Every finding on record at Amable Home Care, LLC

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. This standard was not met as evidenced by clinical record review and interview. In 2 of 12 (17%) clinical records reviewed revealed the agency did not ensure that an initial bereavement assessment was completed as part of the comprehensive assessment. Clinical Record 1: The patient elected the hospice benefit on 01/25/2024. The record lacked evidence that an initial bereavement assessment was completed as part of the comprehensive assessment. Clinical Record 6: The patient elected the hospice benefit on 04/19/2023. The record lacked evidence that an initial bereavement assessment was completed as part of the comprehensive assessment. The Administrator and RN stated in an interview on 03/07/2024 that the agency did not ensure that an initial bereavement assessment was completed as part of the comprehensive assessment.

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 1 of 14 (7%) clinical records reviewed revealed the agency did not ensure the plan of care (POC) reflected patient and family goals and interventions based on problems identified in the initial and updated comprehensive assessments. Clinical Record 1: The Social Worker initial assessment stated, "Patient wife had considered possible nursing home placement or placement in a 24-hr supervised home for the future." The POC dated 01/25/2024 lacked evidence of a problem, goal(s), and intervention(s) for caregiver strain and potentially planning for facility placement. The Administrator and RN stated during an interview on 03/07/2024 the agency did not ensure the POC reflected patient and family goals and interventions based on problems identified in the initial and updated comprehensive assessments.

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/IDF (intermediate care facility/intellectual disability facility) 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; and 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 for patients discharged due to death revealed the agency did not ensure a post-death bereavement assessment was completed. Clinical Record 6: The election of hospice benefit was dated on 04/19/2023. The patient died on 05/04/2023. The record lacked evidence of a completed post-death bereavement assessment. The Administrator and RN stated in an interview on 03/07/24 that the agency did not ensure a post-death bereavement assessment was not completed.

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 9 of 10 (90%) clinical records reviewed for patients that elected hospice aide services revealed the agency did not ensure the hospice aide care plan prepared by the registered nurse (RN) included aide tasks that were permitted to be performed by the hospice aides. Clinical Record 2: The aide care plan dated 01/09/2024 ordered the tasks: Temperature, Blood pressure, Pulse, Respirations. The aide visit notes dated 01/10/2024 and 01/15/2024 lacked evidence that the aide completed vital signs. Clinical Record 4: The aide care plan dated 01/30/2024 ordered the tasks: Temperature, Blood pressure, Pulse, Respirations. The aide visit notes dated 02/02/2024 and 02/09/2024 lacked evidence that the aide completed vital signs. Clinical Record 6: The aide care plan dated 04/19/2023 ordered the tasks: Temperature, Blood pressure, Pulse, Respirations. The aide visit notes dated 04/20/2023 and 04/26/2023 lacked evidence that the aide completed vital signs. Clinical Record 7: The aide care plan dated 08/18/2023 ordered the tasks: Temperature, Blood pressure, Pulse, Respirations. The aide visit notes dated 08/21/2023 and 09/04/2023 lacked evidence that the aide completed vital signs. Clinical Record 8: The aide care plan dated 07/11/2023 ordered the tasks: Temperature, Blood pressure, Pulse, Respirations. The aide visit notes dated 07/17/2023 and 07/28/2023 lacked evidence that the aide completed vital signs. Clinical Record 9: The aide care plan dated 11/07/2023 ordered the tasks: Temperature, Blood pressure, Pulse, Respirations. The aide visit notes dated 11/13/2023 and 12/01/2023 lacked evidence that the aide completed vital signs. Clinical Record 10: The aide care plan dated 06/24/2023 ordered the tasks: Temperature, Blood pressure, Pulse, Respirations. The aide visit notes dated 06/26/2023 lacked evidence that the aide completed vital signs. Clinical Record 11: The aide care plan dated 08/11/2023 ordered the tasks: Temperature, Blood pressure, Pulse, Respirations. The aide visit note dated 08/14/2023 lacked evidence that the aide completed vital signs. Clinical Record 13: The aide care plan dated 03/15/2023 ordered the tasks: Temperature, Blood pressure, Pulse, Respirations. The aide visit notes dated 03/24/2023 and 04/10/2023 lacked evidence that the aide completed vital signs. The RN (Employee Record # 1) stated in an interview while completing joint clinical record reviews on 03/06/2024 that the aides do not perform vitals sign on any patients. The hospice aide stated in an interview on 03/06/2024 that she was told not to do vital signs during her visits. The Administrator (Employee Record # 5) and RN (Employee Record # 1) stated in an interview on 03/07/2024, that the agency did not permit the aides to take vital signs and blood pressure. She verified that the hospice aide care plan prepared by the RN did not include accurate aide tasks, but stated the aides were aware that they were not permitted to take vital signs and blood pressure, and did not take the vitals.

It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. This standard was not met as evidenced by clinical record review and interview. In 2 of 10 (20%) clinical records reviewed in which the patient elected hospice aide services revealed the agency did not ensure the hospice aide reported changes in the patient's medical needs to the registered nurse (RN) as the changes related to the plan of care (POC). Clinical Record 6: The aide care plan dated 04/19/2023 ordered the task: Assist with dressing. The visit note dated 04/26/2023, the aide documented "Refused" for the task: Assist with dressing. The record lacked evidence of the aide notifying the RN of the refusal. Clinical Record 7: The aide care plan dated 08/18/2023 order the task: Assist to toilet. The visit note dated 09/04/2023, the aide documented "Refused" for the task: Assist to toilet. The record lacked evidence of the aide notifying the RN of the refusal. The Administrator and RN stated in an interview on 03/07/2024 that the agency did not ensure the hospice aide reported changes in the patient's medical needs to the RN as the changes related to the aide's POC.

It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This standard was not met as evidenced by document review and interview. The Volunteer Program was reviewed and reflected that the agency did not ensure that volunteers provided day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. The Volunteer Coordinator (VC) stated in an in-person interview on 03/07/2024 that there have been challenges in recruitment of volunteers. The agency had an active volunteer with evidence of completion of volunteer training and a competency assessment. This site visitor reviewed their possible recruitment strategies with the VC. When questioned about recent three months utilization, the VC reported 0%. A discussion was had about the waiver that was in place through 12/31/2023, and the waiver has been lifted for 2024 with good re-verbalization of understanding of requirements going forward. Document 1: The Volunteer Cost reported for the months of January and February 2024 lacked evidence of volunteers having provided the required 5% of the total patient care hours of all paid hospice employees and contract staff. The percentage provided in January and February 2024 was 0%. The Administrator and RN stated in an interview on 03/07/2024 that the agency did not ensure that volunteers provided day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. The Volunteer Program was reviewed and reflected that the agency did not ensure that volunteers provided day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff.

It is required that the hospice medical director or physician-designee provides written and signed recertification of the terminal illness to meet the hospice care benefit requirement. The recertification for the hospice care benefit is informed by the medical director or physician designee’s review of the patient’s clinical information. This standard was not met as evidenced by clinical record review and interview. In 1 of 8 (12%) clinical records that a recertification of terminal illness was required revealed the agency did not ensure the recertification for the hospice care benefit was written by the medical director or physician designee's review of the patient's clinical information. Clinical Record 4: The patient elected the hospice benefit on 08/03/2023. The record lacked evidence of the recertification of terminal illness for benefit period number eight (8) for the certification period of 12/01/2023 through 01/29/2024. The IDG documentation referenced the recertification for the 8th benefit period. The record included the signed and dated initial certificate of terminal illness and the recertification dates through 11/30/2023. The record also included the recertification of terminal illness for benefit period number nine (9) for the certification period 1/30/2024 through 03/29/2024. The Administrator and RN stated in an interview on 03/07/2024 that the agency did not ensure the recertification for the hospice care benefit was filed in the clinical record. They both mentioned the certification of terminal illness are on paper and may have been misfiled or misplaced. The Administrator stated she will continue to search for it and follow-up accordingly with billing.

It is required that the hospice medical director or physician-designee provides written and signed recertification of the terminal illness to meet the hospice care benefit requirement. The recertification is completed no later than two (2) calendar days after the first day of each benefit period, and no more than fifteen (15) days before the next benefit period begins. This standard was not met as evidenced by clinical record review and interview. In 1 of 8 (12%) clinical records that a recertification of terminal illness was required revealed the agency did not ensure the recertification was completed no later than two (2) calendar days after the first day of each benefit period, and no more than fifteen (15) days before the next benefit period begins. Clinical Record 4: The patient elected the hospice benefit on 08/03/2023. The record lacked evidence of the recertification of terminal illness for benefit period number eight (8) for the certification period of 12/01/2023 through 01/29/2024 being completed no later than two (2) calendar days after the first day of each benefit period, and no more than fifteen (15) days before the next benefit period begins. The record included the signed and dated initial certificate of terminal illness and the recertifications covering dates through 11/30/2023. The record also included the recertification of terminal illness for benefit period number nine (9) for the certification period 1/30/2024 through 03/29/2024. The Administrator and RN stated in an interview on 03/07/2024 that the agency did not ensure the recertification was completed no later than two (2) calendar days after the first day of each benefit period, and no more than fifteen (15) days before the next benefit period begins.

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 and interview. In 1 of 1 (100%) clinical records reviewed for patients that revoked hospice services, and transferred to the hospital revealed the agency did not ensure a copy of the hospice discharge summary was forwarded to the receiving facility (hospital). Clinical Record 14: The patient elected the hospice benefit on 06/22/2023. The patient revoked the hospice benefit on 12/29/2023 to pursue aggressive treatment, and was transferred to the hospital. The record lacked evidence of a copy of the discharge summary being forwarded to the receiving facility (hospital). The Administrator and RN stated in an interview on 03/07/2024 that the agency did not ensure a copy of the hospice discharge summary was forwarded to the receiving facility (hospital).

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary, and the patient's record, if requested. This standard was not met as evidenced by clinical record review and interview. In 7 of 7 (100%) clinical records reviewed for patients that revoked hospice services revealed the agency did not ensure a copy of the hospice discharge summary was forwarded to the patient's attending physician. Clinical Record 8: The patient elected the hospice benefit on 03/15/2023. The patient revoked the hospice benefit on 09/10/2023 to pursue aggressive treatment. The record lacked evidence of a copy of the discharge summary being forwarded to the patient's attending physician. Clinical Record 9: The patient elected the hospice benefit on 08/11/2023. The patient revoked the hospice benefit on 12/02/2023 to pursue aggressive treatment. The record lacked evidence of a copy of the discharge summary being forwarded to the patient's attending physician. Clinical Record 10: The patient elected the hospice benefit on 06/24/2023. The patient revoked the hospice benefit on 06/26/2023 to pursue aggressive treatment. The record lacked evidence of a copy of the discharge summary being forwarded to the patient's attending physician. Clinical Record 11: The patient elected the hospice benefit on 08/11/2023. The patient revoked the hospice benefit on 08/14/2023 to pursue aggressive treatment. The record lacked evidence of a copy of the discharge summary being forwarded to the patient's attending physician. Clinical Record 12: The patient elected the hospice benefit on 11/17/2022. The patient revoked the hospice benefit on 10/21/2023 to pursue aggressive treatment. The record lacked evidence of a copy of the discharge summary being forwarded to the patient's attending physician. Clinical Record 13: The patient elected the hospice benefit on 03/15/2023. The patient revoked the hospice benefit on 09/10/2023 to pursue aggressive treatment. The record lacked evidence of a copy of the discharge summary being forwarded to the patient's attending physician. Clinical Record 14: The patient elected the hospice benefit on 06/22/2023. The patient revoked the hospice benefit on 12/29/2023 to pursue aggressive treatment. The record lacked evidence of a copy of the discharge summary being forwarded to the patient's attending physician. The Administrator and RN stated in an interview on 03/07/2024 that the agency did not ensure a copy of the hospice discharge summary was forwarded to the patient's attending physician for patient's that revoked hospice services.

Condition of Participation: Emergency Preparedness

Upon observation, there was no evidence the hospice has developed and maintained an emergency preparedness plan that must be reviewed, and updated at least every two years. The last evidence of an update to the emergency preparedness plan was dated 2019.

Upon observation, there was no evidence the Emergency Preparedness plan: • Is based on and includes a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach • Includes strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care

Upon observation, there was no evidence the Emergency Preparedness plan includes a process for cooperation and collaboration with local, tribal, regional, state, and federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation.

Upon observation, there was no evidence of contracts/agreements with other facilities/agencies/hospices to receive patients in the event the hospice cannot provide care to their patients during an emergency.

Upon observation, there was no evidence the hospice develops and maintains an emergency preparedness communication plan that complies with federal, state, and local laws and must be reviewed and updated every two years. There was no evidence the emergency preparedness plan was updated since 2019.

Upon observation, there was no evidence the Emergency Plan communication plan includes all of the following: • Names and contact information for the following: • Hospice employees • Entities providing services under arrangement • Patients' physicians • Other hospices

Upon observation, there was no evidence the Emergency Plan communication plan must includes a primary and alternate means for communicating with hospice's employees and Federal, state, tribal, regional, and local emergency management agencies.

Upon observation, there was no evidence the Emergency Plan communication plan includes: • A method for sharing information and medical documentation for patients under the hospice's care, as necessary, with other health care providers to maintain the continuity of care • A means, in the event of an evacuation, to release patient information as permitted under 45 CFR 164.510(b)(1)(ii) • A means of providing information about the general condition and location of patients under the facility's care as permitted under 45 CFR 164.510(b)(4)

Upon observation, there was no evidence of emergency preparedness training and testing program that is based on the emergency plan, policies and procedures and the communication plan. There was no evidence of training and testing reviewed or provided since 2020.

Upon personnel record review, 4 of 10 (Personnel #1,#3,#5,#6) did not have evidence Emergency Preparedness training including: • Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles • Demonstrate staff knowledge of emergency procedures • Provide emergency preparedness training at least annually • Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others • Maintain documentation of all emergency preparedness training Personnel 1,3,5,6: There was no evidence of Emergency Preparedness training since initial orientation.

Upon observation, there was no evidence the agency has conducted exercises to test the emergency plan every two years. The last emergency drill documented was dated 6/18/19 and no actual events were documented.

Condition of Participation: Initial and Comprehensive Assessment of the Patient.

Upon patient record review 4 of 14 (Patients #3,#7,#8,#9) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient 3: The medical record contained an initial spiritual assessment 3/23/23 with start of care 3/17/23. Patient 7: The medical record contained an initial spiritual assessment 4/7/23 with start of care 11/15/22. Patient 8: The medical record contained an initial spiritual assessment 5/19/23 with start of care 5/12/23. Patient 9: The medical record contained an initial spiritual assessment 3/30/23 with start of care 3/15/23.

Upon patient record review 5 of 14 (Patients #1,#2,#4,#5,#6) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient 1: There was no evidence of a comprehensive spiritual assessment. Patient 2: There was no evidence of comprehensive spiritual and psychosocial assessments. Patient 4: There was no evidence of a comprehensive spiritual assessment. Patient 5: There was no evidence of a comprehensive spiritual assessment. Patient 6: There was no evidence of a comprehensive spiritual assessment.

Upon patient record review, 10 of 14 (Patients #1,#2,#3,#4,#5,#6,#7,#8,#9,#14) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications. Patient 1: The medical record contained an order for docusate sodium. There was no evidence of the docusate listed on the medication profile. Patient 2: The medical record contained nursing documentation 11/8/23 identifying patient use of oxygen. There was no evidence of oxygen listed on the medication profile. Patient 3: The medical record contained nursing documentation 11/10/23 identifying patient use of oxygen. There was no evidence of oxygen listed on the medication profile. Patient 4: The plan of care identified patient use of oxygen. There was no evidence of oxygen listed on the medication profile. Patient 5: The medical record contained an order for an oxygen concentrator. There was no evidence of oxygen listed on the medication profile. Patient 6: The medical record contained nursing documentation 10/16/23 identifying patient use of oxygen. There was no evidence of oxygen listed on the medication profile. Patient 7: The plan of care identified patient use of oxygen. There was no evidence of oxygen listed on the medication profile. Patient 8: The medical record contained an order for oxygen. There was no evidence of oxygen listed on the medication profile. Patient 9: The plan of care identified patient use of oxygen. There was no evidence of oxygen listed on the medication profile. Patient 14: The medical record contained nursing documentation 9/14/23 identifying patient use of oxygen. There was no evidence of oxygen listed on the medication profile.

Upon patient record review, 4 of 14 (Patients #2,#7,#8,#13) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes 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 is considered in the bereavement plan of care. Patient 2: There was no evidence of a bereavement assessment. Patient 7: The medical record contained an initial bereavement assessment 1/15/23 with a start of care 11/15/22. Patient 8: There was no evidence of a bereavement assessment. Patient 13: There was no evidence of a bereavement assessment.

Upon patient record review, 7 of 14 (Patients #1,#2,#3,#4,#5,#6,#9) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual's attending physician, if any) • Changes that have taken place since the initial assessment • Information on the patient's progress toward desired outcomes • Reassessment of the patient's response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days Patients 1,2,3,4,5,6,9: Upon review of all comprehensive assessments updated during IDG process since 8/22/23, there was no evidence of spiritual and psychosocial update provided in the assessment and no information regarding the patient's response to psychosocial and spiritual care or the progress toward goals.

Condition of Participation: Interdisciplinary Group, Care Planning, and Coordination of Services. L536

Upon patient record review, 7 of 14 (Patients #1,#2,#3,#4,#5,#6,#7) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient 1: The medical record contained ordered frequencies for social work and spiritual care visits. There was no evidence of problems, goals, and interventions related to psychosocial and spiritual care. Patient 2: The medical record contained an ordered frequency for social work visits. There was no evidence of problems, goals, and interventions related to psychosocial care. Patient 3: The medical record contained an ordered frequency for social work visits. There was no evidence of problems, goals, and interventions related to psychosocial care. Patient 4: The medical record contained ordered frequencies for social work and spiritual care visits. There was no evidence of problems, goals, and interventions related to psychosocial and spiritual care. Patient 5: The medical record contained ordered frequencies for social work and spiritual care visits. There was no evidence of problems, goals, and interventions related to psychosocial and spiritual care. Patient 6: The medical record contained an ordered frequency for social work visits. There was no evidence of problems, goals, and interventions related to psychosocial care. Patient 7: The medical record contained an ordered frequency for spiritual care visits. There was no evidence of problems, goals, and interventions related to spiritual care.

Upon patient record review, 7 of 14 (Patients #2,#3,#4,#5,#7,#9,#14) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient 2: The medical record contained nursing documentation 11/8/23 identifying patient use of oxygen. There was no evidence of an order for oxygen dose, frequency, and delivery method. Patient 3: The medical record contained nursing documentation 11/10/23 identifying patient use of oxygen. There was no evidence of an order for oxygen dose, frequency, and delivery method. Patient 4: The plan of care identified patient use of oxygen. There was no evidence of an order for oxygen dose, frequency, and delivery method. Patient 5: The medical record contained an order for an oxygen concentrator. There was no evidence of an order for oxygen dose, frequency, and delivery method. The medical record contained nursing documentation 10/16/23 identifying patient use of oxygen. There was no evidence of an order for oxygen dose, frequency, and delivery method. Patient 7: The plan of care identified patient use of oxygen. There was no evidence of an order for oxygen dose, frequency, and delivery method. Patient 9: The plan of care identified patient use of oxygen. There was no evidence of an order for oxygen dose, frequency, and delivery method. Patient 14: The medical record contained nursing documentation 9/14/23 identifying patient use of oxygen. There was no evidence of an order for oxygen dose, frequency, and delivery method.

Upon patient record review, 6 of 14 (Patients #2,#3,#4,#6,#9,#14) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient 2: The medical record contained nursing documentation 11/8/23 identifying patient use of oxygen. There was no evidence of oxygen equipment and supplies included in the plan of care. Patient 3: The medical record contained nursing documentation 11/10/23 identifying patient use of oxygen. There was no evidence of oxygen equipment and supplies included in the plan of care. Patient 4: The plan of care identified patient use of oxygen and a nebulizer. There was no evidence of oxygen equipment and supplies, or a nebulizer included in the plan of care. Patient 6: The medical record contained nursing documentation 10/16/23 identifying patient use of a nebulizer. There was no evidence of the nebulizer included as DME in the plan of care. Patient 9: The plan of care identified patient use of oxygen. There was no evidence of oxygen equipment and supplies included in the plan of care. Patient 14: The medical record contained nursing documentation 9/14/23 identifying patient use of oxygen. There was no evidence of oxygen equipment and supplies included in the plan of care.

Upon client record review, 4 of 14 (Patients #1,#2,#4,#5) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 1: The medical record contained orders for spiritual care 1M1 on 8/11/23 and 1M1 on 11/9/23. There was no evidence of spiritual care visits completed. Patient 2: The medical record contained orders for spiritual care 1M1 and social work visits once monthly upon admission. There was no evidence of spiritual care or social work visits completed. Patient 4: The medical record contained an order for spiritual care 1M1 on 9/20/23. There was no evidence of a spiritual care visit completed. Patient 5: The medical record contained an order for spiritual care 1M1 on 8/18/23. There was no evidence of spiritual care visits completed.

Condition of Participation: Quality Assessment and Performance Improvement.

Upon observation, there was no evidence the program shows measurable improvement in indicators related to improved palliative outcomes and hospice services. The agency was unable to provide any data utilized for QAPI meeting summaries. The meeting minutes did not provide any quantitative data.

Upon observation, there was no evidence the board of directors/governing body approves the frequency and detail of the data collection.

Upon observation, there was no evidence the number and scope of distinct QAPI projects conducted annually is based on the needs of the hospice's population and internal organizational needs and must reflect the scope, complexity, and past performance of the hospice's services and operations. The agency did not provide any evidence that QAPI projects were being conducted currently or in the past.

Upon observation, there was no evidence the hospice documents what QAPI projects are being conducted, the reasons for conducting these projects, and the measurable progress achieved on these projects. The agency did not provide any evidence that QAPI projects were being conducted currently or in the past.

Upon observation, there was no evidence of involvement of the governing body and organizational leaders in the Quality Assessment/Performance Improvement (QAPI) program.

Upon observation, there was no evidence the hospice's governing body is responsible for ensuring that the hospice-wide Quality Assessment and Performance Improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness.

Upon observation, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. During the home visit with the CNA, bag technique per agency policy was not followed which requires cleaning surface or using a barrier underneath bag. The CNA put her work bag on a chair in the patients room.

Upon personnel record review, 4 of 10 (Personnel #2,#3,#5,#6) did not have evidence that the hospice routinely provide substantially all core services directly by hospice personnel (The hospice issues a W-2 form for the employee). These services include: • Physician services (may contract for physician services) • Nursing • Medical social services • Counseling Personnel 2,3,5,6: There was no evidence of withholding statements in the personnel files.

Upon patient record review, 2 of 14 (Patients #13,#14) did not have evidence the hospice offers bereavement counseling that includes: • Making bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. Bereavement counseling also extends to residents of a SNF/NF or ICF/IID when appropriate and identified in the bereavement plan of care • Ensuring that bereavement services reflect the needs of the bereaved • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery Patient 13: There was no evidence of a bereavement plan of care, completion of bereavement tasks, or refusal of bereavement. Patient 14: There was no evidence of a bereavement plan of care or completion of tasks. The bereavement coordinator did document 9/17/22 that monthly visits would occur, but no further documentation was in the record.

Condition of Participation: Hospice Aide and Homemaker Services. L607

Upon observation, there was no evidence the hospice must maintain a written description of the in-service training provided during the previous 12 months. There was no evidence of hospice aide training.

Upon patient record review, 11 of 14 (Patients #1,#2,#3,#5,#6,#8,#9,#10,#12,#13,#14) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patients 1,2,3,5,6,8,9,10,12,13,14: The aide care plans contained the task to obtain vital signs including temperature, pulse, respirations, and blood pressure with no instructions of parameters to require RN notification.

Upon patient record review 9 of 14 (Patients #1,#2,#3,#5,#6,#8,#9,#10,#12) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care Patient 1: The medical record contained an ordered aide frequency of three times weekly. There was no evidence of visits completed the week of 11/18/23. The aide care plan contained tasks for vital signs, nail care, shaving, shampoo, and assist with dressing every visit. There was no evidence the aide completed vital signs, nail care, shampoo, shaving, and assistance with dressing 11/10/23; vital signs, nail care, shampoo, and shaving 11/13/23 and 11/15/23; and vital signs, nail care or shaving 11/17/23. Patient 2: The medical record contained an ordered aide frequency of three times weekly. There was no evidence of visits completed the week of 11/18/23. The aide care plan contained tasks for vital signs, nail care, shampoo, and shower. There was no evidence the aide completed vital signs or shampoo 11/1/23; vital signs, shower, and assistance with dressing 11/8/23; vital signs or shampoo 11/10/23 and 11/13/23; and vital signs or shampoo 11/15/23. Patient 3: The medical record contained an ordered aide frequency of three times weekly. There was no evidence of visits completed the week of 11/18/23. The aide care plan contained task for vital signs, nail care, shampoo, shower, shaving, and assist with dressing every visit. There was no evidence the aide completed vital signs, assistance with dressing, shampoo, nail care, and shaving 11/1/23; vital signs, nail care and shaving 11/3/23; vital signs, nail care, shaving, assist with dressing 11/8/23; and vital signs, shower, nail care, assist with dressing 11/10/23 and 11/17/23. Patient 5: The medical record contained an ordered aide frequency of three times weekly. There was no evidence of visits completed the week of 11/18/23. The aide care plan contained tasks vital signs, nail care, oral care and shaving. There was no evidence the aide completed vital signs and nail care 11/10/23; vital signs, nail care, and oral care 11/13/23; vital signs, nail care, oral care, and shaving 11/15/23. Patient 6: The medical record contained an ordered aide frequency of three times weekly. There was no evidence of visits completed the week of 11/18/23. The aide care plan contained tasks for vital signs, nail care, and shampoo every visit. There was no evidence the aide completed vital signs and nail care 11/17/23; and vital signs, nail care, and shampoo 11/10/23 and 11/15/23. Patient 8: The aide care plan contained tasks for vital signs every visit. There was no evidence the aide completed vital signs 5/29/23, 5/31/23, and 6/2/23. Patient 9: The aide completed visits after discharge on 9/11/23, 9/13/23, and 9/15/23. Patient revoked 9/10/23. The aide care plan contained tasks for vital signs, bed bath, nail care, shampoo, shaving, and oral care. There was no evidence the aide completed vital signs, nail care, oral care, and shaving 9/4/23; vital signs, nail care, and oral care 9/4/23; vital signs, bed bath, and nail care 9/6/23; and vital signs, shampoo, nail care, and shaving 9/8/23. Patient 10: The aide completed visits after discharge on 8/16/23 and 8/18/23. Patient revoked 8/14/23. The aide care plan contained tasks for vital signs and nail care. There was no evidence the aide completed vital signs and nail care 8/14/23. Patient 12: The aide completed visits after discharge on 9/11/23, 9/13/23, and 9/15/23. Patient revoked 9/10/23.

Upon personnel record review, 1 of 10 (Personnel #2 ) did not have evidence the individual who supervises volunteers is qualified by meeting the hospice's policies and procedures and/or job description criteria and is a designated hospice employee. There was no evidence of withholding statement.

Upon observation, there was no evidence the hospice maintains, documents and provides volunteer orientation and training that is consistent with hospice industry standards. The agency did not provide information on a volunteer orientation outline. The ability to provide volunteers was dependent on the DPCS/Volunteer Coordinator to provide services if necessary.

Upon observation, there was no evidence the hospice documents and demonstrates viable and ongoing efforts to recruit and retain volunteers.

Upon observation, there was no evidence the hospice documented the cost savings achieved through the use of volunteers. Documentation must include the following: • The identification of each position that is occupied by a volunteer • The work time spent by volunteers occupying those positions • Estimates of the dollar costs that the hospice would have incurred if paid employees occupied the positions identified in paragraph (d)(1) of CFR 418.78 for the amount of time specified in paragraph (d)(2) of CFR 418.78 The agency was unable to provide any documented use of volunteers and cost savings.

Upon observation, there was no evidence BOD/governing body minutes reflect the involvement in the hospice's management and administration of its resources to provide hospice services to patients and families. The agency was unable to provide evidence of Governing Body meeting minutes.

Upon observation, there was no evidence the hospice is directed by a Board of Directors/governing body which assumes full legal authority and responsibility for the operation of the hospice. The governing body did not assume full legal authority and responsibility of the operation as evidenced by the lack of personnel oversight including qualified personnel per Texas State regulations, active licensures, competency, continued education, and background checks. There was a lack of ensuring core and non-core services are provided for nursing, medical social services, counseling, therapy, and volunteers. There was no evidence of the ability to provide all levels of care specific to in-patient and respite. There was no evidence of a quality assessment/performance improvement program and emergency preparedness training,education, and preparedness. There was no evidence of proper oversight for appropriate completion of face-to face visits, certification, and re-certification of terminal illness documentation as these were completed by the RN and do not meet accreditation or billing standards.

Upon observation, there was no evidence the hospice is primarily engaged in providing the following care and services: • Nursing services • Medical social services • Physician services • Counseling services, including spiritual counseling, dietary counseling and bereavement counseling • Hospice aide, volunteer, homemaker services • Physical therapy, occupational therapy, speech-language pathology services • Short-term inpatient care • Medical supplies (including drugs and biologicals) and medical appliance The agency provided a GIP/respite contract for an agency that no longer existed. The administrator confirmed that the location is still in existence and has changed ownership twice in recent history per her recollection. Agency was unable to provide any evidence of communication with new ownership in order to validate the contract is relevant and the location would be able to provide service.

Upon personnel record review, 4 of 10 (Personnel #7,#8,#9,#10) did not have evidence the hospice employees and contract employees have received orientation on the hospice philosophy.

Condition of Participation: Medical Director.

Upon patient record review, 11 of 14 (Patient #1,#2,#3,#4,#5,#6,#8,#9,#10,#12,#13) did not have evidence that the medical director or physician designee provides written certification that it is anticipated that the patient's life expectancy is 6 months or less if the illness runs its normal course. The physician must consider the following when making this determination: • The primary terminal condition • Related diagnosis • Current subjective and objective medical findings • Current medication and treatment orders • Information about the medical management of any of the patient's conditions unrelated to the terminal illness Patients 1,2,3,4,5,6,8,9,10,12,13: There was no evidence of a narrative composed by the medical director on the initial CTIs. Upon interview with the MD and RN, the agency confirmed that the CTI narrative is the imported RN assessment narrative upon admission. The MD stated that he does not compose a narrative or complete any electronic signature, he does not access the EMR. All documents that are signed are created and signed by the RN with the MD's wet signature provided when able.

Upon patient record review, 10 of 14 (Patient #1,#2,#3,#4,#5,#6,#7,#9,#11,#12) did not have evidence that before the recertification period for each patient, the medical director or physician designee must review the patient's clinical information and provide written documentation that it is anticipated that the patient's life expectancy is 6 months or less. Patients 1,2,3,4,5,6,7,9,11,12: There was no evidence of a narrative composed by the medical director on recertification CTIs. Upon interview with the MD and RN, the agency confirmed that the CTI narrative is the imported RN assessment narrative upon recertification visit. The MD stated that he does not compose a narrative or complete any electronic signature, he does not access the EMR. All documents that are signed are created and signed by the RN with the MD's wet signature provided when able. Patient 6: There was no evidence of a CTI for benefit period 7 starting 8/20/23.

Upon patient client record review, 14 of 14 (Patient #1,#2,#3,#4,#5,#6,#7,#8,#9,#10,#11#12,#13,#14) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Upon MD and RN interview, the agency stated that the face to face encounter process was for the MD to join via telehealth visit and the RN created the face to face document with import of the RN assessment at the recertification visit in substitution of a physician assessment. There was no evidence the medical director documented findings of his assessment through the face to face visit. The MD and RN confirmed that all documentation was created in the EMR by the nurse and included the RN's electronic signature in the hospice physician signature section. The MD would later include a wet signature beside or underneath the RN signature, in the attending physician signature section.

Upon observation, there was no evidence that when the hospice provides durable medical equipment under contract, then the DMEPOS provider is accredited by a CMS approved accreditation organization.

Condition of Participation: Personnel Qualifications.

Upon personnel record review, 2 of 10 (Personnel #8,#9) did not have evidence that personnel credentialing activities are conducted to verify qualifications of all credentialed/licensed personnel in the positions they hold at the time of hire, at Reaccreditation or in accordance with specific state practice act requirements. Personnel 8: PT licensure expired 8/31/21. Personnel 9: OT licensure expired 3/31/22.

Upon personnel record review, 1 of 10 (Personnel #9) did not have evidence all Occupational Therapy Services are provided by a qualified licensed Occupational Therapist (OT) in accordance with the state's Occupational Therapy Practice Act and the hospice's policies and procedures and/or job descriptions. Personnel 9: The agency was unable to show evidence of current licensure. The license on file expired 3/31/22.

Upon personnel record review, 1 of 10 (Personnel #8) did not have evidence all Physical Therapy Services are provided by a qualified licensed Physical Therapist (PT) in accordance with the state's Physical Therapy Practice Act and the hospice's policies and procedures and/or job descriptions. Personnel 8: The agency was unable to provide evidence of current licensure. License on file expired 8/31/21.

Upon personnel record review, 1 of 10 (Personnel #9) did not have evidence the hospice obtained a criminal background check on all contracted individuals who have direct patient care and access to patient records. Personnel 9: There was no evidence of a criminal background check in the personnel file.