Every finding on record at American Home Hospice, Inc.

It is required that the hospice has a written Patient Bill of Rights and Responsibilities (Bill of Rights). The patient has the right to be informed of his or her rights and responsibilities, and the hospice defines, protects, and promotes the exercise of these rights. This CONDITION was not met, as evidenced by clinical record review, observation, and interview. The hospice failed to ensure that patients received information on the scope of hospice services provided and the organization's service limitations [HPFC.2.D/L519]; failed to ensure that hospice patients received effective pain management and symptom control [HPFC.2D/L512]; and failure to ensure that hospice patients are involved in the development of their care plan; 75% of the patients did not have a plan of care [HPFC.2D/L500]. The cumulative effect of this deficiency could negatively impact the patient's ability to receive hospice benefits and palliation and management of the terminal illness and related conditions.

It is required that the written Patient Bill of Rights includes the right to receive effective pain management and symptom control for conditions related to the terminal illness. This requirement was not met, as evidenced by interview, observations, and record review. 5 of 8 (63%) records reviewed revealed the hospice failed to ensure patients received pain management and symptom management related to their terminal illness. Record 1 was reviewed and identified the patient elected hospice care on 10.12.22. The clinical record did not contain documentation that the Medical Director completed the recertification and face-to-face assessment, There was no evidence that IDG meetings were conducted after 2/23/23. There was no documented evidence that the Medical Director or designee addressed palliation and management of the terminal illness and related conditions. Record 6 was reviewed and identified the patient elected hospice care on 2/27/23. The Medical Director did not write an initial certification for terminal illness to admit to services on 2/27/23. There was no evidence that IDG meetings were conducted after 2/23/23. There was no documented evidence that the Medical Director or designee addressed palliation and management of the terminal illness and related conditions. Record 7 was reviewed and identified the patient elected hospice care on 1/6/21. The Medical Director did not write the recertification for benefit period 15, 3/27/23, a face-to-face assessment was not done, and the plan of care was not signed. There was no evidence that IDG meetings were conducted after 2/23/23. There was no documented evidence that the Medical Director or designee addressed palliation and management of the terminal illness and related conditions. Record 8 was reviewed and identified the patient elected hospice care on 10/6/22. The Medical Director did not write the recertification for benefit period 3, 4/4/23, a face-to-face assessment was not done, and the plan of care was not signed. There was no evidence that IDG meetings were conducted after 2/23/23. There was no documented evidence that the Medical Director or designee addressed palliation and management of the terminal illness and related conditions. Record 11 was reviewed and identified the patient elected hospice care on 2/18/23. The Medical Director did not write an initial certification for readmission to services on 2/18/23. There was no evidence that IDG meetings were conducted after the date of 2/23/23. There was no documented evidence that the Medical Director or designee addressed palliation and management of the terminal illness and related conditions. During an interview on 5/4/23, in response to the missing documents and assessments, the Administrator/DON (Staff 1) stated that a previous nurse knew all about hospice and was no longer working there. The Administrator added that she is learning hospice but knows home health very well. No additional documentation was presented prior to the conclusion of the site visit.

It is required that the written Patient Bill of Rights includes the right to be involved in the development of his or her plan of care, be informed about the scope of services the hospice provides and any specific limitations on those services, This standard was unmet, as evidenced by clinical record review and interviews. 6 of 8 (75%) records reviewed revealed that the hospice failed to ensure that patients were involved in developing their care plan. Record 1: No hospice plan of care was in the clinical record for benefit period 3, 4/10/23-6/6/23, written by the Interdisciplinary Group (IDG) in consultation with the attending physician to meet the needs of the patient. There was no evidence that the patient was involved in the care plan development without a plan of care and IDG meetings held on 2/23/23. Record 2: There was a hospice care plan for this patient. However, this patient received wound care on an amputation and wound on the left foot on 5/3/23, as observed in the home visit and reviewed in the nursing assessment notes. The care plan does not have orders for wound care. There was no evidence that the patient was involved in the care plan development without a plan of care and IDG meetings held on 2/23/23. Record 6: This clinical record has no hospice plan of care from the election of benefit dated 2/27/23, written by the IDG in consultation with the attending physician to meet the patient's needs. There was no evidence that the patient was involved in the care plan development without a plan of care and IDG meetings held on 2/23/23. Record 7: This clinical record has no hospice plan of care for benefit period 15, dated 3/27/23, written by the IDG in consultation with the attending physician to meet the patient's needs. There was no evidence that the patient was involved in the care plan development without a plan of care and IDG meetings held on 2/23/23. Record 8: No hospice plan of care was in the clinical record for benefit period 3, 4/4/23-6/2/23, written by the Interdisciplinary Group (IDG) in consultation with the attending physician to meet the needs of the patient. There was no evidence that the patient was involved in the care plan development without a plan of care and IDG meetings held on 2/23/23. Record 11: The 12th recertification period began on 4/19/23. There was no plan of care created for this benefit period. There was no evidence that the patient was involved in the care plan development without a plan of care and IDG meetings held on 2/23/23. In an interview, the Administrator (Staff 1) /DON agreed that the care plans were not developed.

It is required that the written Patient Bill of Rights includes the right to be informed about the scope of services the hospice provides and any specific limitations on those services. This standard was not met, as evidenced by interview, document review, and observations. 1 of 2 (50%) of observation visits reviewed revealed that the hospice failed to ensure the patients were aware of service limitations and the scope of services available under the hospice benefit. Record 6 was reviewed and identified the patient elected hospice care on 2/27/23. During an interview, the patient's wife stated said had requested volunteer services and was unaware the agency had no volunteers. The patient’s wife added that she had asked for help to relieve her to attend personal appointments and errands outside the home. She said the one-hour hospice aide visits were not adequate, and she had notified the Administrator of her need and was advised that volunteer services were not offered at the agency. In an interview on 5/4/23, the Administrator/DON (Staff 1) remarked that she thought the volunteers were optional during the PHE waiver.

It is required that the hospice conducts and documents a patient-specific comprehensive assessment that identifies the patient’s need for hospice care and services and the patient’s need for physical, psychosocial, emotional, and spiritual care. The assessment includes all areas of hospice care related to the palliation and management of terminal illness and related conditions. This CONDITION was not met, as evidenced by clinical records review, document review, and interview, which revealed issues with the completion of initial and comprehensive assessments of patients in the following areas: Failure of the hospice Interdisciplinary Group to demonstrate completion of an initial and comprehensive assessment [HCPC.8.I/522]; and failure of the IDG to update the comprehensive assessment every 15 days [HCPC.17.I/L533]. The cumulative effect and scope of these deficiencies could negatively impact the organization’s ability to identify and meet the care needs of the patients and ensure continuity of care and service coordination.

It is required that the hospice registered nurse completes an initial assessment within 48 hours of the patient’s election of hospice care, in accordance with CMS §418.24 (the elements of the hospice care election statement). The physician, patient, or representative may request that the initial hospice assessment be completed in less than 48 hours. This standard was not met, as evidenced by clinical record review and interview. 2 of 8 (25%) records reviewed revealed the hospice failed to ensure that the registered nurse completed and documented comprehensive assessments and to ensure completion within the required time frame. Record 1: This patient entered her 3rd benefit period on 4/10/23, and the face-to-face assessment was missing with no evidence of completion. No nursing visits were documented in the chart after 2/28/23 by the LPN or RN. Record 8: This patient elected hospice care on 10/6/22. The record did not contain an RN comprehensive reassessment in the clinical record for recertification for benefit period #3, 4/4/23-6/2/23. The director of nursing was interviewed on 5/3/23 and agreed the comprehensive assessments were not included in the clinical records.No additional documentation was presented prior to the conclusion of the site visit.

It is required that the update of the comprehensive assessment is completed by the hospice Interdisciplinary Group (IDG), who, in collaboration with the individual’s attending physician, consider the changes that have taken place since the initial assessment. The update of the comprehensive assessment includes information on the patient’s progress toward desired outcomes and the reassessment of the patient’s response to care. And the assessment update is completed as frequently as the condition of the patient requires, no less frequently than every 15 days. This standard was not met, as evidenced by clinical records review and interview. 6 of 8 (75%) clinical records reviewed revealed the the organization did not ensure the Comprehensive Assessments were updated at the Hospice Interdisciplinary Group no less frequently than every 15 days. Clinical Record 1 was reviewed and identified the patient elected hospice on 10/12/22. The last documented IDG was on 2/23/23. The clinical record did not contain evidence of the patient’s progress toward desired outcomes and the reassessment of the patient’s response to care. Clinical Record 2 was reviewed and identified the patient elected hospice on 2/10/23. There were no documented IDG meetings or updated comprehensive assessments in the clinical record. The clinical record did not contain evidence of the patient’s progress toward desired outcomes, assessment updates, or reassessment of the patient’s response to care. Clinical Record 6 was reviewed and identified the patient elected hospice on 2/27/23. This clinical record has no documented IDG updates from the election of benefits on 2/27/23. The clinical record did not contain evidence of the patient’s progress toward desired outcomes, assessment updates, and the reassessment of the patient’s response to care. Clinical Record 7 was reviewed and identified the patient elected hospice on EOB 1/06/21. The last documented IDG was on 2/23/23. The clinical record did not contain evidence of the patient’s progress toward desired outcomes, assessment updates, and the reassessment of the patient’s response to care. Clinical Record 8 was reviewed and identified the patient elected hospice on 10/06/22. The last documented IDG was on 2/23/23. The clinical record did not contain evidence of the patient’s progress toward desired outcomes, assessment updates, and the reassessment of the patient’s response to care. Clinical Record 11 was reviewed and identified the patient elected hospice on 2/18/23. The last documented IDG was on 2/23/23. The clinical record did not contain evidence of the patient’s progress toward desired outcomes, assessment updates, and the reassessment of the patient’s response to care. The Administrator/DON stated in an interview on 5/2/23 during the clinical record review that there have been some IDG meetings since 2/28/23 and will get the sign-in sheets, but they aren't documented in the clinical record. No additional documentation was presented prior to the conclusion of the site visit.

It is required that the hospice designates an Interdisciplinary Group (IDG) composed of individuals who work together to meet the physical, medical, psychosocial, emotional, and spiritual needs of the patient/family facing terminal illness and bereavement. The IDG, in its entirety, supervises the care and services provided to the patient and family. This Condition of Participation was not met, as evidenced by clinical record review, document review, and interview, which revealed the following issues with the development and implementation of the patient's interdisciplinary care plans: Failure of the hospice Interdisciplinary Group (IDG) to develop a documented patient plan of care (HCPC.18.I/L537); failure to ensure that treatment orders were available to meet the patient's care needs [HCPC.21.I/L549]; and oversight of the IDG to update the comprehensive care plans and to meet at least every 15 days HCPC.17.I/L533. A result of substantial non-compliance with the conditions of participation, including the failure of the leadership and Governing Body lack of management oversight of the administrative and clinical operations, could present a serious threat, serious injury, harm, or death to hospice patients served by this organization.

It is required that each patient’s individualized written plan of care drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review, interview and observation. 1 of 2 (50%) records reviewed revealed that the agency did not ensure that treatment orders were available to meet the patient care needs. Record 2 (Home Visit 1) The plan of care update dated 2/23/23 does not have wound care orders for the nurse to follow. This patient has a wound on his left foot that SV observed the nurse changing the dressing during SV. The registered nurse was interviewed during a home visit on 5/3/23 and when SV stated to her that there were no wound care orders on the plan of care and asked how she knew what the doctor wanted her to do, she responded, "There should be because I entered the orders into the computer, and I thought they would pull over to the plan of care." There were orders found on the referral from the physician however no new orders were found in the clinical record and signed by the physician.

It is required that the hospice medical director, in conjunction with the patient’s physician, are responsible for the palliation and management of the terminal illness as well as conditions related to the terminal illness. If the attending physician is , the medical director, contracted physician, and/or hospice physician employee is responsible for meeting the medical needs of the patient. This standard was not met, as evidenced by clinical record review and interview. 5 of 8 (62%) records reviewed revealed the Medical Director failed to assume responsibility for the palliation and management of the terminal illness and related conditions. Clinical Record 1 was reviewed and identified the patient elected hospice care on 10.12.22. The clinical record did not contain documentation that the Medical Director completed the recertification, and face-to-face assessment, There was no evidence that IDG meetings were conducted after the date of 2/23/23. There was no documented evidence that the medical director addressed palliation and management of the terminal illness and related conditions. Clinical Record 6 was reviewed and identified the patient elected hospice care on 2/27/23. The Medical Director did not write an initial certification for terminal illness to admit to services on 2/27/23. There was no evidence that IDG meetings were conducted after the date of 2/23/23. There was no documented evidence that the medical director addressed palliation and management of the terminal illness and related conditions. Clinical Record 7 was reviewed and identified the patient elected hospice care on 1/6/21. The Medical Director did not write the recertification for benefit period 15, 3/27/23, a face-to-face assessment was not done, and the plan of care was not signed. There was no evidence that IDG meetings were conducted after the date of 2/23/23. There was no documented evidence that the medical director addressed palliation and management of the terminal illness and related conditions. Clinical Record 8 was reviewed and identified the patient elected hospice care on 10/6/22. The Medical Director did not write the recertification for benefit period 3, 4/4/23, a face-to-face assessment was not done, and the plan of care was not signed. There was no evidence that IDG meetings were conducted after the date of 2/23/23. There was no documented evidence that the medical director addressed palliation and management of the terminal illness and related conditions. Clinical Record 11 was reviewed and identified the patient elected hospice care on 2/18/23. The Medical Director did not write an initial certification for readmission to services on 2/18/23. There was no evidence that IDG meetings were conducted after the date of 2/23/23. There was no documented evidence that the medical director addressed palliation and management of the terminal illness and related conditions. During an interview on 5/4/23, the Administrator/DON stated that a previous nurse knew all about hospice and was no longer working there now. The Administrator added that she is learning hospice but knows home health very well. No additional documentation was presented prior to the conclusion of the site visit.

It is required that volunteers are used in day-to-day administrative and/or direct patient care roles. Volunteer services provided to patients/families are in a defined role and under the supervision of a designated hospice employee. Volunteer services are noted in the plan of care; and documented in the patient record, including the time spent. THIS IS A CONDITION-LEVEL DEFICIENCY. This CONDITION was not met, as evidenced by record review and interview, which revealed that the hospice failed to provide volunteer services in day-to-day administrative and/or patient care role [HCDT.21.I/644]; failure to document and demonstrate viable and ongoing efforts to recruit and retain volunteers [HCDT.30.I/L645]. The cumulative effect of this deficiency resulted in the hospice agency's inability to provide quality care for the Condition of Participation CFR 418.78, Volunteers. The collaborative practice illustrated needing a process to ensure the provision of volunteer services to all patients.

It is required that volunteers are used in day-to-day administrative and/or direct patient care roles. Volunteer services provided to patients/families are in a defined role and under the supervision of a designated hospice employee and noted in the plan of care. This standard was not met, as evidenced by record review, observations, and interviews. 1 of 2 (50%) home visit observations revealed that the organization failed to ensure that volunteer services were available and provided in response to an identified volunteer need. Record 4: When interviewing the patient's wife during the home visit on 5/3/23, she stated she "didn't know hospice had volunteers to stay with the patient while [she) went out for her doctor's appointment"s. There was no documented evidence that the agency had an active volunteer available, assessed the need, and offered the service to the patient and family. The Administrator (Staff 1) was interviewed on 5/4/23 and verbalized she "thought the Medicare waiver meant I didn't have to have a volunteer." The Volunteer Coordinator (Staff 6) was interviewed on 5/4/23 and verbalized they did not have an active volunteer.

It is required that the hospice documents and demonstrates viable and ongoing efforts to recruit and retain volunteers. This standard was not met, as evidenced by the interview. There was no documented evidence of recruitment efforts. During an interview on 5/4/2023, the Volunteer Coordinator could not present any recruitment documentation or demonstrate viable and ongoing efforts to recruit new volunteers. The volunteer coordinator (Staff 6) was interviewed on 5/4/23 and verbalized how she might start recruiting volunteers but had not been focusing on that due to the Covid-19 waiver being in place.

It is required that the hospice organizes, manages, and administers its resources to provide the hospice care and services to patients, families, and caregivers necessary for the palliation and management of the terminal illness and related conditions. THIS IS A CMS CONDITION-LEVEL FINDING This CONDITION was not met, as evidenced by record reviews and interviews which revealed a failure by the Governing Body and the Administrator/DON to ensure the hospice ensured that the management and oversight of administrative and clinical operations of the hospice were occurring on a day-to-day basis and that the individuals charged with providing oversight were completing the duties associated with their roles (HSLG.3.I/L651); failure to ensure the services provided to patients was consistent with the standards of care and physician orders [HCDT.1.I/G652]; and failure to ensure that physician coverage was available 24 hours a day/7 days a week. [HCDT.4.I/L653]. The cumulative effect and scope of this deficiency could negatively impact the agency's ability to provide safe, quality care that meets the needs of patients, families, and caregivers for the palliation and management of the terminal illness and related conditions.

It is required that the hospice’s governance assumes full legal authority and responsibility for the organization’s overall management and operation provision of care and services. This standard was not met, as evidenced by document review, interview, and review of Governing Body meeting minutes, which revealed the failure of the Administrator/DON to assume responsibility for the organization's overall management and care and services delivery. The governing body failed to provide oversight and management to ensure that the provision of care and services followed physician orders and was in compliance with federal and state regulations. 5 of 8 (62%) records reviewed identified that a plan of care was not developed and physician orders were missing. [Records #: 1, 2, 6, 7, 8] 6 of 8 records (75%) reviewed revealed that medication orders were not received, and there was no evidence of a medication profile or review. [Records #: 1, 2, 6, 7, 8, 11] The previous medical director resigned on 2/28/23. The current medical director's contract was effective on 3/27/23. There was no evidence of an active Medical Director or designee from 3/1/23- 3/26/23. There was no documented evidence in the Governing Body minutes that the resignation of the Medical Director, the period the agency operated without a medical director, and the approval of a new Medical Director were addressed. There was no evidence of a coverage plan. In an interview on 5/3/23, the owner stated that she was overwhelmed after the LPN left (in January 2023) and that she was currently the sole RN except for one nurse assigned to only one patient. The Administrator also stated that a previous nurse knew all about hospice and was no longer working there. She added that she is now learning hospice but knows home health very well. During an interview on 5/4/2023, the Administrator agreed the patients had not received all the hospice services they were entitled to manage their terminal illness.

It is required that the hospice is primarily engaged in providing the following care and services in a manner consistent with accepted standards of practice; nursing services, medical social services, and physician services. This standard was not met, as evidenced by clinical record review, home observation visit, and interview. 6 of 8 (75%) records reviewed revealed the organization failed to ensure that services provided to the patients served were consistent with accepted standards of practice for receiving medication orders and a medications profile and review, care plans and certification of terminal illness. Record 2 was reviewed, and it identified that the patient elected hospice on 2/10/23. The diagnoses were BP 1, and Dx Atherosclerotic Heart Disease. There was no documented evidence of wound care orders to support the wound care provided. During the home visit, RN Employee # 2 stated, "I received orders from the doctor and entered them into an order, but I don't see them on the care plan. I don't know why they aren't showing up". Record 1 was reviewed and identified the patient elected hospice on 10/12/2022. There was no documented evidence that a plan of care was developed. There was no evidence that medication orders had been received. No medication profile was in the home, and a medication review was not completed. Record 6 was reviewed and identified the patient elected hospice on 2/27/23. The record was missing the certification of a terminal illness, the initial nursing comprehensive assessment, and the plan of care. There was no documented evidence these documents were completed. Record 7 was reviewed and identified the patient elected hospice on 1/6/2021. There was no documented evidence that a plan of care was developed. There was no evidence that medication orders were received, and a medication review was not completed. Record 8 was reviewed and identified the patient elected hospice on 10/6/22. There was no documented evidence that a plan of care was developed. There was no evidence that medication orders were received, and a medication review was not completed. Record 11 was reviewed and identified the patient elected hospice on 2/18/23. There was no documented evidence that a plan of care was developed. There was no evidence that medication orders were received, and a medication review was not completed. During an interview on 5/10/23, the Administrator/DON (Staff 1) stated the clinical records were missing documentation of treatment orders that they had, just not entered in the EMR. No additional documentation was presented before the conclusion of the site visit.

It is required that hospice physician services are made routinely available on a 24-hour basis, seven (7) days per week. All covered services are available on a 24-hour basis when reasonable and necessary to meet the needs of the patient and family. This standard was not met as evidenced by document review and interview. The review of contracts for the Medical Director revealed the hospice failed to ensure physician services were made available on a 24-hour basis, 7 days a week. Medical Director Contract 1 was effective 3/27/23. Medical Director Contract 2 was dated 2/21/20 - 2/28/23. There was no evidence that a Medical Director or designee was available after the Medical Director's resignation on 2/28/23 until the newly contracted medical director was effective on 3/27/23. During an interview on 5/4/2023, the owner who is the Administrators/DON (Staff 1) , stated the previous Medical Director resigned on 2/28/23. She verified that the newly contracted Medical Director began on 3/27/2023. She agreed there was no Medical Director available between 3/1/23 and 3/26/23. The Administrator/DON was unable to voice an alternate plan that was used to meet the patient need for physician services when a contracted Medical Director was unavailable. During an interview, the current Medical Director (Staff 5) stated that she is available 24 hours a day, 7 days per week. She stated that in the event that if she is unavailable that the Hospice would have to, at that time, secure the services of another physician or contact the patient's primary attending physician. She further stated that she is the only Hospice Medical Director and there is no alternate or designated medical director in place.

It is required that the hospice medical director, physician employees, and contracted physician(s), in conjunction with the patient’s attending physician, are responsible for the palliation and management of the terminal illness as well as conditions related to the terminal illness. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This CONDITION was not met as evidenced by record review and interviews which revealed that the Medical Director had not completed a review of medical information and certification of terminal Illness on all patients [HCPC.4.I/L667], failure to complete the re-certification of terminal illness on all applicable patients [HCPC.6.I/L676, and failure of the Medical Director to assume responsibility for the palliation and management of the terminal illness and patient needs [HCDT.5.I/L590], and failure to ensure physician services were made available on a 24-hour basis, 7 days a week after the previous medical director resigned [HCDT.4.I/L653]. The cumulative effect of these deficiencies could result in the physician providing oversight of the patients, not having a full understanding of their needs and/or potential changes in their condition.

It is required that the hospice medical director or physician designee reviews the clinical information for each patient being evaluated for admission and provides written certification that it is anticipated that the patient's life expectancy is six months or less if the illness runs its normal course. The physician considers the following when making this determination: the primary terminal condition; related diagnosis(es), if any; current subjective and objective medical findings; current medication and treatment orders; and information about the medical management of any of the patient's conditions unrelated to the terminal illness. This standard was not met, as evidenced by interview and record review. 1 of 8 (13%) clinical records reviewed revealed the agency did not ensure that the medical director or physician designee documented a review of clinical information and initial written certification. Record 6 was reviewed and identified the patient elected hospice care on 2/27/23. The orders section of the clinical record showed that the initial written and verbal certifications had not been started. There was no documented evidence that the record contained evidence of a review of clinical information to evaluate the patient for admission, and the initial certification of terminal illness was not completed. The Administrator/ DON (Staff 1) was interviewed on 5/2/23 during the clinical record review and agreed the clinical record did not have evidence of the written certification of the terminal illness by the Medical Director.

It is required that a patient clinical record containing past and current findings be 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: the initial plan of care, updated plans of care, initial assessment, comprehensive assessment, updated comprehensive assessments, and clinical notes, including the care and services provided; physician certification and recertification of terminal illness as required; and physician orders. THIS IS A CMS CONDITION-LEVEL DEFICIENCY. This CONDITION was not met, as evidenced by clinical record review and interview. The agency demonstrated a failure to maintain physician certification and re-certification of terminal illness requirements as described in 418.102(b)(1) and 418.102(a)(5) [HCPC.6.I/L676]; failure to provide evidence in the record that a copy of the patient's Discharge Summary was sent to the receiving facility when the patient was discharged or transferred [HCDT.38.I/L682]; failure to document physician treatment orders in the clinical record [HSIM.3.I/L678]; failure to update the plan of care, comprehensive and renewal assessments, and clinical notes in the clinical record [HSIM.3.I/L672]; failure to ensure the clinical record contained a physician certification and recertification of terminal illness [HSIM,3.I/676]; and failure to include a discharge summary to the attending physician in the clinical record when a patient revokes their benefit [HSIM3.I/683]. The cumulative effect of these systemic issues in this area results in the agency's inability to ensure quality health care and patient safety.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient with updated plans of care, updated comprehensive assessments, and clinical notes, including the care and services provided. This standard was unmet, as evidenced by clinical record reviews and interview. 5 of 8 (63%) records reviewed revealed the hospice failed to ensure the patient's clinical record contained past and current findings with updated plans of care, comprehensive assessments, and clinical notes. Record 1 was reviewed and identified the patient elected hospice care on 10/12/22. The clinical record does not contain documentation of updated comprehensive assessments or clinical notes from 2/28/23 through 5/2/23. There was no documented evidence of IDG meetings from 2/23/23-5/2/23. There was no hospice plan of care in the clinical record for benefit period 3, 4/10/23-6/6/23, written by the Interdisciplinary Group (IDG) in consultation with the attending physician to meet the patient's needs. Record 6 was reviewed and identified the patient elected hospice care on 2/27/23. The clinical record does not have documentation of updated comprehensive nursing assessments, no clinical notes from 2/18/23 through 5/2/23, and no plan of care written by the IDG in consultation with the attending physician to meet the patient's needs. Record 7: This clinical record has no hospice plan of care for benefit period 15, dated 3/27/23, written by the IDG in consultation with the attending physician to meet the patient's needs. Clinical Record 8: No hospice plan of care was in the clinical record for benefit period 3, 4/4/23-6/2/23, written by the Interdisciplinary Group (IDG) in consultation with the attending physician to meet the patient's needs. Clinical Record 11: The 12th recertification period began on 4/19/23. There was no plan of care created for this benefit period. The clinical record did not contain updated comprehensive assessments or clinical notes from 2/28/23 through 5/2/23. The Administrator/(DON) (Staff 1) was interviewed on 5/2/23 during the record review and agreed there was no documentation in the record and stated, "I made visits every week, but the notes are written down." She agreed there was no documentation in the clinical records. No additional documentation was presented prior to the conclusion of the site visit.

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. Recertification for the hospice care benefit is informed by the medical director or physician designee’s review of the patient’s clinical information. 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. 4 of 8 (50%) records reviewed revealed that the hospice failed to ensure the clinical record contained documentation of terminal illness for recertification. Record 1: The 3rd certification period began on 4/10/23, and no written recertification was completed in the record as of 5/2/23. This patient did not have a face-to-face completed by 4/10/23. Record 11: The 12th certification period began on 4/19/23; face-to-face or written certification documentation was not found in the clinical record. Record 7: The 15th certification period began on 3/27/23; face-to-face or written certification documentation was not found in the clinical record. Record 8: The 3rd certification period began on 4/4/23; no face-to-face and no written certification documentation was found in the clinical record. The Administrator/Director of Nurses (DON) (Staff 1) was interviewed on 5/3/23 and agreed the clinical records were missing the written recertification and face-to-face encounters. No additional documentation was presented prior to the conclusion of the site visit.

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 with current physician orders. This standard was not met, as evidenced by clinical record review, interview, and observation. 1 of 8 (12%) records reviewed revealed the hospice failed to ensure the clinical record contained current orders for wound care. Record 2: During the home visit on 5/3/2023, the RN Case Manager was observed performing wound care to the patient's left foot. The plan of care was reviewed and was missing wound care treatment orders. The record did not contain physician orders for wound care. The RN was observed providing wound care and dressing change. There were no wound care orders. The RN Case Manager (Staff 2) was interviewed on 5/3/23. She was asked how she knew how to perform wound care without a plan of care and current orders. She responded that she had entered them into the chart and didn't know why they weren't on the plan of care.

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 and the patient’s record, if requested. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) records reviewed revealed the hospice failed to ensure the discharge summary was sent to the hospital after the patient was discharged to the hospital as required Record 10: This patient was sent to the ER on 2/8/23 and discharged from services. There was no evidence in the clinical record that the that the discharge summary was sent to the hospital upon discharge. Record 3: The discharge note dated 3/9/23 stated in part, "pt went to agency that could provide more aide hours. the aide she wanted could provide limited hours no visit done". There is no evidence in the clinical record that a discharge summary and patient information were sent to the receiving Medicare-certified facility. The Administrator/Director of Nursing (Staff 1) was interviewed on 5/2/23 during the record review and confirmed there was no evidence in the clinical record of discharge summaries were sent to the hospital and other hospice agency after the patients were discharged from services.

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. This standard was not met, as evidenced by clinical record review and interview. 1 of 2 (50%) discharged records reviewed revealed that the hospice did not ensure when a patient revoked their benefit that, a discharge summary was sent to the attending physician. Record 3: The patient was discharged on 3/9/23 to go to another hospice, and there is no evidence in the clinical record of a discharge summary being sent to the attending physician.