Every finding on record at Always Loving Home Health Care LLC

It is required that the hospice Interdisciplinary Group, in consultation with the individual's attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review and interview. In 2 of 14 (14%) clinical records reviewed revealed the agency did not ensure that the Interdisciplinary Group completed the initial comprehensive assessment within 5 days after the start of care. Clinical Record 8: The patient elected the hospice benefit and was admitted to hospice services on 10/31/2024. As of the clinical record review date, 11/06/2024, there was no documented evidence in the clinical record that the Chaplain completed an initial assessment and no additional documentation why this visit was not completed. Clinical Record 9: The patient elected the hospice benefit and was admitted to hospice services on 10/07/2024. As of the clinical record review date, 11/06/2024, there was no documented evidence in the clinical record that the Chaplain completed an initial assessment, no addition documentation why this visit was not completed and no documentation in the interdisciplinary Team Meeting dated 10/11/2024. During a joint clinical record review and interview with the Director of Nursing (DON) on 11/06/2024, the DON confirmed that there was no documentation in the clinical record as to why the Chaplain did not document an initial assessment within 5 days after the admission.

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current: Prescription and over-the-counter (OTC) drugs; Supplements; Herbal remedies; Other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following: The effectiveness of drug therapy; Drug side effects; Actual or potential drug interactions; Duplicate drug therapy; Drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and as appropriate, preventive measurements are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added, or changes are made to existing medication. This standard was not met as evidenced by clinical record review, interview, and observation. In 1 of 14 (7%) clinical records reviewed revealed the agency did not ensure the medication profile included all of the patient's current prescription and over the counter (OTC) drugs. Agency Policy PC.85 Medication Listing and Monitoring read in part " The hospice will review, monitor and maintain a current, accurate list of prescription and over the counter (OTC) medications, herbal remedies and other alternative treatments that could affect drug therapy by the patient." Clinical Record 1: The patient elected the hospice benefit on 09/18/2024. During a home visit on 11/06/2024 with the Registered Nurse (RN) (Personnel Record 6), a medication reconciliation was performed comparing the patient's medications to the agency's medication profile. The caregiver brought out a bottle stating that the medication was delivered 2 days ago and the date of the visit 11/6/2024 was the last dose. On 11/4/2024, the skilled nurse performed a visit and contacted the physician and received an order for Lasix 40 mg po daily x 3 dated 11/04/2024. The order was written by the skilled nurse; however, the medication profile was not updated with the Lasix. The findings were reviewed with the DON on 11/06/2024, and it was confirmed that the medication profile was not accurate.

It is required that the comprehensive assessment includes an initial bereavement assessment of the needs of the patient's family and other individuals, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and considered in the bereavement plan of care. This standard was not met as evidenced by clinical record review and interview. In 2 of 14 (14%) clinical records reviewed the agency did not ensure that the comprehensive assessment included an initial bereavement risk assessment of the needs of the patient's family and other individuals, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Clinical Record 2: The hospice election of benefit was dated 08/02/2024. At the time of the clinical record review on 11/06/24, there was no documented evidence that an initial bereavement risk assessment had been completed. Clinical Record 5: The hospice election benefit was dated 08/22/2024. At the time of the clinical record review on 11/06/24, there was no documented evidence that an initial bereavement risk assessment had been completed. During a joint clinical record review and interview with the DON (Personnel Record 3) the DON confirmed that there was no documented evidence that an initial bereavement risk assessment had been completed. No further information was provided.

It is required that counseling services include an organized program for providing bereavement services delivered by or under the supervision of a qualified professional with experience or education in grief or loss counseling. Bereavement services are available to the family and other individuals up to one (1) year following the death of the patient. Bereavement counseling extends to residents of a SNF/NF (skilled nursing facility/nursing facility) or ICF/IID (intermediate care facility/Individuals with Intellectual Disabilities) when appropriate and identified in the bereavement plan of care. The bereavement services reflect the needs of the bereaved per a bereavement plan of care that includes: The types of bereavement services to be offered; The frequency of service delivery. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 2 (50%) clinical records reviewed revealed the agency did not ensure that a post death bereavement risk assessment and a plan of care to include the required elements of pt/family grief and/or loss issues were completed post death. Policy # 130 titled Bereavement read in part "The bereavement coordinator will complete a follow-up assessment and develop a bereavement POC for bereavement services based on the re-assessment and family and/or caregiver's needs." "The bereavement coordinator will ensure bereavement services reflect the needs of the bereaved." Clinical Record 14: The patient’s election of benefit was 09/23/2022 and expired on 12/25/2023. There was no documented evidence of a post death bereavement risk assessment or a plan of care based on family needs. The DON stated, " The family accepted bereavement services." No bereavement services were provided for the family as of survey date 11/06/2023. The findings were reviewed with the DON on 11/06/2024, and it was confirmed that no bereavement services were provided. No further information was provided.

It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid certified facility, the hospice forwards to the receiving facility a copy of: The hospice discharge summary described in HCDT 40.I; and the patient’s record, if requested. This standard was not met as evidenced by clinical record review, document review, and interview. In 2 of 3 (67%) clinical record review of a patient that transferred to a Medicare/Medicaid facility, the hospice did not ensure that the discharge summary was forwarded to the receiving facility. There was no documented evidence in the clinical record of coordination with the receiving facility. The hospice policy titled " Patient Discharge" with the revised date of 09/01/2024, read in part " if the care of a patient is transferred to another Medicare/Medicaid-Certified facility, the Hospice will forward copies of the following to the receiving: A summary of the patient's care (pain management, symptoms and treatments), The patient's current plan of care, including the current medication profile." Clinical Record 10: The patient elected the hospice benefit on 05/05/2024 and was transferred to a non-contracted hospital on 08/01/2024. There was no documentation or evidence that a discharge summary was forwarded to the hospital. Clinical Record 11: The patient elected the hospice benefit on 05/09/2024 and transferred to a non-contracted hospital on 08/01/2024. There was no documentation or evidence that a discharge summary was forwarded to the hospital. During a joint record review and interview on 11/06/2024, the DON confirmed that a discharge summary was not sent to the local hospital. No further information was provided.

It is required that the hospice discharge summary provided to a facility receiving a hospice patient for care—or to the patient’s community attending physician upon hospice discharge—includes at least the following: A summary of the patient’s hospice stay, including treatments, symptoms, and pain management; The patient’s current plan of care; The patient’s latest physician orders; Any other documentation that will assist in the post-discharge continuity of care or that is requested by the receiving facility or the attending physician. This standard was not met as evidenced by clinical record review and interview. In 2 of 3 (67%) clinical reviewed of patient that discharged from hospice services revealed that the agency did not ensure a discharge summary was created and included a summary of the patient's stay, treatments, symptoms, pain management, current plan of care (POC), and physician orders to assist in continuity of care post-discharge. Clinical Record 10: The patient elected the hospice benefit on 05/05/2024.A Physician order to discharge the patient was obtained on 08/07/24. The clinical record did not include documented evidence to support a discharge summary of the patient's stay, treatments, symptoms, pain management, current plan of care (POC), and physician orders to assist in continuity of care post-discharge. There was a patient's documented revocation statement in the clinical record but no discharge summary. Clinical Record 11: The patient elected the hospice benefit on 05/09/2024. A Physician order to discharge the patient was obtained on 08/01/24. The clinical record did not include documented evidence to support a discharge summary of the patient's stay, treatments, symptoms, pain management, current plan of care (POC), and physician orders to assist in continuity of care post-discharge. There was a patient's documented revocation statement in the clinical record but no discharge summary. During a joint record review and interview on 11/06/2024, the DON confirmed that a discharge summary was not created. No further information was provided.

It is required that the hospice documents and maintains an effective infection control program that protects patients, families, visitors, and hospice staff by preventing and controlling infections and communicable diseases. This standard was not met as evidenced by observation, document review and interview. 2 of 3 (66%) observations during home visits revealed the hospice did not ensure adherence to agency infection prevention and control policies and procedures. Agency policy, “HCL/IC.15”, stated, in part "The Agency will identify patients/clients at risk for having COVID-19 infections before or immediately upon arrival to the home. The Agency should ask the patient/client the following: Has the patient/client traveled internationally within the last fourteen (14) days to countries with sustained community transmission? Does the patient have signs or symptoms of a respiratory infection? 1. Criteria for identifying patients/clients with COVID-19 include: fever, cough, dyspnea, sore throat. In the last fourteen 14 days, has the patient/client had contact with someone who or is under investigation for COVID-19, or are ill with a respiratory illness? Does the patient/client reside in a community where community-based spread of COVID-19 is occurring?”. During observation of patient #30984 1/12/2022 at 12:20 pm, staff #25369 entered the patient’s home without prescreening the patient for symptoms of COVID. During observation of patient #51490 on 1/12/2022 at 10:30 am, staff #76478 entered the patient’s home without prescreening the patient or spouse for symptoms of COVID. The Director of Nursing was interviewed on 1/12/2022 and stated, all staff should be prescreening prior to entering the patient’s homes. The Alternate Administrator confirmed this finding on 1/13/2022.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum physician orders. This standard was not met as evidenced by as evidenced by clinical record review and interview. 1 of 5 (20%) clinical records reviewed did not include documented evidence that the record includes all required physician’s orders. Record #30984 was reviewed and identified a nursing assessment was completed on 11/22/2021. The documentation revealed "Feeding tube flushed with 60CC of water. Caregiver educated how to flush feeding tube when needed. Caregiver able to return demonstrate." There was no evidence of signed physicians order for this medication in the electronic medical record or in the patient’s chart in the residential care home. The Director of Nursing was interviewed on 1/13/2022 and stated, an order was added 1/12/2022 but confirmed there was not an order in the medical record for the 60cc flush prior. The Alternate Administrator confirmed this finding on 1/13/2022.