registered Nurse (RN). Record 1: The patient elected hospice care on 9/26/22. The hospice aide care plan effective as of 1/24/23 ordered a partial bath to be provided twice weekly and a shower one time weekly, with an aide visit frequency of three (3) times per week. For the week starting 2/26/23, the aide documented that the partial bath was "completed" on 2/27/23 and "refused" on 3/1/23. The third visit of the week was a shower completed on 3/3/23 as assigned. There was no documented evidence that the aide informed the RN of the patient's refusal. The aide care plan did not designate the patient as a decision-maker, able to refuse tasks without RN notification. During an interview and joint record review with the DON, Administrator, and PCC/RN it was confirmed that the three admission documents did not include the election statement or election of benefit date.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. Each patient’s record includes, at a minimum; signed copies of the notice of patient rights and the hospice election statement. The election statement must include the following: The effective date of the election, which may be the first day of hospice care or a later date but may be no earlier than the date of the election statement. This standard was not met as evidenced by document review, clinical record review, and interview. 6 of 6 (100%) clinical records reviewed revealed the agency did not ensure that the election of benefits form utilized by the hospice contained the required hospice election statement. Record 1: The patient elected hospice benefits on 09/26/22. The form titled "Election of Hospice Benefits Clinical Informed Consent" and "Election of Hospice Benefits Legal Informed Consent" documents were signed on 9/26/22, and did not include the election statement or place to enter the election date on this form. Record 2: The patient elected hospice benefits on 09/09/22. The form titled "Election of Hospice Benefits Clinical Informed Consent" and "Election of Hospice Benefits Legal Informed Consent" documents were signed on 9/9/22, and did not include the election statement or place to enter the election date on this form. Record 3: The patient elected hospice benefits on 01/16/23. The form titled "Election of Hospice Benefits Clinical Informed Consent" and "Election of Hospice Benefits Legal Informed Consent" documents were signed on 1/16/23, and did not include the election statement or place to enter the election date on this form. Record 4: The patient elected hospice benefits on 11/09/22. The form titled "Election of Hospice Benefits Clinical Informed Consent" and "Election of Hospice Benefits Legal Informed Consent" documents were signed on 11/9/22, and did not include the election statement or place to enter the election date on this form. Record 5: The patient elected hospice benefits on 08/15/22. The form titled "Election of Hospice Benefits Clinical Informed Consent" and "Election of Hospice Benefits Legal Informed Consent" documents were signed on 8/15/22, and did not include the election statement or place to enter the election date on this form. Record 6: The patient elected hospice benefits on 03/03/22. The form titled "Election of Hospice Benefits Clinical Informed Consent" and "Election of Hospice Benefits Legal Informed Consent" documents were signed on 3/3/22, and did not include the election statement or place to enter the election date on this form. During an interview and joint record review with the DON, Administrator, and PCC, RN it was confirmed that the three admission documents did not include the election statement or election of benefit date. This impacted all records reviewed, and per the Director of Nursing and Patient Care Coordinator, they did not have any election of benefit forms that contained specifically required information. The Election of Benefit and Informed Consent forms utilized by the agency did not contain the election statement as required in §418.24 Election of hospice care: (b) Content of election statement. The election statement must include the following: (4) The effective date of the election, which may be the first day of hospice care or a later date but may be no earlier than the date of the election statement. This impacted all records reviewed, and per the Director of Nursing and Patient Care Coordinator they did not have any election of benefit forms that contained that specifically required information.

It is required that the hospice designates a registered member of the IDG to provide coordination of care; to ensure continuous assessment of each patient’s and family’s needs; and 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. THIS IS A CONTINUING REQUIRED ACTION This standard was not met as evidenced by clinical record review and interview. 1 of 5 (20%) clinical records reviewed revealed the hospice did not ensure the skilled disciplines followed the plan of care as ordered. Record # 100 was reviewed and identified the date of election was on 5/20/2022. The Chaplain ordered visit frequency was 2 times a month on 5/20/2022. During the month of May 2022, 1 visit was completed. There was no documentation explaining the missed visit. During a joint record review, the DON and the Alternate DON verified the chaplain missed a visit in May. No additional information was provided upon request.

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 A CONTINUING PRIOR REQUIRED ACTION This standard was not met as evidenced by joint review of clinical records and interview. 1 of 5 (20%) records reviewed for patients receiving the services of a Hospice Aide for revealed the hospice did not ensure the aide plan of care (POC), developed by the RN, provided clear and specific instructions for care. Record # 100 was reviewed and the aide POC included the aide POC dated 5/20/2022 assigned the aide to perform “BSC - as needed". The POC did not include how often to use the BSC. A decision maker was not identified to determine when “as needed". During a joint record review, the DON and the Alternate DON acknowledged the Aide POC lacked clear instructions for the BSC and should not have stated “as needed”.

It is required that a hospice aide provides services ordered by the Interdisciplinary Group and included in the plan of care. THIS A CONTINUING PRIOR REQUIRED ACTION This standard was not met as evidenced by clinical review and interview. 2 of 5 (40%) applicable records receiving hospice aide services revealed the hospice did not ensure the aide services provided were consistent with the Interdisciplinary Group orders and the plan of care. The frequency of the aide visits did not match the care plan. Record #100 was reviewed and identified the date of election was 5/20/2022. The ordered Hospice Aide visit frequency was 2 times a week on 5/20/2022. 1 visit was completed the week of 5/20/2022. There was no documentation explaining the reason for the missed visit. Record # 77 was reviewed and identified the date of election on 1/25/2022. The ordered Hospice Aide visit frequency was 4 times a week on 1/21/2022. The week of 1/25/2022, 3 visits were completed. There was no documentation explaining the missed visit. During a joint record review, the DON and the Alternate DON confirmed the visit was missed. The DON stated the order was written wrong for the first week. There was no additional information provided when requested.

It is required that the hospice designates a registered member of the IDG to provide coordination of care; to ensure continuous assessment of each patient’s and family’s needs; and 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. This standard was not met as evidenced by clinical record review and interview. 2 of 13 (15%) clinical records reviewed revealed the hospice did not ensure the skilled disciplines followed the plan of care as ordered. Record #87313 was reviewed and identified an order for skilled nursing visits one time weekly for the week of 9/26/2021. During the week 9/26/2021-10/2/2021, there were no nursing visits and no documented reasons for the missed visit. Record # 100 was reviewed and identified the date of election was on 5/20/2022. The Chaplain ordered visit frequency was 2 times a month on 5/20/2022. During the month of May 2022, 1 visit was completed. There was no documentation explaining the missed visit. The Director of Nursing was interviewed on 5/11/2022 and confirmed the plan of care was not followed by the SN.

It is required that the hospice documents and maintains an effective infection control program that protects patients, families, visitors, and hospice staff by preventing and controlling infections and communicable diseases. The infection control program includes: Identifying risk for acquiring and transmitting infectious agents where the patient resides. THIS IS AN IDENTIFIED THREAT OF IMMEDIATE JEOPARDY This CONDITION was not met as evidenced by document review, personnel record review, and interview with the Alternate Administrator, and identified the agency failed to ensure the agency policy:1. Established the two exceptions to being fully vaccinated for Covid-19. [HIPC.15/L900/418.60(d)(2)] 2.Defines the process for an indivudual to request a medical or spirital exemption from being fully vaccinated for Covid-19 per state and federal law and regulation. [HIPC.13/L900/418.60(d)(3)(iv)] 3. Defines the process for tracking and securely documenting the COVID-19 vaccination status of all staff and contracted staff. [HIPC.13/L900/418.60(d)(3)(vi)] 4. 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. HIPC.18/L900/418.60(d)(3)(iii] Additionally failed to ensure a process for all employees to be screened and documented vaccination status except for those staff and contractors who have been granted exemptions or temporary delays to the vaccination for COVID-19 [HIPC.17/L900/418.60(d)(ii)]. The cumulative effect of this issue has resulted in the home health agency’s inability to ensure the provision of quality health care in a safe environment for the condition of participation CFR 418.60: Infection Control. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the agency. The cumulative effect of these systemic problems resulted in the hospice agency's inability to ensure the provision of quality health care in a safe environment.

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 joint review of clinical records and interview. 1 of 11 (9%) records reviewed for patients receiving the services of a Hospice Aide for revealed the hospice did not ensure the aide plan of care (POC), developed by the RN, provided clear and specific instructions for care. Record # 100 was reviewed and the aide POC included the aide POC dated 5/20/2022 assigned the aide to perform “BSC - as needed". The POC did not include how often to use the BSC. A decision maker was not identified to determine when “as needed”. During a joint record review, the DON and Alternate DON acknowledged the Aide POC lacked clear instructions for the BSC and should not have stated “as needed”.

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. 2 of 11(18 %) applicable records receiving hospice aide services revealed the hospice did not ensure the aide services provided were consistent with the Interdisciplinary Group orders and the plan of care. The frequency of the aide visits did not match the care plan. Record #100 was reviewed and identified the date of election was 5/20/2022. The ordered Hospice Aide visit frequency was 2 times a week on 5/20/2022. 1 visit was completed the week of 5/20/2022. There was no documentation explaining the reason for the missed visit. Record # 77 was reviewed and identified the date of election on 1/25/2022. The ordered Hospice Aide visit frequency was 4 times a week on 1/21/2022. The week of 1/25/2022, 3 visits were completed. There was no documentation explaining the missed visit. During a joint record review, the DON and the Alternate DON confirmed the visit was missed. The DON stated the order was written wrong for the first week. There was no additional information provided when requested.

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%) patients reviewed with a discharge from the agency revealed the hospice did not ensure that the discharge summary was sent to the patient’s attending physician. Record #45500 was reviewed and identified a discharge summary on 2/20/2022. There was no evidence the discharge summary was sent to the attending physician. Record #96020 was reviewed and identified a discharge summary on 2/21/2022. There was no evidence the discharge summary was sent to the attending physician. The Assistant Director of Nursing was interviewed on 5/11/2022. She agreed with the finding that there was no documentation the discharge summary was sent to the attending physician.

It is required that the designated IDG member provides the SNF/NF or ICF/IDF with the following information for each patient/resident: hospice election form, physician certification and recertification of the terminal illness. This standard was not met as evidenced by record review and interview. 2 of 2 (100%) patients reviewed in a SNF revealed the hospice did not ensure the hospice election form, physician certification and recertification of the terminal illness were provided to the SNF by the designated IDG member. During a joint visit with the Aide #25236 to Patient #41649, on 5/11/2022 at 8:45 am, a review of the facility records revealed there was no evidence that the hospice election form, physician certification and recertification of the terminal illness were provided to the SNF. During a joint visit with the Registered Nurse #34348 to Patient #62815, on 5/11/2022 at 9:05 am, a review of the facility records revealed there was no evidence that the hospice election form, physician certification and recertification of the terminal illness were provided to the SNF. The Alternate Administrator was interviewed on 5/11/2022 and confirmed the required documentation had not been provided to the facility.

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 personnel record review, documentation review, interview, and observation. 3 of 4 (75%) of unvaccinated staff with an approved exemption reviewed revealed the hospice did not ensure the implementation of additional precautions to mitigate the transmission and spread of COVID-19 for individuals who are not fully vaccinated for COVID-19. Record #65172 (ADON). Review of the personnel file revealed an approved vaccination exemption. The ADON was observed not wearing a mask in the office on May 10, 2022. The ADON was interviewed on 5/10/2022 and confirmed she had not been required, nor had completed, weekly COVID testing since receiving the vaccination exemption. Record #12363 (Chaplain). Review of the personnel file revealed an approved vaccination exemption. The Chaplain was observed not wearing a mask in the office on May 10, 2022. The Chaplain was interviewed on 5/10/2022 and confirmed he had not been required to wear a mask in the office, “only on visits.” The Chaplain confirmed he had not been required, nor had completed, weekly COVID testing since receiving the vaccination exemption. Record #25236 (Aide). Review of the personnel file revealed an approved vaccination exemption. The Aide was interviewed on 5/11/2022 and confirmed she had not been required, nor had completed, weekly COVID testing since receiving the vaccination exemption. Agency policy " Mandatory Covid-19 Vaccination Policy stated, “If accommodations are granted, HCP (Healthcare personnel) will be required to: wear a company approved face covering, at all times, even in cubicles or private offices. They are to be strictly worn to enter and remain on the premises. Engage in weekly testing and will not be permitted to enter a facility if their last test result is greater than 7 days old. Testing will be provided by the company.” The Alternate Administrator was interviewed on 5/10/2022 and stated, “we can COVID test our staff but haven’t been requiring testing unless they have symptoms.” “It got dropped and it wasn’t tracked or followed.” The Alternate Administrator confirmed the staff identified were not following agency policy.