Every finding on record at All Compassionate Care Hospice LLC

Based on record review and interview, the hospice failed to include all services necessary for the palliation and management of the terminal illness and related conditions in the Plans of Care in that the Plans of Care did not include measurable outcomes anticipated from the implementation and coordination of the plan of care for 6 (Patients #1, #3, #5, #6, #9, and #13) of 14 patient records reviewed. The failure placed the patients at risk that care provided would be inadequate resulting in worsening of symptoms. --- Patient #1:Record review of Patient #1's clinical record revealed a Plan of Care dated 12/24/2025 to 2/21/2026. The Plan of Care indicated that Patient #1 started on the hospice's services on 6/27/2025. The Plan of Care listed Malignant (Primary) Neoplasm (Cancer) Unspecified as the terminal diagnosis. The Plan of Care listed Gastro-Esophageal Reflux Disease without Esophagitis (chronic digestive condition where stomach content flows back up into the esophagus (muscular tube where food/fluids travel to the stomach after being swallowed) as a secondary diagnosis.  Registered Nurse C conducted a recertification comprehensive reassessment on 12/15/2025. Registered Nurse C documented that Patient #1 had constipation, potential for altered nutritional status related to gastro-esophageal reflux disease, and had the potential to fall. Patient #1's Plan of Care listed constipation, potential for altered nutritional status, and the potential to fall in the Plan of Care in the intervention and goals portion of the Plan of Care. Patient #1's Plan of Care did not include measurable outcomes anticipated from the implementation and coordination of the plan of care for constipation, potential for altered nutritional status, and the potential to fall.  Patient #3:Record review of Patient #3's clinical record revealed a Plan of Care dated 9/2/2025 to 10/23/2025. The Plan of Care indicated that Patient #3 started on the hospice's services on 6/4/2025. The Plan of Care listed Parkinsonism (syndrome characterized by slowness, muscle stiffness, involuntary body movements, and an unstable posture) as the terminal diagnosis. Registered Nurse C conducted a recertification comprehensive assessment on 9/2/2025. Registered Nurse C documented that Patient #3 had communication problem with activity intolerance, anticipatory grieving, compromised family coping, disease process, dying process/imminent death; a caregiver problem regarding a lack of understanding of hospice philosophy services available and knowledge deficit related to the disease process; safety problem with ambulatory aid issues, fall risk, poor coordination and weakness. Patient #3's Plan of Care listed these problems in the Plan of Care in the intervention and goals portion of the Plan of Care. The Plan of Care did not include measurable outcomes anticipated from the implementation and coordination of the plan of care for the listed communication problem, caregiver problem, and the fall risk problem. Patient #5:Record review of Patient #5's clinical record revealed a Plan of Care dated 11/10/2025 to 12/13/2025. The Plan of Care indicated that Patient #5 started on the hospice's services on 11/10/2025. The Plan of Care listed Senile Degeneration of the Brain (progressive decline of the brain causing severe impairment in memory, reasoning, and judgement) as the terminal diagnosis. The Plan of Care listed Hypertension (chronic high pressure of the force of the blood against blood vessel walls would be consistently too high, forcing the heart to work harder) as a secondary diagnosis. Registered Nurse D conducted an initial comprehensive assessment on 11/10/2025. Registered Nurse D documented that Patient #5 had the potential for altered cardiac (heart) status related to hypertension. Patient #5's Plan of Care listed the potential for altered cardiac status related to hypertension in the intervention and goals section of the Plan of Care. The Plan of Care did not include measurable outcomes anticipated from the implementation and coordination of the Plan of Care for the potential for altered cardiac status related to hypertension. Patient #6:Record review of Patient #6's clinical record revealed a Plan of Care dated 1/15/2026 to 3/15/2026. The Plan of Care indicated that Patient #6 started on the hospice's services on 10/17/2025. The Plan of Care listed Parkinson's Disease (progress disorder of the central nervous system causing involuntary body movements, slowness, muscle rigidity -stiffness, and postural balance instability) with Dyskinesia (involuntary movement caused by use of medications to treat Parkinson's Disease) with Fluctuations (instability)   Chaplain E conducted a spiritual counselor assessment as part of the initial comprehensive assessment on 10/20/2025. Chaplain E documented that Patient #6 and Patient #6's family were grieving the death of a family member and Patient #6 was at risk for loneliness due to not being able to go to an adult day rehab. Registered Nurse C conducted a recertification comprehensive assessment on 1/5/2026. Registered Nurse C documented that Patient #6 and Patient #6's family were grieving the death of a family member and Patient #6 was at risk for loneliness due to the inability to go to an adult day rehab. Patient #6's Plan of Care listed Patient #6 and Patient #6's family were grieving the death of a family member and Patient #6 was at risk for loneliness. The Plan of Care did not include measurable outcomes anticipated from the implementation and coordination of the Plan of Care for grief and risk of loneliness. Patient #9:Record review of Patient #9's clinical record revealed a Plan of Care dated 1/4/2026 to 3/4/2026. The Plan of Care indicated that Patient #9 started on the hospice's services on 5/9/2025. The Plan of Care listed Parkinson's Disease without Dyskinesia, without mention of Fluctuations as the terminal diagnosis.  Registered Nurse C conducted a recertification comprehensive reassessment on 1/2/2026. Registered Nurse C documented that Patient #9 had difficulty swallowing and had a reduction in the amount of food Patient #9 was eating.  Patient #9's Plan of Care listed difficulty swallowing and reduced food portion consumption in the intervention and goals section of the plan of care. The Plan of Care did not include measurable outcomes anticipated from implementation and coordination of the Plan of Care for difficulty swallowing and reduced food consumption.  Patient #13:Record review of Patient #13's clinical record revealed a Plan of Care dated 2/8/2026 to 5/8/2026. The Plan of Care indicated that Patient #13 started on the hospice's services on 2/8/2026. The Plan of Care listed Senile Degeneration of the Brain as the terminal diagnosis. Registered Nurse G conducted an initial comprehensive assessment on 2/8/2026. Registered Nurse G documented that Patient #13 had problems with communication and caregiver knowledge deficit- activity intolerance, family needing more education regarding opioid medication (drugs to relieve pain) and Cheyne Stoke breathing (severe, abnormal breathing pattern characterized by a repeating cycle of gradually deepening and faster breathing, followed by a gradual decrease in breathing, and ending in a temporary cessation of breathing). Patient #13's Plan of Care listed problems with communication and caregiver knowledge deficit- activity intolerance, family needing more education regarding opioid medication, Cheyne Stoke breathing, and hospice philosophy and protocols. The Plan of Care did not include measurable outcomes anticipated from implementation and coordination of the Plan of Care for problems with communication and caregiver knowledge deficit- activity intolerance, family needing more education regarding opioid medication, Cheyne Stoke breathing, and hospice philosophy and protocols. During an interview on 3/27/2026 at 9:23 AM with the Administrator and the Alternate Supervising Nurse, the surveyor discussed that the plans of care did not contain measurable outcomes for problems identified during the comprehensive assessments. The Surveyor asked who would be responsible to ensure the measurable outcomes would be included in the plans of care. The Alternate Supervising Nurse stated, "I am."  The surveyor asked how the interdisciplinary team reviewed the plan of care. The Alternate Supervising Nurse informed the surveyor that the core team would collaborate; "We go over goals and outcomes, problems and interventions."  The Administrator reviewed the Plans of Care and agreed the measurable outcomes were not included in the Plans of Care. The Alternate Supervising Nurse did not know why the measurable outcomes were not included in the plans of care. Review of the agency's policy titled "Plan of Care Process PC.30", last reviewed on 3/16/26 read in part; "Purpose To ensure that the care provided is in accordance with the written Plan of Care (POC), appropriately planned, and delivered in a timely manner to meet the patient's and family's specific needs. Policy...II. I. The Hospice will develop an individualized written POC for each patient, The POC must reflect patient and family goals and interventions based on the problems identified...Procedure...VI. The POC includes, but is not limited to...C Measurable outcomes anticipated from implementing and coordinating the POC..."

Based on record review and interview, the interdisciplinary group- core group of a physician, registered nurse, chaplain, and social worker that provides/supervises all care and services, ensuring a holistic approach to terminal illness and bereavement, (in collaboration with the individual's attending physician, in any) failed to review, revise and document the patient's individualized plan of care as frequently as the patient's condition required but no less frequently than every 15 days, in that the interdisciplinary group failed to revise the plan of care regarding wound care for 1 (Patient #7) of 3 patient records reviewed where the hospice nursing staff provided wound care. The failure placed Patient #7 at risk of the wound becoming infected or worsening. --- Client #7:Record review of Client #7's clinical record revealed a Plan of Care dated 12/30/2025 to 2/27/2026. The Plan of Care indicated that Client #7 started on the hospice's services on 7/3/2025. The Plan of Care listed Senile Degeneration of the Brain (progressive decline in memory, reasoning, and judgment) as the terminal diagnosis.  Patient #7's clinical record contained a physician order dated 12/31/2025 for a skilled nurse to make a skilled nurse visit to evaluate Patient #7 due to reports that Patient #7 had a wound to the sacral (lower back) area. Registered Nurse C conducted a skilled nurse visit on 12/31/25. Registered Nurse C documented that Patient #7 had a Stage II Pressure Ulcer (partial-thickness loss of skin, open ulcer with a moist, pink/red wound bed, or as an intact/ruptured serum-filled blister caused by friction, sheering or pressure) to the sacrum (lower back) that measures 3 centimeters by 3 centimeters. Registered Nurse C documented cleaning the wound with saline (sterile solution of salt and purified water, matching the body's physiological concentration and used to clean wounds) wound cleanser and applied a wound dressing with border (sterile dressing featuring a central absorbent pad surrounded by skin-friendly adhesive border.  Registered Nurse C conducted skilled nurse visits on 1/4/2026, 1/11/2026, and 1/18/2026. Registered Nurse C documented at each of the visits that Registered Nurse C cleaned Patient #7's wound with saline wound cleanser and applied a wound dressing with a border. Registered Nurse C conducted a skilled nurse visit on 1/28/2026 and documented that Patient #7's sacral wound had healed.  Patient #7's clinical record contained documentation of interdisciplinary group meetings on 1/12/2026 and 1/26/2026. The interdisciplinary group failed to review and revise the Plan of Care regarding wound care orders for Patient #7's wound.  During an interview on 3/27/2026 at 9:23 AM with the Administrator and Alternate Supervising Nurse, the surveyor discussed that Patient #7 had a sacral wound and that the Plan of Care did not contain orders for wound care and the Plan of Care was not revised by the interdisciplinary group. The surveyor asked how the interdisciplinary group reviewed the Plan of Care. The Alternate Supervising Nurse informed the surveyor that the core team would collaborate. The Alternate Supervising Nurse stated, "We look at the plan of care and update it. We go over goals and outcomes, problems and interventions." The surveyor asked why the plan of care was not updated. The Alternate Supervising Nurse reviewed the interdisciplinary group documentation. The Alternate Supervising Nurse did not know why the Plan of Care had not been revised for the wound care. Review of the agency's policy titled "Plan of Care Process PC.30," last reviewed 3/16/2026 read in part; "Purpose To ensure that the care provided is in accordance with the written Plan of Care (POC), appropriately planned, and delivered in a timely manner to meet the patient's and family's specific needs. Policy...III The Hospice will review and revise patient care in accordance with changes in the patient's condition: spiritual status; psychosocial status; residential environment; patient's response to care; and changes that have occurred regarding diagnosis, treatment, medications, precautions and limitations. Procedure...VI. The POC includes, but is not limited too...D. Drugs and treatments necessary to meet the needs of the patient...VII. The Hospice IDG/IDT (Interdisciplinary Group/Team), in collaboration with the individual's attending physician, if any, will review, revise, and document the individualized plans as frequently as the patient's condition requires, but no less frequently than every 15 calendar days..." Review of the agency's policy titled "Timelines IM.40," last reviewed on 1/1/2026, read in part; "Purpose To establish timely parameters for medical record information. Policy I. The Hospice will ensure timely provision of care to meet patient's needs in compliance with all federal and state laws and regulations...Procedure...D. The IDG/IDT (Interdisciplinary Group/Team) Plan of Care (POC) will be developed within 15 days of the start of care, and updated at least every 15 days..."

Based on record review and interview, the agency failed to include in the patient record clinical notes of the continuous care staff for 1 (Patient #2) of 2 patient records reviewed of patients that died while on the hospice's services. The failure placed the patients at risk of receiving inadequate care, safety issues, and increased risk of harm. --- Code of Federal Regulation, Title 42, Chapter IV, Subchapter B, Part 418, reviewed August 4, 2021, read in part; ..."418.3 Definitions...Clinical note means a notation of a contact with the patient and/or the family that is written and dated by any person providing services and that describes signs and symptoms, treatments and medications administered, including the patient's reaction and/or response, and any changes in physical, emotional, psychosocial or spiritual condition during a given period of time..." Patient #2: (record reviewed on 3/20/2026)Record review of Patient #2's clinical record revealed a Plan of Care dated 12/17/2025 to 12/18/2025. The Plan of Care indicated that Patient #2 started on the hospice's services on 12/17/2025. The Plan of Care listed Cerebral Infarction Unspecified (blocked blood vessel leading to brain tissue death) as the terminal diagnosis.  Registered Nurse F conducted an initial comprehensive assessment on 12/17/2025. Registered Nurse F documented that Patient #2 was in respiratory distress, had moderate pain, was non-responsive, and Registered Nurse F was unable to obtain a heart rate or blood pressure. Registered Nurse F documented that continuous care was initiated for management of respiratory distress and pain.  Patient #2's record did not contain documentation of continuous care. On 3/20/2026 the surveyor requested the continuous care documentation. The agency was unable to provide documentation of the continuous care provided to Patient #2. During an interview on 3/20/2026 at 11:53 AM with the Administrator, the surveyor was informed that the agency did not meet the criteria of 8 hours of continuous care. Registered Nurse F was not at Patient #2's home for 8 hours; Registered Nurse F’s care time was 3:30 pm to 10:35 pm.  During an interview on 3/202026 at 12:21 PM with the Administrator and Registered Nurse F, the surveyor asked about continuous care for Patient #2. Registered Nurse F informed the surveyor; Patient #2 was actively dying; Registered Nurse F administered Morphine (medication used for pain) and Lorazepam (used for anxiety) before the continuous care nurse arrived; the continuous care documentation would be in the continuous care book in the home; and the nurse that pronounced death would bring the book back to the office. The Administrator informed the surveyor that the Administrator thought only Registered Nurse F had been there. The Administrator stated, "We called (Agency Z) staffing agency, we were told the notes were in the book." The Administrator informed the surveyor that the continuous care nurse stayed at the home for 4 hours plus 3 hours and Agency Z did not have the continuous care notes.   Review of the agency's invoice from Agency Z revealed that Agency Z provided a continuous care nurse on 12/17/2025 for 3 hours and on 12/18/2025 provided a continuous care nurse for 6 hours.  During an interview on 3/23/2026 at 12:48 pm with the Alternate Supervising Nurse, the Alternate Supervising Nurse brought two documents regarding continuous care for Patient #2. The documents were physician's orders dated 12/17/2025 for continuous care, medications, and care to be provided. The Alternate Supervising Nurse informed the surveyor that the continuous care nurse handed Registered Nurse G the notes, but Registered Nurse G did not look at it to make sure the notes were there.  Review of the agency's policy titled "Timelines IM.40," last reviewed on 1/1/2026 read in part; "Purpose To establish timely parameters for medical record information. Policy...II. The Hospice will establish staff responsibilities for acceptable timeframes for completion and submission of medical record information including, but not limited to: visit notes and assessments, physician orders, certifications and recertification, transfer and discharges. Procedure I. All hospice, staff, physicians(s) and/or other licensed independent practitioner(s) and physician office staff as appropriate, will be oriented to the following parameters...III. All medical record information will be incorporated into the patient's medical record in a timely manner…" Review of the agency's policy titled "Timelines-Addendum IM.40 TX," last reviewed on 4/14 2023 read in part; " Procedure I. In addition to the requirements defined in the Timelines policy in the Information Management section of the Administrative Policy Manual, the following requirement will be met: A. All clinical and progress notes will be written the day service is rendered and incorporated into the patient's medical record within 14 working days." Review of the agency's policy titled "Medical Record Content IM.30," last reviewed on 9/1/2024 read in part; "Purpose To ensure each medical record contains complete, correct information which identified the patient, describes problems, and needs of the patient, justifies patient care, and accurately describes care provided, outcomes, significant events and continuity/coordination of care. Policy I. The Hospice will initiate and maintain an individual and accurate medical record containing past and current information for each patient accepted for care. The record will contain correct information that is available to the patient's attending physician and hospice staff...Procedure I. The content of the medical record will include, at a minimum...D. Clinical notes...III. Additionally, the medical record will contain, but not be limited to, the following...D. Clinical notes documenting functional and activity limitations, all actions, interventions, and procedures provided by the Hospice, including medication administration, treatments and services, the responses to interventions and..7. Care provided through contracted staff..."

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as hand hygiene. This standard was not met as evidenced by a review of observations and document reviews. 2 of 3 (67%) home visits observed revealed the hospice did not ensure the nurses followed the agency policy and procedure on hand hygiene during home visits. Home Visit 1: This site visitor did not observe the Registered Nurse (RN) using hand sanitizer after touching the patient or the patient's immediate environment and did not follow the Hand Hygiene policy. The RN touched the assessment equipment and then pen and paper to document, and then touched the patient's arm and touched her bag again. Home Visit 3: This site visitor did not observe the LVN on 2/21/22 using hand sanitizer after touching the patient or the patient's immediate environment and did not follow the Hand Hygiene policy. The LVN was observed using the assessment equipment when taking the vital signs and then touching her pen and paper and getting in and out of her bag. Hand Hygiene Policy, was last reviewed on 081522, and included in part, "Staff may use an alcohol-based hand rub for routinely decontaminating hands in the clinical situations described below: 6. After touching a patient or the patient's immediate environment."

It is required that the comprehensive assessment includes consideration of the following factors: bowel regimen when opioids are prescribed. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 1 (100%) clinical record reviewed of a patient on opiods revealed the hospice did not ensure that the comprehensive assessment included consideration of a bowel regimen. Clinical Record 1: The patient elected hospice care on 11/5/2022 with the primary diagnosis of malignant neoplasm of the prostate. The initial comprehensive assessment completed by the Registered Nurse (RN) on 11/5/2022 documented the patient was taking the opiods: methadone and fentanyl. The RN documented that the patient complained of occasional constipation. Review of the record revealed no evidence that the patient was offered or the hospice considered placing the patient on a bowel regimen due to the opiod use and constipation during the assessment. There was no evidence of a bowel regiment on the plan of care. A physician's order dated 11/17/2022 included Senna S for constipation. During an interview with the Administrator and RN confirmed the finding. The RN referred to the medication list dated 11/17/2022 where Senna S had been added. In an interview with the administrator and RN there was no explanation for the bowel regimen not being added at admission. The RN continually referred to the med list on 11/17 where Senna S had been added. The agency never provided surveyor with a Comprehensive Assessment Policy.

iIt is required that the comprehensive assessment includes consideration of 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 a review of clinical records and interviews. 1 of 8 (13%) clinical records reviewed revealed that the hospice did not address the severity of symptoms that the patient experienced during the comprehensive assessment. Clinical Record 4: was reviewed and identified the patient elected hospice care on 10/31/2022 with the primary diagnosis of malignant neoplasm of the pancreas. During the initial comprehensive assessment completed on 10/31/2022, the Registered Nurse (RN) documented that the patient was experiencing nausea and vomiting, and the patient had vomited 4 times on that day. There was no evidence that the RN reported the patient’s nausea and vomiting to the physician during the comprehensive assessment. The RN visit note dated 11/12/2022 documented that the patient had a suppository for nausea, but the family was not comfortable administering the suppository. The RN documented the administration of the suppository during the visit on 11/12/2022. There was no evidence that the RN followed up with the family and the physician to ensure the patient was receiving the suppository in the absence of the hospice nurse. In addition, two (2) “as needed” visits were completed by the RN with no evidence of changes made to the plan of care or medication. There was no evidence the symptoms identified during the comprehensive assessment were addressed. During an interview, the RN confirmed the finding and stated that the patient had a suppository ordered for the nausea. In an interview with RN, she did not provide any explanations as to why the severity of symptoms were not addressed. She did state that the patient was on a suppository for nausea, and she felt like it worked. However, it was documented in a nursing note on 11/12/22 that the family was not comfortable giving the suppository medication. The RN administered medication that day. There was no documented evidence that the RN ensured that the patient was getting this medication in the absence of the hospice staff.

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 other alternative treatments that could affect drug therapy. 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 a review of clinical records. 2 of 8 (25%) clinical records reviewed revealed the agency did not ensure the comprehensive assessment included a drug profile that contained the patient's current prescription. Clinical Record 2: The patient elected hospice care on 9/29/2022 with the diagnosis mulitple myeloma. The initial comprehensive assessment completed by the Registered Nurse documented the patient was taking Tylenol. The medication was reviewed during the comprehensive assessment. Tylenol was not added to the medication profile until 11/13/2022. Clinical Record 3: The patient elected hospice care on 11/4/2022 with the diagnosis malignant neoplasm of the cervix. The initial comprehensive assessment completed by the Registered Nurse documented that patient was on continuous oxygen.The medication was reviewed during the comprehensive assessment. The oxygen was not included on the patient's medication profile. In addition, there was an order for Tylenol entered by the RN on 11/7/2022. The Tylenol was not added to the patient's medication profile.

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 was not met as evidenced by a review of clinical records and interview which revealed the hospice failed to ensure that a plan of care specified the hospice care and services [HCPC.18.I/538]; Failed to ensure that the plan of care included the frequency of services necessary to meet the needs of the patient [HCPC.21.I/547]; Failed to ensure the plan of care included the medical supplies and appliances necessary to meet the needs of the patient [HCPC.21.I/550]; and Failed to ensure the Interdisciplinary Group reviewed, revised, and documented the individualized care plan no less frequently than every 15 calendar days [HCPC.22.I/552].

It is required that the plan of care must specify the hospice care and services necessary to meet the patient and family-specific needs identified in the comprehensive assessment as such needs relate to the terminal illness and related conditions. This standard was not met as evidenced by a review of clinical records. 1 of 7 (14%) clinical records reviewed of patients electing hospice care prior to 12/7/2022 revealed the hospice did not ensure that the plan of care specified the hospice care and services necessary to meet the patient and family-specific needs. Clinical Record 7: was reviewed and identified the patient elected hospice care on 10/15/2022. The patient expired on 10/20/2022. Review of the clinical record revealed no evidence of a written plan of care for the patient.

It is required that the hospice must designate an interdisciplinary group or groups composed of individuals who work together to meet the physical, medical, psychosocial, emotional, and spiritual needs of the hospice patients and families facing terminal illness and bereavement. Interdisciplinary group members must provide the care and services offered by the hospice, and the group, in its entirety, must supervise the care and services. This standard was not met as evidenced by clinical record and document reviews, and interviews. 3of 8 (36%) clinical records reviewed revealed the hospice did not ensure documented evidence of team members providing psychosocial, medical and bereavement need or supervision to ensure patient/family care and services. Clinical Record 1: The patient elected hospice care on 11/5/2022 with the primary diagnosis of malignant neoplasm of the prostate. The initial comprehensive assessment completed by the Registered Nurse (RN) on 11/5/2022 documented the patient was taking the opiods: methadone and fentanyl. The RN documented that the patient complained of occasional constipation.Review of the clinical record revealed no evidence that the patient was offered or the hospice considered placing the patient on a bowel regimen due to the opiod use and constipation during the assessment. There was evidence of a physician's order dated 11/17/2022 for Senna S for constipation.During the home visit #1 conducted on 12/8/2022, the RN asked about pain and bowel movements. After the patient complained of constipation there was no abdominal assessment performed by the RN. Review of the electronic medical record (EMR) IDG documented an IDG was held on 11/8/2022, there were no clicial notes for this IDG. There was evidence of IDG meetings for this patient dated 11/11/2022 and 11/24/2022. Review of the EMR IDG documentation for these meetings revealed the Chaplain was the only attendee, there were no medical/clinical notes and there was no evidence the patient's medications were reviewed. There was no evidence that the identified physical symptoms of the patient were reviewed and managed by the IDG. Clinical Record 2: The patient elected hospice care on 9/29/2022. Review of the IDG notes in the EMR revealed the first documented IDG meeting for this patient was documented as 10/26/2022. The IDG documentation was missing the orders for the discipline visit frequency, and medical/clinical findings. The only listed attendee for this meeting was the social worker. The IDG meeting documentation dated 11/11/2022 and 12/7/2022 listed the attendee as the chaplain. Clinical Record 3: The patient elected hospice care on 11/4/2022 following hospitalization. The patient was discharged from the hospital with a Foley and Pleurex drain. There was no evidence of IDG meeting for this patient prior to the patient's death on 11/23/2022. During an interview and a joint review of the agency's IDG binder ", the Administrator and RN stated that the Interdisciplinary Group (IDG) meetings were held every other Tuesday. Both stated that they record IDG meetings in the electronic medical record (EMR) and on paper as well in the binder. The agency did not provide any further paper or EMR evidence prior to the conclusion of the site visit.

It is required that the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 7 (14%) clinical records reviewed of patients electing hospice care prior to 12/7/2022 revealed the hospice did not ensure that the written plan of care included a detailed statement of the scope and frequency of services necessary to meet specific patient and family needs. Clinical Record 2: was reviewed and identified the patient elected hospice care on 9/29/2022. The initial plan of care did no include orders for the frequency of services to be provided.

It is required that each patient’s individualized written plan of care includes medical supplies and appliances necessary to meet the needs of the patient. This standard was not met as evidenced by a review of clinical records and observation. 2 of 3 (67%) home visits revealed the hospice did not ensure the plan of care included the medical supplies and appliances necessary to meet the needs of the patient. Home Visit 2: During the home visit conducted on 12/8/2022, review of the patient's medical supplies revealed the patient had a cane, shower chair, nebulizer, and over bed table in the home. The medical supplies observed in the patient's home were not included on the patient's plan of care (Clinical Record 2). Home Visit 1: During the home visit conducted on 12/8/2022, review of the patient's medical supplies revealed the patient had a hospital bed and wheelchair in the home. The medical supplies observed in the patient's home were not included on the patient's plan of care (Clinical Record 1).

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 a review of clinical records and interview. 3 of 7 (43%) records reviewed of patients electing hospice care prior to 12/7/2022 revealed the hospice did not ensure the Interdisciplinary Group (IDG) reviewed, revised, and documented the individualized care plan no less frequently than every 15 calendar days. Clinical Record 2: was reviewed and identified the patient elected hospice care on 9/29/2022. There was no documented evidence of an IDG meeting discussion until 11/11/2022, and then again on 12/7/2022, 43 and 26 days outstanding, respectively. Clinical Record 3: was reviewed and identified the patient elected hospice care on 11/4/2022. The patient expired on 11/23/2022. There was no documented evidence that the patient's plan of care was reviewed prior to or following the patient's expiration,19 days outstanding. Clinical Record 4: was reviewed and identified the patient elected hospice care on 10/31/2022. The patient expired on 11/17/2022. There was no documented evidence that the patient's plan of care was reviewed prior to or following the patient's expiration, 17 days outstanding. During an interview, the Administrator stated that they have not figured out the meeting section of the electronic medical record and put it all on paper. The IDG binder the agency provided did not provide any further information. In a interview with the administrator and office managers, the surveyor was given a binder that had handwritten notes in it labeled "IDG Meetings" The administrator stated that they have not figured out how to the meeting section of the electronic medical record and they put it all on paper. During review of the binder, it only revealed a brief note from the administrator that stated the group had met. There was no evidence of plan of care discussion or review of medication list.

It is required that the hospice develops, implements, and maintains an effective, ongoing, hospice-wide, data-driven quality assurance and performance improvement program (QAPI). The hospice governing body is responsible for ensuring that the program reflects the complexity of the hospice and services, involves all hospice services, including those provided under contract, addresses efforts and sets priorities for improved quality of care and patient safety, and ensures all improvement actions are evaluated for effectiveness, focuses on indicators related to improved palliative outcomes, includes investigation and analysis of sentinel and adverse events, includes defined data detail and frequency of collection, and approves such, has evidence of action taken that results in improvement in hospice performance, and is evaluated annually. THIS IS A CMS CONDITION LEVEL DEFICENCY This CONDITION was not met as evidenced by review of Governing Body documents, policies and procedures, Quality Improvement documents, and interviews with the Administrator and , which revealed issues with the organization's Quality Assessment Performance Improvement (QAPI) program in the following areas: Failure of the organization's Governing Body to appoint one or more individual(s) who are responsible for operating the quality assessment and performance improvement program [HQPI 2.I/L576]; Failure of the organization to implement quality improvement activities that are capable of showing measurable improvement [HQPI 3.I/L561]; Failure of the organization to use quality indicator data collected, including patient care data, and other relevant data in the QAPI program [HQPI 5.I/L564]; Failure of the organization to focus performance activities on high -risk, problem-prone area [HQPI 6.I/L566]; Failure of the organization's performance improvement activities to track adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospice [HQPI 7.I/L569]; and Failure of the Governing Body to demonstrate responsibility for ensuring the QAPI program is defined, implemented, maintained, and evaluated [HSLG 2.I/L574]. The cumulative effect of these deficiencies could impact the organization's ability to assess the care and services provided by the hospice and ensure the provision of high-quality care and services.

It is required that the QAPI program demonstrates measurable improvement among indicators related to improved palliative outcomes and hospice services. This standard was not met as evidenced by review of the agency's QAPI program. The hospice did not ensure the QAPI program demonstrated measurable improvement among indicators related to improved palliative outcomes and hospice services. There was no evidence that the agency collected data and tracked indicators to demonstrate measurable improvement. On 12/7/2022 the hospice was unable to provide information for the QAPI program. On day three 12/9/2022, of the site visit, the Director of Nursing stated during interview that the hospice utilized a consultant for the QAPI program. The hospice did not provide documentation for the QAPI program. During an interview, the Administrator stated that the meetings for QAPI with the contracted consultant company would only be every quarter and it was not the end of the quarter. He stated, this was why the information was not available. No further information was provided as of the conclusion of the site visit.

It is required that the hospice must use the data collected to do the following: monitor the effectiveness and safety of services and quality of care; and identify opportunities and priorities for improvement. This standard was not met as evidenced by review of the agency’s QAPI program documents and interview. The hospice did not ensure to use the data collected to monitor the effectiveness and safety of services and quality of care; and identify opportunities and priorities for improvement. The hospice had no documentation available for review related to measurable improvement among indicators related to improved hospice services. There was no documented evidence that the agency had collected data and tracked indicators to demonstrate measurable improvement. During the document review on 12/7/2022, the hospice was unable to provide information for the QAPI program. On day three of the site visit, 12/9/2022, during interview the Director of Nursing stated that the hospice utilized a consultant for the QAPI program. The hospice did not provide documentation for the QAPI program. During an interview, the Administrator stated that the meetings for QAPI with the contracted consultant company would only be every quarter and it was not the end of the quarter. He stated, this was why the information was not available. No further information was provided as of the conclusion of the site visit.

It is required that the hospice's performance improvement activities must: focus on high risk, high volume, or problem-prone areas. This standard was not met as evidenced by document reviews and interviews. The hospice did not ensure that performance improvement activities focused on high risk, high volume, or problem-prone areas. A review of administrative documents revealed no evidence that the agency identified any problem areas or needs for improvement in process. There were no governing body minutes, no performance improvement plans, no documented incidence logs or evidence of performance improvement activities. On 12/7/2022 the hospice was unable to provide information for the QAPI program. On day three 12/9/2022, of the site visit, the Director of Nursing stated during interview that the hospice utilized a consultant for the QAPI program. The hospice did not provide documentation for the QAPI program. During an interview, the Administrator stated that the meetings for QAPI with the contracted consultant company would only be every quarter and it was not the end of the quarter. He stated, this was why the information was not available. No further information was provided as of the conclusion of the site visit.

It is required that performance improvement activities must track adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospice. This standard was not met as evidenced by document reviews and interviews. The hospice did not ensure that performance improvement activities tracked adverse patient events, analyzed their causes, and implemented preventive actions and mechanisms that included feedback and learning throughout the hospice. A review of the administrative documents provided by the agency revealed the agency was not tracking and analyzing patient adverse events. On 12/7/2022 the hospice was unable to provide information for the QAPI program and performance improvement activities. On day three 12/9/2022, of the site visit, the Director of Nursing stated during interview that the hospice utilized a consultant for the QAPI program. The hospice did not provide documentation for the QAPI program. There was no evidence of activities involving adverse events and the implementation of preventive actions as part of a performance improvement plan. During an interview, the Administrator stated that the meetings for QAPI with the contracted consultant company would only be every quarter and it was not the end of the quarter. He stated, this was why the information was not available. No further information was provided as of the conclusion of the site visit.

It is required that the hospice’s governance (or designated person(s) so functioning) assumes full legal authority and responsibility for the organization's ongoing performance improvement and patient safety program that is defined, implemented and evaluated annually. This standard was not met as evidenced by document reviews and interviews. The hospice did not ensure that the governing body assumed responsiblity for defining, implementing and evaluating annually the hospice's ongoing program for quality improvement and patient safety Review of the governing body (GB) minutes provided revealed no evidence that the governing body addressed the agency's quality program and patient safety. There was no evidence that the GB defined and implemented and evaluated the QAPI program. During an interview, the Administrator stated they had not had any meetings with the contracted consultant company and it was not the end of the quarter. He stated, this was why the information was not available. No further information was provided as of the conclusion of the site visit.

It is required that one or more individual(s) is appointed by the governance as responsible for operating the QAPI program. This standard was not met as evidenced by document review and interviews. The hospice did not ensure that one or more individuals were appointed by the governing body to operate the QAPI program. A review of administrative and governing body documents revealed no evidence that one or more individuals had been appointed by the governing body to oversee the QAPI program as of 12/9/2022. On day three 12/9/2022, of the site visit, the Director of Nursing stated during interview that the hospice utilized a consultant for the QAPI program. The hospice did not provide evidence that the governing body appointed an individual responsible for iperating the QAPI program. During an interview, the Administrator stated that the meetings for QAPI with the contracted consultant company would only be every quarter and it was not the end of the quarter. He stated, this was why the information was not available. No further information was provided as of the conclusion of the site visit.

It is required that the hospice provides infection control education to patients, family members, and other caregivers that is individualized to the needs of each patient. This standard was not met as evidenced by a review of clinical records and document reviews. 1 of 8 (12%) clinical records reviewed revealed the hospice did not ensure that infection control education was provided to patients, family members and caregivers. The hospice policy #IC.2 "Infection Control Plan" stated in part, "Patient and family will be educated on precautions and infection control practices. Clinical Record 3: was reviewed and identified the patient elected hospice care on 11/4/2022 following hospitialzation with the diagnosis neoplasm of the cervix. The patient was discharged from the hospital with bilateral plurex drains and a foley catheter. Review of the clinical record revealed no documented evidence that the interdisciplinary team provided education to the patient or family on infection control. Agency policy IC.2 Infection Control Plan states in part, "Patient and family will be educated on precautions and infection control practices.

It is required that consistent with current professional standards of practice, licensed professionals actively participate in the coordination of all aspects of patient care including: conducting ongoing interdisciplinary comprehensive assessments; developing and evaluating the plan of care; contributing to patient and family counseling and education. Hospice “core” services are substantially provided directly by hospice employees in a manner consistent with acceptable standards of practice. “Core” services include nursing services, medical social work, and counseling. THIS IS A CONDITION LEVEL DEFICIENCY. This CONDITION was not met as evidenced by personnel record and clincial record reviews, and interviews with the Administrator. The hospice failed to ensure that medical social work, and counseling core services were provided directly by hospice employees [HCDT.2.I/L588]; and Failed to ensure that nursing needs of the patient were met as identified in the initial assessment and updated assessments [HCDT.6.I/L591]. The cumulative effect of these issues have resulted in the hospice’s inability to ensure the provision of quality health care in a safe environment. The deficient practices illustrated process failures that had the potential to affect all patients cared for by the agency.

It is required that a hospice must routinely provide substantially all core services directly by hospice employees. These services must be provided in a manner consistent with acceptable standards of practice. These services include nursing services, medical social services, and counseling. This standard was not met as evidenced by a review of personnel records, document review, and interview. The hospice did not ensure that all core services were provided directly by hospice employees. Staff 6: Review of the personnel record of the Licensed Medical Social Worker (LMSW) revealed a contract dated 9/20/2022 that was not signed. There was no evidence the LMSW was employed by the agency. Staff 7: Review of the personnel record of the Chaplain/Bereavement Coordinator revealed a contract dated 10/12/2022 that was not signed. There was no evidence the haplain/Bereavement Coordinator was employed by the agency. During the interview, the hospice office manager confirmed that the contracts were not fully executed and that the chaplain and the LMSW were contracted with and not employed by the hospice.

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 a review of clinical records. 2 of 8 (25%) clinical records reviewed revealed the hospice did not ensure that nursing needs of the patient were met as identified in the initial assessment and updated assessments. Clinical Record 1: The patient elected hospice care on 11/5/2022 with the primary diagnosis of malignant neoplasm of the prostate. The initial comprehensive assessment completed by the Registered Nurse (RN) on 11/5/2022 documented the patient was taking the opiods: methadone and fentanyl. The RN documented that the patient complained of occasional constipation.Review of the clinical record revealed no evidence that the patient was offered or the hospice considered placing the patient on a bowel regimen due to the opiod use and constipation during the assessment. There was evidence of a physician's order dated 11/17/2022 for Senna S for constipation.During the home visit #1 conducted on 12/8/2022, the RN asked about pain and bowel movements. After the patient complained of constipation there was no abdominal assessment performed by the RN. There was no evidence that the identified physical symptoms of the patient were managed by the hospice Clinical Record 4: was reviewed and identified the patient elected hospice care on 10/31/2022 with the primary diagnosis of malignant neoplasm of the pancreas. During the initial comprehensive assessment completed on 10/31/2022, the Registered Nurse (RN) documented that the patient was experiencing nausea and vomiting, and the patient had vomited 4 times on that day. There was no evidence that the RN reported the patient’s nausea and vomiting to the physician during the comprehensive assessment. The RN visit note dated 11/12/2022 documented that the patient had a suppository for nausea, but the family was not comfortable administering the suppository. The RN documented the administration of the suppository during the visit on 11/12/2022. There was no evidence that the RN followed up with the family and the physician to ensure the patient was receiving the suppository in the absence of the hospice nurse. In addition, two (2) “as needed” visits were completed by the RN with no evidence of changes made to the plan of care or medication. There was no evidence the patient's physical symptoms identified during the comprehensive assessment were addressed and managed by the hospice. Sn also called the contacted staffing agency for LVN nurse to start the Continuous care. RN delegated the care to continuous care nurse and instructed to call the RN on any change of the condition.

It is required that volunteers are used in day-to-day administrative and/or direct patient care roles. Volunteer services provided to patients/families are in a defined role and under the supervision of a designated hospice employee. This standard was not met as evidenced by a review of personnel records and interviews. 10 of 10 (100%) personnel records reviewed revealed the hospice did not ensure that volunteer services were provided under the supervision of a designated hospice employee. A review of the 10 personnel records revealed the agency did not have a hospice employee designated to supervise the volunteer program. A volunteer coordinator job description was not present in the 10 personnel records reviewed. During an interview and a joint review of the personnel records with the hospice office manager (HOM), it was revealed that there was no one person in the hospice designated to supervise volunteer services. The HOM stated that the Home Care office manager does volunteer work but confirmed there was not a Volunteer Coordinator. There was no written or verbal knowledge of a plan to meet the patient's' need in the event a volunteer was requested by a patient or family. In a discussion with the Hospice office manager and the Home Care office manager it was discovered that there was no one person in the agency designated as a Volunteer Coordinator. They stated that the Home Care office manager does some administrative volunteer work, 0.1% of time for Hospice. There was no written or verbal knowledge of a plan to meet the patient's' need in the event a volunteer was requested by a patient or family.

It is required that the hospice documents and demonstrates viable and ongoing efforts to recruit and retain volunteers. This standard was not met as evidenced by a review of documents and interviews. The agency did not ensure that ongoing recruitment and retention of volunteers was documented. The hospice was not able to provide documentation of a viable and ongoing effort to recruit and retain volunteers. In an interview with the Hospice Office Manager, it was confirmed that there was no one individual appointed to the position of Volunteer Coordinator. The Agency's recruitment manager stated recruitment for volunteers is, "Just word of mouth once and awhile." The office manager for the organization's home health agency is listed and completed training with the hospice as a volunteer. No additional information was provided. It is required that the hospice must document and demonstrate viable and ongoing efforts to recruit and retain volunteers. In a discussion with the Hospice office manager, it was found that there was no one individual appointed to the position of Volunteer Coordinator. The agency failed to provide any documented evidence that there are any efforts being made to recruit any volunteers. When surveyor asked about recruitment manager stated, "Just word of mouth once and awhile." The Home Health office manager is listed with the hospice as it's only volunteer. As a volunteer she completed the volunteer training.