Every finding on record at Amazing Hospice Care, LLC

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 related conditions. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This CONDITION was not met as evidenced by clinical record review, document review, and interviews with the Clinical Manager and Regional Manager, which revealed the hospice: Failed to ensure that each patient's written plan of care included planned interventions based on problems identified in the initial and updated comprehensive assessments in 6 of 14 (43%) clinical records reviewed [HCPC.21.I/L545]. 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: Interdisciplinary group, care planning, and coordination of service. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the hospice agency.

It is required that each patient’s individualized written plan of care: Identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy #TX.06 stated in part, “The plan of care must reflect patient and family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments.” In 6 of 14 (43%) clinical records reviewed, the agency did not ensure that the plan of care documented all individualized interventions for problems identified in the initial and updated comprehensive assessments. Clinical Record 2: The patient elected the hospice benefit on 04/30/2024 with a diagnosis of congestive heart failure (CHF). The patient was admitted with oxygen of 2-4 liters continuously. The initial plan of care, dated 04/30/2024, ordered oxygen as needed and documented the patient’s goal was to verbalize oxygen safety. The initial and updated plans of care did not include documentation of interventions specific to oxygen safety instruction. Additionally, the nursing assessment visit note dated 05/01/2024 identified that the patient had a history of suicide risk, and the daughter and patient were fearful of having morphine in the house related to this. The plan of care did not document interventions related to the patient's history of suicide risk as of the patient’s revocation for aggressive treatment on 05/06/2024. Clinical Record 3: The patient elected hospice care on 05/12/2024. The initial comprehensive assessment documented that the patient was not always compliant using their oxygen, the patient had a fall while going out to smoke, and on the CTI (certificate of terminal illness), the physician documented the patient was non-compliant with oxygen. The initial POC documented the patient intervention: “The SN will educate the patient and wife on oxygen safety.” The intervention was not individualized to what the patient may need for oxygen safety related to the non-compliance. Clinical Record 7: The patient elected hospice care on 08/18/2023 with a diagnosis of CHF. On 01/02/2024, the patient’s diagnosis was updated to include COVID-19 positive. The patient was started on oxygen at 2-4 liters on 01/02/2024. The updated plans of care dated 01/11/2024 and 01/25/2024 did not include documentation of interventions or goals for oxygen safety. Clinical Record 8: The patient elected hospice care on 07/26/2024 with a diagnosis of CHF. The patient resided in a skilled nursing facility (SNF). The initial comprehensive assessment identified diabetes as a risk for infections. The follow-up comprehensive assessments dated 08/06/2024 and 09/24/2024 documented blood sugars being checked by the facility, with the highest of 270 but usually 120 -150. As of the review on 10/23/2024, there were no documented interventions for blood sugar monitoring or diabetes on the plan of care. Clinical Record 10: The patient elected hospice care on 02/29/2024 with diagnoses: end-stage renal disease and urinary tract infections (UTI). The updated nursing comprehensive assessment dated 10/10/2024 documented that the patient started oxygen 10/10/2024 for increased shortness of breath. The plan of care was not updated to include documentation of interventions and goals for oxygen safety as of the review on 10/23/2024. Clinical Record 14: The patient elected hospice care on 06/21/2024 with a diagnosis of Alzheimer’s disease. The updated nursing comprehensive assessments dated 07/22/2024 documented a blood sugar range of 179-293; 08/22/2024 documented a blood sugar range of 80-122; 09/09/2024 documented a blood sugar range of 164 - 334, and 10/08/2024 documented a blood sugar of 201. The updated plans of care did not include documentation of interventions or goals for blood sugar monitoring or management. During an interview and a joint record review, the Clinical Manager and Regional Manager stated that the interventions for oxygen were not documented or for diabetes but that the patient handbook did have oxygen information that likely was used.

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the nterdisciplinary Group. The 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, personnel record review, and interview. In 1 of 14 (7%) clinical records reviewed of patients that received Hospice Aide (HA) services, the agency did not ensure that the HA received written instructions to meet the patient's needs. Clinical Record 8: The patient elected hospice care on 07/26/2024 with a diagnosis of congestive heart failure (CHF). The patient resided in a skilled nursing (SNF). The HA care plan dated 07/26/2024 and updated 09/03/2024 and 09/16/2024 assigned the HA the relevant task of using the Hoyer Lift every visit. The skilled nursing (SN) assessment dated 08/06/2024 documented that the patient was a "3-person assist for a Hoyer transfer related to patient anxiety." The nursing assessments completed through 10/23/2024 documented that the patient was a "3-person assist for a Hoyer transfer." The HA documented the transfer per Hoyer lift but did not document if others assisted. There was evidence that the HA was competent to use the Hoyer lift. The HA care plan did not reflect the 3-person assist for the Hoyer lift transfer. During the interview, the Clinical Manager stated that the HA care plan would be updated to include the "3-person assist for a Hoyer transfer."

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. Agency policy #PE.3 stated in part, "If the care of a patient is transferred to another Medicare/Medicaid-certified facility, the Agency will forward copies of the following to the receiving facility: The discharge summary which includes but is not limited to: a summary of the patient care, the patient current plan of care, including the current medications profile, the latest physician orders; and any other documentation requested." In 1 of 1 (100%) clinical records reviewed of patients discharged to a facility, the agency did not ensure that the discharge summary was sent to the facility, Clinical Record 3: The patient elected hospice care on 05/21/2024 with a diagnosis of congestive heart failure (CHF). The patient fell on 06/15/2024 and was sent via ambulance to a hospital that did not contract with the hospice. The patient was discharged from the hospice on 06/16/2024. There was no documentation of the discharge summary being sent to the facility as of review 10/22/2024. During an interview and a joint record review, the Clinical Manager stated that the triage nurse spoke to the hospital several times about the patient but did not send the discharge summary.

It is required that hospice care of the patient/resident is stated in a written plan of care established and maintained in consultation with SNF/NF or ICF/IID representatives. The hospice plan of care identifies the care and services that are needed and specifies which provider is responsible for performing the functions that are agreed upon and included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 3 (33%) clinical records reviewed of patients who resided in a skilled nursing facility (SNF), the agency did not ensure that the plan of care identified the care and services that were needed and specified which provider was responsible for performing the functions that were agreed upon and included in the plan of care. Clinical Record 8: The patient elected hospice care on 07/26/2024 with the diagnosis of Congestive heart failure (CHF). The patient resided in a SNF. The initial comprehensive assessment identified diabetes as a risk for infections. The follow-up comprehensive assessments dated 08/06/2024 and 09/24/2024 documented that blood sugars were checked by the facility with the highest of 270 but usually 120 -150. The plan of care did not document interventions for blood sugar monitoring or who would perform the blood sugar monitoring and reporting as of the review on 10/23/2024. During an interview and a joint record review, the Clinical Manager confirmed that the interventions for blood sugar monitoring were not documented in the plan of care.

It is required that each patient’s individualized written plan of care reflects patient and family goals, identifies planned interventions based on problems identified in the initial and updated comprehensive assessments, 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 and the documentation in the patient’s record is in accordance with the hospice’s policies and procedure. This standard was not met as evidenced by a review of clinical records, document reviews and interviews. Agency Policy TX .06 revised 01/01/2020, "Plan of Care" states in part, "The plan of care includes but it is not limited to measurable outcomes anticipated from implementation and included in the plan of care." 4 of 5 (80%) records reviewed failed to document measurable goals. Clinical Record 1: This patient was admitted on 06/29/2022 with COPD. The RN documented "Decrease oxygen sat 77 % on 8 liters of oxygen. The documented goal stated, "weekly visits." This is not a measurable goal with a primary diagnosis of COPD. Clinical Record 2: This patient was admitted on 03/18/2022 with a diagnosis of COPD. The RN documented "Multiple Skin Tears" with the intervention being "Clean wound with wound cleanser, applied xeroform, A&D ointment, cover with ABD pad and Kerlex." The documented goal stated, "weekly visits." This is not a measurable goal for a patient with multiple skin tears. Clinical Record 4: The patient was admitted on 10/26/2022 with Cerebral Atherosclerosis. The RN documented "Patient complained of dizziness." No interventions for this identified issue were documented. The goal stated, " Weekly Visits." This is not a measurable goal for a patient complaining of dizziness. Clinical Record 5: This patient was admitted on 04/13/2022 with Cerebral Atherosclerosis. The RN documented "Altered Neurological Status." The documented intervention was "Assess neurological status every visit." The goal stated, "Neurological status will be addressed appropriately." This is not a measurable goal for altered neurological status. Interview with the Regional Vice President. She stated that the agency has an ongoing performance improvement plan. She also stated that the staff have not been documenting progress towards goals and that some of their employees are new. No further information was provided. THIS FORMER REQUIRED ACTION CONTINUES at a higher non-compliance percentage than previously cited (25%).

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 a review of clinical records, document review, and interview. Agency Policy PE.1, Patient Assessment (revised 010120) stated in part, "The Interdisciplinary Group in consultation with the patient attending physician will compete the comprehensive assessment no later than five calendar days after the election of the hospice benefit …includes psychosocial and emotional and immediate care and support needs." 2 of 7 (29%) records in which the patient was provided service for five days, the record failed to document all elements of the required comprehensive assessment. Record #85366: Hospice benefit election signed 11/24/2021. Documented Coordination Note on 11/30/2021 from Medical Social Worker stated, "request visit Tuesday." The entry is made on Tuesday, and the assessment is completed on Tuesday, day six and one day late. Record #84173: Hospice benefit election signed 10/28/2021. Documented Coordination Note on 11/05/2021 from the Chaplain stated, "Continue to decline Chaplain." No documented evidence before coordination note on 11/05/2021 of refused Chaplain. Initial Nursing documented accepted Chaplain on 10/28/201—no written contact from Chaplain until 11/05/2021, day eight and three days late. Interview with the Area Clinical Manager on 12/21/2021 stated that the documentation is not clear from Medical Social Work and Chaplain.

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. The medication review process includes the identification of the following: the effectiveness of drug therapy; drug side effects; actual or potential drug interactions; duplicate drug therapy; and drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and, as appropriate, preventive measurements are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by a review of clinical records, document review, and interview. Agency Policy TX.17 Medication List and Monitoring (revised 05110) stated in part, "Agency will maintain a current accurate list of all prescription and over the counter medications taken by the patient. 1 of 8 (13%) records, the medication profile was not updated with accurate and current medications ordered, and consequently, a complete medication review was not conducted. Record #93877: Nursing visit note 10/27/2021 stated Levsin [stomach pill for comfort] 0.125mg started for terminal symptom control. Additionally, Oxygen 8 Liters per face mask is documented on the Nursing visit note 10/27/2021. The medication profile failed to document Levsin. The medication profile documented Oxygen at 3-5 liters continuous but failed to be updated for 8 Liter flow per face mask as of review 11/21/2021. Interview with Area Clinical Manager on 11/21/2021 stated that the medication profile was not updated with all medications and that the review of all medications was not documented.

It is required that each patient’s individualized written plan of care: Identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by a review of clinical records, document review, and interview. Agency Policy TX.06 (revised date 010120), Plan of Care stated in part, " The plan of care includes update.... update will include information on the patient progress toward desired outcomes, as well as a reassessment of the patient response to care." 5 of 8 (63%) records failed to include all problems identified on the comprehensive assessment or update the patient plan of care with problems identified in updated assessments. Record #96198: The initial comprehensive assessment on 11/12/2021 identified Nutrition as a problem with weight loss and thin liquids needed. The problem of Nutrition is identified with a documented intervention but there was no documented goal as of review 12/22/2021. Record #34753: The initial comprehensive assessment on 11/16/2021 identified problems of Pain and Dyspnea but these problems were not included with goals on the plan of care. On 11/19/2021 the nursing visit note documented imminent death. There was no documented update on the plan of care to include imminent death as of review 12/21/2021. Record #85366: The initial comprehensive assessment on 11/24/2021 identified problems of Pain and a Wound caused by a traumatic injury. These problems were not included with goals on the plan of care as of review date 12/22/2021. Record #74859: The initial comprehensive assessment on 12/09/2021 identified problems of Diabetes, a Skin Ulcer, and a need for Personal Care. These problems were not included with goals on the plan of care as of review date 12/22/2021. Record #84173: The initial comprehensive assessment on 10/28/2021 identified an upper respiratory assessment problem. This problem was not included on the plan of care as of review date 12/22/2021. Additionally, on 11/15/2021, a nursing assessment identified increasing pain and shortness of breath with no documented update to the plan of care. On 11/22/2021, a nursing assessment identified a fall with a laceration over the right eyebrow and steri strips to a skin tear on the left wrist with no update to the plan of care as of review 12/22/201. Interview with the Area Clinical Manager and Regional Vice President stated that they were working on a process improvement with the corporate office for these identified documentation issues.

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 the following: measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by a review of clinical records, document review, and interview. Agency Policy TX.06 Plan of Care (revised 010120) stated in part, "The plan of care includes but is not limited to measurable outcomes anticipated from implementation and included in the plan of care." 2 of 8 (25%) records failed to document measurable goals and outcomes on the plan of care (POC). Record #84173: Cardiopulmonary Goal stated, "patient will exhibit reduction/relief of cardio pulmonary symptoms." This is not measurable for a patient with a primary diagnosis of Alzheimer's and a history of Congestive Heart Failure. Record #85366: Skin Integrity Goal stated, "skin integrity will be maintained." This patient has a stage 3 pressure ulcer, and this is not measurable for the interventions of reducing pressure and maintaining the drainage from the wound. Interview with the Area Clinical Manager and Regional Vice President stated that they were working on a process improvement with the corporate office for these identified documentation issues.

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as: Hand hygiene. This standard was not met as evidenced by document review and observation during home visits. Agency Policy IC.3 Hand Hygiene (revised 08/0121) stated in part, "With hands held upright, staff will dry wrists thoroughly with a clean paper towel. They will use a paper towel to turn off the faucet. Staff may use an alcohol-based hand rub for routinely decontaminating hands in the clinical situations described below: after removing gloves." 2 of 3 (66%) observations during home visits, staff failed to demonstrate compliance with the agency policy for Hand hygiene. Observed Visit Record #85366: Visit 12/21/2021 with Registered Nurse (RN) [#62244] (9:00am - 9:30am). The RN assessed the patient with correct handwashing and cleaning of equipment. The RN then provided wound care with multiple glove changes to remove the dressing, clean the wound, apply the medication, and redress the wound. The RN failed to sanitize hands after glove change, between cleaning wound and application of Medihoney (an antibacterial gel for wounds). Observed Visit Record #96660: Visit 12/21/2021 with Hospice aide [#57092] (11:15am - 11:30am). The Hospice aide coordinated with the assisted living staff, greeted the patient, and then prepared equipment for the bath. The aide washed hands with soap and water at the sink in the patient room, dried hands on the cloth towel hanging by the patient sink, and turned off the faucet with the lower arm. Interview with the Area Clinical Manager and Area Executive Director stated that they must have gotten nervous.

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 a review of clinical records, document review, and interview. Agency Policy TX., 26 Bereavement (reviewed date 1.1.2020) Agency Policy, stated in part, "The Agency will make bereavement services available...A bereavement file will be maintained on each family/caregiver and will contain: all bereavement clinical notes and documentation of letters and or resources sent to the bereaved." 3 of 3 (100%) patient deceased records in which bereavement services were accepted failed to document bereavement provided per the plan of care. Record #34752: Deceased 11/29/2021 with a bereaved identified and plan of care documented with direction (not limited to) sympathy call in seven days, sympathy call in 4-6 weeks, sympathy card, and a one-month mailing. All duties are documented as completed except the seven-day sympathy call, blank as of review 12/21/2021. Record #20869: Deceased 10/21/2021 with a bereaved identified and plan of care documented with direction (not limited to) sympathy call in seven days, sympathy call in 4-6 weeks, sympathy card, and a one-month mailing. All duties are documented as completed except the seven-day sympathy call, blank as of review 12/21/2021. Record #92877: Deceased 10/28/201 with a bereaved identified and plan of care documented with direction (not limited to) sympathy call in seven days, sympathy call in 4-6 weeks, sympathy card, and a one-month mailing. All duties are documented as completed except the seven-day sympathy call, blank as of review 12/21/2021. Interview with the Bereavement Coordinator on 12/23/2021 (9:00 am) stated that a team member makes the seven-day sympathy call, but communication of when this was completed is not documented. Interview with the Area Clinical Manager on 12/23/2021 (9:20 am) stated that a process would need to be identified to assure that documentation is accurate.

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 a review of clinical records and interview. 1 of 5 (20%) records in which a hospice aide was accepted revealed a lack of clear and specific written instruction for the aide assignment, thus leaving the aide to make decisions outside of the aide's scope of practice. Record #85366: Hospice Aide plan of care documented 11/24/2021 failed to include direction for the gauze dressing on the right foot and management of the dressing during the shower. Interview with the aide [#57092] on 12/21/2021 (3:00 pm) stated that the dressing was removed, and the foot was held outside the shower to avoid getting wet. After the shower, the foot is patted dry, and the facility staff re - dress the wound. Interview with Area Clinical Manager on 12/21/2021 (3:10 pm) stated that the direction for the dressing should be on the aide plan of care.

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: responses to medications, symptom management, treatments, and services. This standard was not met as evidenced by clinical record review, document review, and interview. 1 of 4 (25%) records in which an aide provided care and documented updates to the case manager or patient care manager, the response to the reported symptoms by the aide failed to be documented. Record #74859: Hospice Aide visit documentation on 12/20/2021 stated that the wound is worse, multiple wounds with multiple skin issues, patient care manager notified by phone. No documentation from the patient care manager related to follow-up with patient, caregiver, case manager, or physician as of review 12/22/2021. A nursing planned visit is documented on 12/21/2021 with an assessment of the wound. The nursing note did not indicate a worsening of the stage 3 wound. The agency did not include documentation of the reported decline with follow-up, as documented as reported by the hospice aide. Interview with the Area Executive Director stated the aide documents what is seen. Interview with the Area Clinical Manager said the follow-up documentation for the report from the aide is not documented in the record as of review 12/22/2021.

It is required that a patient clinical record containing past and current findings are maintained for each hospice patient. The document 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 a review of clinical records and interview. 2 of 8 (25%) records failed to document required physician orders. Record #84173: Documentation on nursing visit note 11/21/2021 stated a patient fell, resulting in a laceration on the right eyebrow and a skin tear on the left wrist and elbow. Wounds cleaned with wound cleanser, and steri-strip applied—no physician order documented for wound care as of review date 12/21/2021. Record #92877: Documentation on nursing visit note on 10/27/2021 was that oxygen at 8 liters per face mask. The only physician order for oxygen is at 3-5 liters continuously—no physician order for increased oxygen flow with face mask, documented as of review date 12/21/2021. A joint record review with the Area Clinical Manager stated that the orders should have been written.