Every finding on record at All Star Hospice Inc

It is required that each patient’s individualized written plan of care reflects patient and family goals and identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. CONTINUING PRIOR REQUIRED ACTION This standard was not met as evidenced by clinical record review and interview. In 1 of 6 (17%) clinical records reviewed, the agency did not ensure the individualized plan of care reflected patient and family goals and identified planned interventions based on problems identified in the initial and updated comprehensive assessments. Clinical Record 2: The patient elected hospice care on 07/26/2024. The initial nursing assessment dated 07/26/2024 included documentation that the patient had dyspnea at rest on 3L continuous oxygen, mild pain as an active problem, and a fall risk with recurrent falls, The plan of care dated 07/26/2024 and updated through 08/07/2024 did not reflect the patient and family goals and planned interventions associated with the identified shortness of breath, pain and fall risk. The Administrator was interviewed on 08/08/2024 and stated, "We discovered the previous DON was not following through with her responsibilities. She was brought in for coaching two different times, I was going to let her go and she chose to resign last week." During a joint clinical record review and an interview on 08/08/2024, the Director of Nursing (DON) confirmed that the plans of care did not reflect patient and family goals and planned interventions based on problems identified in the initial and comprehensive assessments. Additionally, during an interview on 08/08/2024, the DON stated, "These care plans are incomplete and should have all the problems on the plan of care with interventions and goals, but they were not done correctly." "The previous DON reviewed them with the nurses but did not follow through on the action plan to ensure they were all updated. The DON was supposed to be doing weekly boot camps on this, but we realized they weren't done consistently."

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. CONTINUING PRIOR REQUIRED ACTION This standard was not met as evidenced by clinical record review and interview. In 2 of 6 (33%) clinical records reviewed with hospice aide services provided, the agency did not ensure the Registered Nurse provided patient-specific care instructions to the hospice aide. Clinical Record 1: The patient elected hospice care on 07/12/2024. The initial nursing assessment dated 07/12/2024 included documentation that the patient had a stage 3 pressure wound on the left lower leg. The nursing assessment on 07/23/2024 included documentation that the patient had a stage 2 sacral coccyx wound and ace wraps daily to be removed at bedtime. A physician’s order on 07/23/2024 revealed, “apply compression wraps to lower extremities to help minimize edema, applied daily, remove at bedtime.” The hospice aide care plan dated 07/12/2024 and updated through 08/07/2024 did not alert the hospice aide to the left lower leg wound, the sacral coccyx wound, or the compression wraps on the lower extremities. Clinical Record 2: The patient elected hospice care on 07/26/2024. The initial nursing assessment dated 07/26/2024 included documentation that the patient had a PEG tube for feedings, a PICC line in the right upper arm, a left heel wound, and was on 3 liters of continuous oxygen. The hospice aide care plan dated 07/26/2024 and updated through 08/07/2024 did not alert the hospice aide to the PEG tube, PICC line, heel wound, or the 3 liters of continuous oxygen. The Administrator was interviewed on 08/08/2024 and stated, "We discovered the previous DON was not following through with her responsibilities. She was brought in for coaching two different times, I was going to let her go and she chose to resign last week." During a joint clinical record review and an interview on 08/08/2024, the Director of Nursing (DON) confirmed that the hospice aide care plans did not provide patient-specific care instructions and alerts for the aide, including wounds, compression wraps, peg tube, PICC line, and oxygen. Additionally, during an interview on 08/08/2024, the DON stated, "These aide care plans are missing the required information. The previous DON did not follow through on the action plan to review all the aide care plans. We are still teaching staff. They will need more training to ensure they understand the requirements to include everything on the aide care plan."

It is required that the hospice must conduct and documents a patient-specific comprehensive assessment that identifies the patient’s need for hospice care and services, and the patient’s need for physical, psychosocial, emotional, and spiritual care. The assessment includes all areas of hospice care related to the palliation and management of the terminal illness and related conditions. THIS IS A CMS CONDITION LEVEL FINDING This CONDITION was not met as evidenced by a review of clinical records, interviews, document review and interviews which revealed the hospice: Failed to ensure the hospice Registered Nurse (RN) completed the initial assessment within 48 hours of the patient's election of hospice services {HCPC.8. I/L522}; Failed to ensure that the Interdisciplinary Group completed the patient's initial comprehensive assessments within five calendar days after admission {HCPC.9. I/L523 and Failed to ensure the drug profile was updated to include all prescription medications including medication associated with laboratory monitoring {HCPC.15. I/L530}. 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 418.54: Initial and comprehensive assessment of the patient. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the agency.

It is required that the hospice registered nurse completes an initial assessment within 48 hours of the patient’s election of hospice care, in accordance with CMS §418.24 (the elements of the hospice care election statement). This standard was not met as evidenced by clinical record review and interview. In 7 of 19 (37%) clinical records reviewed, the agency did not ensure the hospice Registered Nurse (RN) completed the initial assessment within 48 hours of the patient's election of hospice services. Clinical Record 1: The patient completed and signed a hospice care election statement and designated the election of hospice care effective 04/04/2024. The Registered Nurse documented an initial nursing assessment on 04/07/2024, 72 hours after the election of hospice care and 24 hours outstanding. Clinical Record 3: The patient’s representative completed and signed a hospice care election statement and designated the election of hospice care effective 11/09/2023. The Registered Nurse documented an initial nursing assessment on 11/21/2023, 12 days after the election of hospice care and 10 days outstanding. Clinical Record 8: The patient’s representative completed and signed a hospice care election statement and designated the election of hospice care effective 11/17/2023. The Registered Nurse documented an initial nursing assessment on 11/27/2023, 10 days after the election of hospice care and eight days outstanding. Clinical Record 10: The Registered Nurse documented an initial nursing assessment on 07/27/2023. The patient signed a hospice care election statement on 07/27/2023; however, the election statement did not contain evidence of an effective date on which the hospice benefit was elected. The completed initial nursing assessment within 72 hours of the patient electing hospice services could not be confirmed. Clinical Record 11: The Registered Nurse documented an initial nursing assessment on 06/28/2023. The patient signed a hospice care election statement on 06/28/2023; however, the election statement did not contain evidence of an effective date on which the hospice benefit was elected. The completed initial nursing assessment within 72 hours of the patient electing hospice services could not be confirmed. Clinical Record 16: The Registered Nurse documented an initial nursing assessment on 01/13/2023. The patient signed a hospice care election statement on 01/13/2023; however, the election statement did not contain evidence of an effective date on which the hospice benefit was elected. The completed initial nursing assessment within 72 hours of the patient electing hospice services could not be confirmed. Clinical Record 19: The patient signed a hospice care election statement on 06/05/2023 and designated the election of hospice care effective 06/05/2020. The Registered Nurse documented an initial nursing assessment on 06/05/2023. The clinical record contained no evidence of a hospice care election statement with the designation of hospice care effective within 72 hours of the initial nursing assessment. During joint clinical record reviews and interviews on 06/28/2024, the Executive Director/Assistant Director of Nursing and Administrator/Director of Nursing confirmed the Registered Nurse had not completed the initial nursing assessment within 72 hours of the documented date hospice care was elected. Leadership also confirmed that the completion of the initial nursing assessment within 72 hours of the patient electing hospice care could not be confirmed in the identified clinical records because the effective date of hospice election was not documented on the hospice care election statement.

It is required that the hospice Interdisciplinary Group, in consultation with the individual's attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review and interview. In 7 of 19 (37%) clinical records reviewed, the agency did not ensure the hospice Interdisciplinary Group (IDG) completed an initial comprehensive assessment no later than five (5) calendar days after the patient elected hospice care. Clinical Record 1: The patient completed and signed a hospice care election statement and designated the election of hospice care effective 04/04/2024. The Chaplain and Medical Social Worker completed the spiritual, psychosocial, and emotional aspects of the initial comprehensive assessment on 04/10/2024 and 04/11/2024 respectively, six and seven days after the election of hospice care and one and two days outstanding. Clinical Record 3: The patient’s representative completed and signed a hospice care election statement and designated the election of hospice care effective 11/09/2023. The Chaplain and Medical Social Worker completed the spiritual, psychosocial, and emotional aspects of the initial comprehensive assessment on 11/22/2023 and 11/25/2023 respectively, 13 and 16 days after the election of hospice care and eight and eleven days outstanding. Clinical Record 8: The patient’s representative completed and signed a hospice care election statement and designated the election of hospice care effective 11/17/2023. The Medical Social Worker completed the spiritual, psychosocial, and emotional aspects of the initial comprehensive assessment on 11/27/2023, 10 days after the election of hospice care and five days outstanding. Clinical Record 10: The Medical Social Worker and Chaplain documented the psychosocial, emotional, and spiritual aspects of the comprehensive assessment on 07/29/2023 and 07/28/2023 respectively. The patient signed a hospice care election statement on 07/27/2023; however, the election statement did not contain evidence of an effective date on which the hospice benefit was elected. The completed comprehensive assessment by the hospice Interdisciplinary Group within five days of the patient electing hospice services could not be confirmed. Clinical Record 11: The Medical Social Worker and Chaplain documented psychosocial, emotional, and spiritual aspects of the comprehensive assessment on 07/02/2023 and 06/30/2023 respectively. The patient signed a hospice care election statement on 06/28/2023; however, the election statement did not contain evidence of an effective date on which the hospice benefit was elected. The completed comprehensive assessment by the hospice Interdisciplinary Group within five days of the patient electing hospice services could not be confirmed. Clinical Record 16: The Medical Social Worker and Chaplain documented the psychosocial, emotional, and spiritual aspects of the comprehensive assessment on 01/15/2023 and 01/16/2023 respectively. The patient signed a hospice care election statement on 01/13/2023; however, the election statement did not contain evidence of an effective date on which the hospice benefit was elected. The completed comprehensive assessment by the hospice Interdisciplinary Group within five days of the patient electing hospice services could not be confirmed. Clinical Record 19: The patient signed a hospice care election statement on 06/05/2023 and designated the election of hospice care effective 06/05/2020. The Medical Social Worker and Chaplain documented the psychosocial, emotional, and spiritual aspects of the comprehensive assessment within five days of the initial nursing assessment. The clinical record contained no evidence of a hospice care election statement with the designation of hospice care effective within five days of the Interdisciplinary Group’s completed comprehensive assessment. During joint clinical record reviews and interviews on 06/28/2024, the Executive Director/Assistant Director of Nursing and Administrator/Director of Nursing confirmed the Interdisciplinary Group (IDG) had not completed the comprehensive assessment within five days of the documented date hospice care was elected. Leadership also confirmed that the comprehensive assessment, completed by the IDG, no later than five calendar days after the patient elected hospice care could not be confirmed in the identified clinical records because the effective date of hospice election was not documented on the hospice care election statement.

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current prescription and over-the-counter (OTC) drugs, supplements, herbal remedies, and other alternative treatments that could affect drug therapy. The medication review process includes the identification of any drug therapy associated with laboratory monitoring. This standard was not met as evidenced by clinical record review, interview and observation. In 1 of 19 (5%) clinical records reviewed, the agency did not ensure the drug profile was updated to include all prescription medications including medication associated with laboratory monitoring. Document 1: Agency policy PC.85 Medication List and Monitoring, last reviewed 10/01/2021, stated in part, “The Hospice will maintain a current, accurate list of all prescriptions and over the counter (OTC) medication taken by the patient. (Medication Profile). ...The medication profile will be updated as frequently as necessary to reflect changes in the medication regimen, keeping the profile accurate.” Clinical Record 3: Hospice care and services were started on 11/21/2023. During the home visit (Home Visit 3) with the Medical Social Worker (Personnel Record 3) on 06/26/2024, a medication review was completed by comparing the hospice medication profile with the current medication bottles used by the caregiver to administer the patient’s daily medications. The medication bottles provided by the caregiver included Levothyroxine 100mcg tablet taken every day, last filled 05/21/2024. The hospice plan of care dated 06/25/2024 and medication profile current 06/25/2024 did not include Levothyroxine. During joint clinical record reviews and interviews on 06/28/2024, the Executive Director/Assistant Director of Nursing and Administrator/Director of Nursing confirmed that the drug profile was not updated to include Levothyroxine.

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 FINDING This CONDITION was not met as evidenced by a review of clinical records, interviews, and document review which revealed the hospice: Failed to ensure hospice care and services provided to patients and families followed the individualized plan of care established by the Interdisciplinary Group (IDG){HCPC.19.I/L543}; Failed to ensure the individualized plan of care reflected patient and family goals and identified planned interventions based on problems identified in the initial and updated comprehensive assessments (HCPC.21. I/L545}; Failed to ensure the individualized plan of care included measurable outcomes anticipated from implementing and coordinating the plan of care {HCPC.21. I/L548}; and Failed to ensure the individualized plan of care included all medical supplies and appliances used and necessary to meet the patient's needs {HCPC.21.I/L550}. 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 418.56: IDG, Care Planning, Coordination of Services. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the agency.

It is required that hospice care and services provided to patients and families follow the individualized plan of care established by the hospice Interdisciplinary Group (IDG) in collaboration with the attending physician (if any), the patient or patient representative, the primary caregiver in accordance with the patient’s needs if any of them so desire. 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 hospice care and services provided to patients and families followed the individualized plan of care established by the Interdisciplinary Group (IDG). Clinical Record 1: The patient elected the hospice benefit on 04/04/2024. The plan of care updated 04/18/2024 included an order for the Volunteer to visit at a frequency of one visit per month. A volunteer documented a visit was performed on 05/31/2024. The clinical record contained no documented evidence that the volunteer performed a visit in April 2024 and no documentation of why the visit was missed. Clinical Record 4: The patient elected the hospice benefit on 03/12/2024. The plan of care updated 03/21/2024 included an order for the Volunteer to visit at a frequency of one visit per month. A volunteer documented visits were performed on 04/02/2024 and 05/06/2024. The clinical record contained no documented evidence that the volunteer performed a visit in March 2024 and no documentation of why the visit was missed. Clinical Record 18: The patient elected the hospice benefit on 10/04/2023. The plan of care updated 10/19/2023 included an order for the Volunteer to visit at a frequency of one visit per month. A volunteer documented a visit was performed on 11/08/2023. The clinical record contained no documented evidence that the volunteer performed a visit in October 2023 and no documentation of why the visit was missed. During joint clinical record reviews and interviews on 06/28/2024, the Executive Director/Assistant Director of Nursing and Administrator/Director of Nursing confirmed that the volunteer did not follow the individualized plans of care established by the Interdisciplinary Group in the identified clinical records, and the clinical record contained no documented evidence of why the visits were missed.

It is required that each patient’s individualized written plan of care reflects patient and family goals and 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 17 of 19 (89%) clinical records reviewed, the agency did not ensure the individualized plan of care reflected patient and family goals and identified planned interventions based on problems identified in the initial and updated comprehensive assessments. Clinical Record 1: The patient elected the hospice benefit on 04/04/2024. The initial nursing assessment dated 04/07/2024 included documentation that the patient had labored breathing, required the use of accessory muscles to breathe, and continuous oxygen was ordered. The nursing assessment also included documentation that the patient was bedbound, prescribed opioids as needed for pain, and had constipation issues. The plan of care dated 04/07/2024 identified the patient's respiratory status as an issue with interventions to administer oxygen as ordered; however, the plan did not reflect the patient's goals and planned interventions associated with labored breathing, shortness of breath, oxygen safety, and constipation. Clinical Record 2: The patient elected the hospice benefit on 03/22/2024 with a terminal illness of Alzheimer's disease. The initial nursing assessment dated 03/22/2024 included documentation that the patient had depression and anxiety scores of ten out of ten. The plan of care dated 03/22/2024 did not reflect the patient and family goals and planned interventions associated with identified depression and anxiety. Clinical Record 3: The patient elected the hospice benefit on 11/09/2023 with a terminal illness of degenerative disease of the nervous system. The initial nursing assessment completed on 11/21/2023 included documentation that the patient did not speak English, was bedbound, incontinent of bowel and bladder, and unable to turn and position self. The plan of care dated 11/21/2023 did not reflect the patient and family goals and planned interventions associated with the identified language barrier and risk for skin breakdown related to decreased mobility and incontinence. Clinical Record 4: The patient elected the hospice benefit on 03/12/2024 with a terminal illness of chronic obstructive pulmonary disease. The initial nursing assessment dated 03/12/2024 included documentation that the patient was short of breath when moving and oxygen was ordered as needed. The plan of care dated 03/12/2024 did not reflect the patient and family goals and planned interventions associated with the identified shortness of breath and oxygen safety. Clinical Record 5: The patient elected the hospice benefit on 05/31/2023 with a terminal illness of end-stage heart failure. The initial nursing assessment dated 05/31/2023 included documentation that the patient had severe shortness of breath with minimal exertion and required continuous oxygen and nebulizer treatments every four hours to manage. The plan of care dated 05/31/2023 did not reflect the patient and family goals and planned interventions associated with the identified shortness of breath and oxygen safety. Clinical Record 6: The patient re-elected the hospice benefit on 05/31/2024 with a terminal illness of cerebral infarction. The initial nursing assessment dated 06/01/2024 included documentation that the patient did not speak English. The plan of care dated 06/01/2024 did not reflect the patient and family goals and planned interventions associated with the identified language barrier. Clinical Record 7: The patient elected hospice services on 05/19/2023 with a terminal illness of chronic obstructive pulmonary disease. The initial nursing assessment dated 05/19/2023 included documentation that the patient lived a bed-to-chair existence, had paralysis of bilateral lower extremities, had a history of chronic constipation, and required both scheduled and as needed laxatives to manage constipation. The plan of care dated 05/19/2023 did not reflect the patient and family goals and planned interventions associated with the identified risks for constipation. Clinical Record 8: The patient elected the hospice benefit on 11/17/2023 with a terminal illness of unspecified combined systolic (congestive) and diastolic (congestive) heart failure. The initial nursing assessment completed on 11/27/2023 included documentation that the patient did not speak English. The plan of care dated 11/27/2023 did not reflect the patient and family goals and planned interventions associated with the identified language barrier. Clinical Record 10: Hospice care and services were started on 07/27/2023. The patient had a terminal illness of Parkinsonism. The initial nursing assessment dated 07/27/2023 included documentation that the patient had an indwelling urinary catheter. The plan of care dated 07/27/2023 and updated through the current date identified urinary elimination as a problem with goals of symptoms managed, compliance with bladder regimen, effective control of bladder discomfort, and free from urinary tract infection. The plan did not reflect patient and family goals individualized and specific to the patient’s indwelling urinary catheter. Clinical Record 11: Hospice care and services were started on 06/28/2023. The patient had a terminal illness of degenerative disease of the nervous system. The initial nursing assessment dated 06/28/2023 included documentation that the patient had an anxiety score of two out of ten, dyspnea with moderate exertion, ordered oxygen at 2 to 4 liters per minute as needed, and had one plus edema to bilateral lower extremities. The plan of care dated 06/28/2023 did not reflect the patient and family goals and planned interventions associated with the identified anxiety, dyspnea, oxygen safety, and edema. Clinical Record 13: The patient elected hospice services on 08/11/2023 with a terminal illness of Parkinsonism. The initial nursing assessment dated 08/11/2023 included documentation that the patient had a history of seizures, required three medications to manage and prevent seizures, had dyspnea with minimal exertion, used oxygen at two liters per minute continuous, had a history of chronic constipation, and required both scheduled and as needed laxatives to manage constipation. The plan of care dated 08/11/2023 did not reflect patient and family goals and planned interventions associated with the identified history of seizures, dyspnea, oxygen safety, and constipation. The recertification assessment dated 05/22/2024 included documentation of an additional anticonvulsant since the initial election of hospice services and the ongoing need for scheduled and as needed laxatives to manage constipation. The plan of care updated for the benefit period 06/06/2024 through 08/04/2024 did not reflect patient and family goals and planned interventions associated with the identified seizure and constipation risks. Clinical Record 14: The patient elected hospice services on 01/08/2024 with a terminal illness of unspecified protein-calorie malnutrition. The initial nursing assessment dated 01/08/2024 included documentation that the patient exhibited signs of pain including facial grimacing, restlessness, and agitation with positioning, had contractures of bilateral upper and lower extremities, and was non-English speaking and required the caregiver to translate. The plan of care dated 01/08/2024 did not reflect the patient and family goals and planned interventions associated with the identified pain and language barrier. Clinical Record 15: The patient elected hospice services on 11/15/2023 with a terminal illness of malignant neoplasm of the colon. The initial nursing assessment dated 11/15/2023 included documentation that the patient could not swallow and received nothing by mouth (NPO). The plan of care dated 11/15/2023 did not reflect the patient and family goals and planned interventions associated with the identified dysphagia and risks. Clinical Record 16: Hospice care and services were started on 01/13/2023. The patient had a terminal illness of Hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side. The initial nursing assessment dated 01/13/2023 included documentation that the patient had a gastrostomy tube (G-tube) in place for feeding. The plan of care dated 01/13/2023 did not reflect patient and family goals and planned interventions associated with the G-tube. Clinical Record 17: The patient elected the hospice benefit on 04/19/2024 with a terminal illness of Atherosclerotic heart disease of the native coronary artery without angina pectoris. The initial nursing assessment dated 04/20/2024 included documentation that the patient was at risk for falls with a fall risk score of six out of ten and at risk for aspiration. The plan of care dated 04/19/20224 did not reflect patient and family goals and planned interventions associated with the identified fall and aspiration risks. Clinical Record 18: The patient elected the hospice benefit on 10/04/2024 with a terminal illness of end-stage heart failure. The initial nursing assessment dated 10/04/2023 included documentation that the patient was short of breath with exertion and exhibited comfort from dyspnea only at rest. The plan of care dated 10/04/2023 did not reflect the patient and family goals and planned interventions associated with the identified dyspnea. Clinical Record 19: Hospice care and services were started on 06/05/2023. The patient had a terminal illness of degenerative disease of the nervous system. The patient resided in a skilled nursing facility (SNF). The initial nursing assessment dated 06/05/2023 included documentation that the patient had pressure wounds to the sacrum and left lateral hip and had an indwelling urinary catheter in place. The plan of care dated 06/05/2023 did not reflect patient and family goals and planned interventions associated with the identified wounds and indwelling urinary catheter. During joint clinical record reviews and interviews on 06/28/2024, the Executive Director/Assistant Director of Nursing and Administrator/Director of Nursing confirmed the written plans of care did not reflect patient and family goals and planned interventions based on problems identified in the initial and comprehensive assessments, including dyspnea, oxygen safety, constipation, language barrier, anxiety, seizures, aspiration risk, fall risk, gastrostomy tube, wound, and indwelling urinary catheter.

It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review and interview. In 8 of 19 (42%) clinical records reviewed, the agency did not ensure the individualized plan of care included measurable outcomes anticipated from implementing and coordinating the plan of care. Clinical Record 1: The patient elected the hospice benefit on 04/04/2024 with a terminal illness of malignant neoplasm of the nipple and areola, unspecified male breast. The initial nursing assessment dated 04/07/2024 included documentation that the patient had labored breathing, required accessory muscles to breathe, and had an indwelling urinary catheter in place for urinary retention. The plan of care dated 04/07/2024 identified the goal of improved respiratory status, but the goal did not include the measurability of “improved” for the patient. The plan also included the goal of “free from complications” related to urinary elimination; however, the plan did not include measurable goals associated with urinary retention and the indwelling urinary catheter. Clinical Record 2: The patient elected the hospice benefit on 03/22/2024 with a terminal diagnosis of Alzheimer’s disease. The plan of care dated 03/22/2024 identified pain as a problem for the patient with the goal, “signs and symptoms of pain will be diminished to acceptable levels;” however, the goal did not include the measurability of “acceptable” for the patient. Clinical Record 3: The patient elected the hospice benefit on 11/09/2023. The initial nursing assessment dated 11/21/2023 included documentation that the patient had lower back and knee pain. The plan of care dated 11/21/2023 and updated no less frequently than every 15 days to the current date, identified pain as a problem for the patient with the goal, that pain would be palliated; however, the goal did not include the measurability of “palliated” for the patient. Clinical Record 4: The patient elected the hospice benefit on 03/12/2024 with a terminal diagnosis of chronic obstructive pulmonary disease. The initial nursing assessment dated 03/12/2024 included documentation that the patient had bowel and bladder incontinence, confusion, and constipation. The plan of care dated 03/12/2024 identified bowel and bladder incontinence, confusion, and constipation as problems for the patient with the goals, “free from complications” and “bowel regimen maintained.” The plan did not include anticipated measurable outcomes associated with the patient’s bowel and bladder incontinence, confusion, and constipation. Clinical Record 8: The patient elected the hospice benefit on 11/17/2023 with a terminal diagnosis of unspecified combined systolic (congestive) and diastolic (congestive) heart failure. The plan of care dated 11/27/2023 identified pain as a problem with the goal, “patient will achieve self-identified pain goal.” The goal did not include a measurable outcome for pain identified by the patient. Clinical Record 10: Hospice care and services were started on 07/27/2023. The patient had a terminal illness of Parkinsonism. The recertification nursing assessment dated 05/15/2024 included documentation that the patient remained on Norco as needed for pain management. The plan of care effective 05/22/2024 through 07/20/2024 identified the goals, “pain to be well palliated and patient comfortable;” however, the goals did not include the measurability of “well palliated” and “comfortable” for the patient. Clinical Record 12: The patient was transferred from another hospice provider on 03/03/2024. The initial nursing assessment dated 03/04/2024 included documentation that the patient had pain rated two out of ten to bilateral knees. The plan of care dated 03/03/2024 identified pain as a problem with the goal, “patient will achieve self-identified pain goal threshold;” however, the goal did not include a measurable outcome for pain identified by the patient. Clinical Record 14: The patient elected the hospice benefit on 01/08/2024 with a terminal illness of unspecified protein-calorie malnutrition. The initial nursing assessment dated 01/08/2024 included documentation that the patient was confused and disoriented. The plan of care updated 01/11/2024 identified confusion and disorientation as a problem with the goal, “confusion and disorientation.” The plan did not include an anticipated measurable outcome associated with the patient’s confusion and disorientation. During joint clinical record reviews and interviews on 06/28/2024, the Executive Director/Assistant Director of Nursing and Administrator/Director of Nursing confirmed the plans of care identified did not include measurable outcomes anticipated from the coordination, development, and implementation of the plan of care.

It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including medical supplies and appliances necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. In 2 of 19 (11%) clinical records reviewed, the agency did not ensure the individualized plan of care included all medical supplies and appliances used and necessary to meet the patient's needs. Clinical Record 5: The patient elected the hospice benefit on 05/31/2023. The initial nursing assessment completed on 05/31/2023 included documentation that the patient had a wound to the coccyx area with a bordered silicone foam dressing in place to treat. The plan of care dated 05/31/2023 did not include the bordered silicone foam dressing as an ordered supply or a planned intervention that included the dressing as part of the skin/wound care. Clinical Record 6: The patient re-elected the hospice benefit on 05/31/2024. The initial nursing assessment completed on 06/01/2024 included documentation that the patient had a gastrostomy tube, and an abdominal binder was used to help protect the tube from pulling. The plan of care dated 06/01/2024 did not include the abdominal binder as an ordered supply or a planned intervention that included the abdominal binder as part of the gastrostomy tube care. During joint clinical record reviews and interviews on 06/28/2024, the Executive Director/Assistant Director of Nursing and Administrator/Director of Nursing confirmed the plans of care identified did not include all medical supplies and appliances used and necessary to meet patient needs.

It is required that hospice aides are assigned to a specific patient by a Registered Nurse (RN) who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 11 of 17 (65%) clinical records reviewed with hospice aide services provided, the agency did not ensure the Registered Nurse provided patient-specific care instructions to the hospice aide. Clinical Record 2: The patient elected the hospice benefit on 03/22/2024 with a terminal diagnosis of Alzheimer's disease. The initial nursing assessment dated 03/22/2024 included documentation that the patient was at risk for falls with a fall risk score of nine out of ten. The hospice aide care plan dated 03/22/2024 instructed the aide to perform a complete shower and assist with ambulation every visit. The plan did not alert the aide to the patient’s fall risk. The supervisory visit dated 04/19/2024 included documentation that the caregiver had requested a phone call from the hospice aide during or after every visit with the patient. The clinical record contained no documented evidence that the aide’s care plan was updated to include the caregiver’s request. Clinical Record 6: The patient elected the hospice benefit on 05/31/2024. The initial nursing assessment dated 06/01/2024 included documentation that the patient was non-English speaking, had a gastrostomy tube (G-tube) in place for feeding, and required an abdominal binder to prevent pulling on the G-tube by the patient. The hospice aide care plan dated 06/01/2024 did not alert the aide to the patient’s language barrier, G-tube site and care, and the need for an abdominal binder. Clinical Record 9: The patient elected the hospice benefit on 04/13/2022. The initial nursing assessment dated 04/13/2022 included documentation that the patient was non-English speaking. The initial hospice aide care plan dated 04/13/2022 and last updated on 05/17/2024 did not alert the aide to the patient’s language barrier. Clinical Record 10: Hospice care and services were started on 07/27/2023. The recertification nursing assessment dated 05/15/2024 included documentation that the patient was at risk for falls with a fall risk score of ten out of ten. The hospice aide care plan dated 05/22/2024 instructed the aide to assist the patient with transfers and perform a complete shower every visit. The plan did not alert the aide to the patient’s fall risk. Clinical Record 11: Hospice care and services were started on 06/28/2023. The recertification nursing assessment dated 06/22/2024 included documentation that the patient was at risk for falls with a documented fall on 06/08/2024. The hospice aide care plan updated 06/22/2024 did not alert the aide to the patient’s fall risk. Clinical Record 12: The patient transferred the hospice benefit to the current hospice provider on 03/03/2024. The initial nursing assessment dated 03/03/2024 included documentation that the patient was at risk for falls with a fall risk score of six out of ten. The hospice aide care plan dated 03/03/2024 instructed the aide to perform a complete shower every visit. The plan did not alert the aide to the patient’s fall risk. Clinical Record 13: The patient elected the hospice benefit on 08/11/2023. The initial nursing assessment dated 08/11/2023 included documentation that the patient had a history of seizures, required three medications to prevent and manage seizures, and was at risk for falls with a fall risk score of nine out of ten. The initial hospice aide care plan dated 08/11/2023 and updated each benefit period through the current date did not alert the aide to the patient’s seizure and fall risks. Clinical Record 14: The patient elected the hospice benefit on 01/08/2024. The initial nursing assessment dated 01/08/2024 included documentation that the patient was non-English speaking. The hospice aide care plan dated 01/08/2024 did not alert the aide to the patient’s language barrier. Clinical Record 16: Hospice care and services were started on 01/13/2023. The initial nursing assessment dated 01/13/2023 included documentation that the patient had a gastrostomy tube (G-tube) in place for feeding. The hospice aide care plan dated 01/13/2023 and updated 04/13/2023 did not alert the aide to the G-tube and any care to be performed. Clinical Record 17: The patient elected the hospice benefit on 04/19/2024. The hospice aide care plan dated 04/20/2024 included instructions for the aide to perform two types of baths, complete bed bath and partial bath/shower, every visit. The bath plan forced the aide to decide the kind of bath to be given which is outside the aide’s scope of practice. Clinical Record 19: Hospice care and services were started on 06/05/2023. The initial nursing assessment dated 06/05/2023 included documentation that the patient had a gastrostomy tube (G-tube) in place for feeding. The hospice aide care plan dated 06/05/2023 did not alert the aide to the G-tube and any care to be performed. During joint clinical record reviews and interviews on 06/28/2024, the Executive Director/Assistant Director of Nursing and Administrator/Director of Nursing confirmed that the hospice aide care plans did not provide patient-specific care instructions and alerts for the aide, including fall risks, caregiver requests, language barriers, seizure risks, and gastrostomy tube sites and care needs.

It is required that hospice aides are supervised by a Registered Nurse (RN) who makes an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s needs. The hospice aide does not need to be present. This standard was not met as evidenced by clinical record review and interview. In 7 of 17 (41%) clinical records reviewed with hospice aide services provided, the agency did not ensure the Registered Nurse completed and documented an on-site supervisory visit to assess the quality of care and services provided by the hospice aide no less frequently than every 14 days. Clinical Record 2: The patient elected the hospice benefit on 03/22/2024. The plan of care dated 03/22/2024 included an order for hospice aide services to begin on 03/25/2024. The Registered Nurse (RN) completed and documented an on-site supervisory visit on 04/09/2024, 15 days after the first hospice aide visit on 03/25/2024, and one day outstanding. The RN completed and documented an on-site supervisory visit on 05/27/2024 followed by the next on-site supervisory visit by the RN on 06/11/2024, 15 days after the previous supervisory visit and one day outstanding. Clinical Record 7: The patient elected the hospice benefit on 05/19/2023. The plan of care dated 05/13/2024 included an order for hospice aide services to assist with the patient’s personal care needs. The Registered Nurse (RN) completed and documented an on-site supervisory visit on 05/14/2024 followed by the next on-site supervisory visit by the RN on 05/29/2024, 15 days after the previous supervisory visit and one day outstanding. The RN completed and documented an on-site supervisory visit on 06/10/2024 followed by the next on-site supervisory visit by the RN on 06/26/2024, 16 days after the previous supervisory visit and two days outstanding. Clinical Record 11: Hospice care and services were started on 06/28/2023. The initial plan of care dated 06/28/2023 was updated no less frequently than every 15 days and included hospice aide services to assist with the patient’s personal care needs. The Registered Nurse (RN) completed and documented an on-site supervisory visit on 03/04/2024 followed by the next on-site supervisory visit by the RN on 03/22/2024, 18 days after the previous supervisory visit and four days outstanding. The RN completed and documented an on-site supervisory visit on 05/01/2024 followed by the next on-site supervisory visit by the RN on 05/16/2024, 15 days after the previous supervisory visit and one day outstanding. Clinical Record 12: The patient was transferred from another hospice provider on 03/03/2024. The initial plan of care dated 03/03/2024 was updated no less frequently than every 15 days and included hospice aide services to assist with the patient’s personal care needs. The Registered Nurse (RN) completed and documented an on-site supervisory visit on 03/19/2024 followed by the next on-site supervisory visit by the RN on 04/03/2024, 15 days after the previous supervisory visit and one day outstanding. The RN completed and documented an on-site supervisory visit on 04/16/2024 followed by the next on-site supervisory visit by the RN on 05/03/2024, 17 days after the previous supervisory visit and three days outstanding. The RN completed and documented an on-site supervisory visit on 05/27/2024 followed by the next on-site supervisory visit by the RN on 06/11/2024, 15 days after the previous supervisory visit and one day outstanding. Clinical Record 13: The patient was transferred from another hospice provider on 08/11/2023. The initial plan of care dated 08/11/2023 was updated no less frequently than every 15 days and included hospice aide services to assist with the patient’s personal care needs. The Registered Nurse (RN) completed and documented an on-site supervisory visit on 04/16/2024 followed by the next on-site supervisory visit by the RN on 05/02/2024, 16 days after the previous supervisory visit and two days outstanding. Clinical Record 18: The patient was transferred from another hospice provider on 10/04/2023. The initial plan of care dated 10/04/2023 was updated no less frequently than every 15 days and included hospice aide services to assist with the patient’s personal care needs. The Registered Nurse (RN) completed and documented an on-site supervisory visit on 11/02/2023 followed by the next on-site supervisory visit by the RN on 11/30/2023, 28 days after the previous supervisory visit and 14 days outstanding. Clinical Record 19: Hospice care and services were started on 06/05/2023. The initial plan of care dated 06/05/2023 was updated no less frequently than every 15 days through the date of death and included hospice aide services to assist with the patient’s personal care needs. The Registered Nurse (RN) completed and documented an on-site supervisory on 06/24/2023, 20 days after the first hospice aide visit on 06/07/2023, and six days outstanding. During joint clinical record reviews and interviews on 06/28/2024, the Executive Director/Assistant Director of Nursing and Administrator/Director of Nursing confirmed the clinical records identified contained no evidence that the Registered Nurse completed and documented an on-site supervisory visit to assess the quality of care and services provided by the hospice aide no less frequently than every 14 days.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes physician orders. This standard was not met as evidenced by clinical record review and interview. In 4 of 19 (21%) clinical records reviewed, the agency did not ensure the clinical record contained physician orders for all care and services provided. Clinical Record 2: The patient, a resident of the assisted living facility, elected hospice services on 03/21/2024 with a terminal illness of Alzheimer's disease. The initial nursing assessment dated 03/22/2024 included documentation that the patient was taking Gabapentin 100mg two times a day for arthritic pain. The clinical record contained no documented evidence of a physician's order for the Gabapentin. Clinical Record 4: The patient, a resident of the skilled nursing facility, elected hospice services on 03/12/2024. The hospice aide care plan updated 05/29/2024 included skin barrier cream as a supply to be provided by the aide. The clinical record contained no documented evidence of a physician’s order for skin barrier cream and instructions for use including location, frequency, and persons to apply. Clinical Record 6: The patient re-elected hospice services on 05/31/2024. An order written on 06/14/2024 included instructions to decrease skilled nursing visits to one visit per week and skilled nursing wound care to once per week. The order included documentation that the daughter performed wound care every two days. The clinical record contained no documented evidence of a completed physician’s order which included the specific location and type of wound, treatment and dressing to be applied, frequency of dressing change, and persons responsible for performing. Clinical Record 10: Hospice care and services were started on 07/27/2023. The plan of care dated 07/27/2023 and updated no less frequently than every 15 days included documentation that the facility staff performed indwelling urinary catheter irrigation. The clinical record contained no documented evidence of a physician’s order that specified irrigate solution, amount, and frequency of indwelling urinary catheter flush. During joint clinical record reviews and interviews on 06/28/2024, the Executive Director/Assistant Director of Nursing and Administrator/Director of Nursing confirmed the clinical records identified did not contain completed physician orders for all hospice care and services provided.

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/IDF 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 and interview. In 1 of 7 (14%) clinical records reviewed where the patient resided in a skilled nursing facility (SNF), the agency did not ensure the hospice plan of care specified which provider was responsible for performing the functions agreed upon and included in the plan of care. Clinical Record 10: Hospice care and services were started on 07/27/2023. The patient resided in the skilled nursing facility (SNF). The initial nursing assessment dated 07/27/2023 included documentation that the patient had a history of diabetes. The plan of care dated 07/27/2023 included a medication order for insulin Lispro to be administered three times a day before meals with a sliding scale dose based on blood sugar results. The admission verbal orders dated 07/27/2023 included orders to turn and position the patient every two hours and to perform mouth care every two hours as needed. The hospice plan of care, effective 07/27/2023 and updated no less frequently than every 15 days through the current date, did not include an order to perform blood sugar checks, and the plan did not identify the specific provider responsible for performing blood sugar checks, turning and positioning the patient, and mouth care. During joint clinical record reviews and interviews on 06/28/2024, the Executive Director/Assistant Director of Nursing and Administrator/Director of Nursing confirmed the plan of care identified contained no evidence of instructions to perform blood sugar checks and no evidence that the provider responsible for performing blood sugar checks, turning and positioning the patient, and mouthcare was specified.

It is required that hospice care and services provided to patients and families follow the individualized plan of care established by the hospice IDG in collaboration with the attending physician (if any). THIS IS A CONTINUING PRIOR REQUIRED ACTION. This standard was not met as evidenced by interviews and clinical records review. In 1 of 7 (14%) applicable clinical records with Social Worker visit frequencies after the plan of correction implementation date of 10/22/21, there was no documented evidence that the Social Worker was compliant with visits as assigned in the individualized plan of care that was established by the IDG. Record #50084 - Social Worker visit frequency was one time a week and the clinical record was missing one Social Worker visit the week of 10/22/21. In 1 of 6 (17%) applicable clinical records with Spiritual Counselor visit frequencies after the plan of correction implementation date of 10/22/21, there was no documented evidence that the Spiritual Counselor was compliant with visits as assigned in the individualized plan of care that was established by the IDG. Record #50084 - Spiritual Counselor visit frequency was one time a week and the clinical record was missing one Spiritual Counselor visit the the week of 10/22/21. During review of the clinical record, the Alternate Director of Nursing and the Administrator confirmed the missing visit notes and that the visit frequency was one time a week for the Social Worker and Spiritual Counselor. During interview, the Alternate Director of Nursing stated "The visit frequencies should have been one time a month and incorrectly put in as one time a week", "there are no missed visit reports, physician's orders regarding changes in the visit frequencies, and/or IDG Meeting discussions regarding the missing Social Worker and Spiritual Counselor visit notes".

It is required that a hospice aide provides services ordered by the Interdisciplinary Group and included in the plan of care. THIS IS A CONTINUING PRIOR REQUIRED ACTION. This standard was not met as evidenced by interview and clinical record review. In 1 of 8 (13%) applicable records of patients with Hospice Aide (HA) visit frequencies after the plan correction implementation date of 10/22/21, there was no documented evidence that the hospice aide was compliant with visits as ordered by the Interdisciplinary Group and included in the hospice plan of care. Summary of findings as follows: Record #79943 - The HA visit frequency was two times a week on the "IDG Meeting" plan of care dated 10/21/21 and 11/4/21. During dates of service reviewed, the clinical record was missing two HA visit notes the week of 10/24/21 and missing one the week of 10/31/21. There were no physician's orders for changes to the HA visit frequency, HA missed visit note documentation, and/or IDG/IDT discussion documented in the "IDG Meeting" forms dated 10/21/21 and 11/4/21. During clinical record review, the Alternate Director of Nursing and Administrator confirmed that the HA visit frequency was two times a week on the hospice plan of care. During interview, the Alternate Director of Nursing stated, "I do not see the missing HA visit notes", and "There are no other physician's orders, missed visit reports, and/or IDG discussions to cover the missing Hospice Aide visits for the weeks of 10/24/21 and 10/31/21".