Every finding on record at American Hospice, L.L.C.

Based on record review and interview, the IDG failed to ensure the comprehensive assessment was completed within 5 days of the election of hospice care for two (#3 and #8) of nineteen (#1 -#19) records reviewed. --- Patient #3 Review of clinical record #3 initial certification period revealed a primary diagnosis of Cerebrovascular Disease with a SOC date of 11/29/23. Further review of Clinical Visit Notes indicated a Social Worker Initial Assessment was conducted on 12/19/23 (15 days late). Patient #8 Review of clinical record #8 initial certification period revealed a primary diagnosis of Cerebrovascular Disease with a SOC date of 04/19/24. Further review of Clinical Visit Notes indicated a Social Worker Initial Assessment was conducted on 04/25/24 (1 day late). During an interview on 06/19/24 at 10:00 AM, the Patient Care Coordinator stated the Social Worker failed to ensure the Initial Assessment was completed within 5 days of the SOC as required for Patients #3 and #8.

Based on record review and interview, the IDG failed to ensure documentation of Imminence of Death as part of the Comprehensive Assessment for three (#3, #13 and #14) of nineteen (#1 -#19) records reviewed. --- Patient #3 Review of clinical record #3 with a SOC date of 11/29/24 failed to provide evidence of documentation regarding imminence of death as part of the Comprehensive Assessment. Patient #13 Review of clinical record #13 with a SOC date of 04/12/24 failed to provide evidence of documentation regarding imminence of death as part of the Comprehensive Assessment. Patient #14 Review of clinical record #14 with a SOC date of 10/06/22 failed to provide evidence of documentation regarding imminence of death as part of the Comprehensive Assessment. During an interview on 06/19/24 at 10:00 AM, the Patient Care Coordinator stated the SN failed to provide documentation regarding Imminence of Death as part of the Comprehensive Assessment for Patients #3, #13 and #14.

Based on record review and interview, the IDG failed to ensure an Initial Bereavement Risk Assessment was conducted as part of the Comprehensive Assessment to identify needs of the patient and family and to incorporate that information into the hospice bereavement plan of care for one (#3) of nineteen (#1 -#19) records reviewed. --- Patient #3 Review of clinical record #3 with a SOC date of 11/29/23 failed to provide evidence an initial Bereavement Risk Assessment was completed as required. During an interview on 06/19/24 at 10:00 AM, the Patient Car Coordinator stated the SN failed to ensure the Initial Bereavement Risk Assessments for Patients #3 was completed timely as part of the Comprehensive Assessment.

Based on a review of clinical records and interview, the hospice failed to ensure the development of a plan of care which specified all hospice care and services for five (Patients #1, 2, 3, 4 and 5) of 13 clinical records reviewed. Findings: Patient #1 A review of the electronic medical record showed no development of a plan of care for the certification period of 12/06/21 to 02/03/22. Patient #2 A review of the electronic medical record showed no development of a plan of care for the certification period of 12/22/21 to 03/21/22. Patient #3 A review of the electronic medical record showed no development of a plan of care for the certification period of 12/20/21 to 02/17/22. Patient #4 A review of the electronic medical record showed no development of a plan of care for the certification period of 11/23/21 to 01/21/22. Patient #5 A review of the electronic medical record showed no development of a plan of care for the certification period of 10/27/21 to 01/24/22. On 03/08/22 at 12:30 pm, Staff A stated there was no plan of care developed for Patients #1, 2, 3, 4 and 5 for the specified certification periods.

Based on record review and interview, the hospice failed to ensure spiritual (Chaplain) services were provided in accordance with the plan of care frequency for one (Patient #8) of 13 patients. Findings: Patient #8 A review of the electronic medical record showed interdisciplinary group comprehensive assessments dated 12/08/21, 12/22/21, 01/05/22 and 01/19/22 which documented a Chaplain frequency of two visits per month. A review of the electronic medical record showed no Chaplain visits from 01/01/22 to 01/31/22 (no visits made). Documentation showed no patient or family refusal of visits and no changes in the ordered frequencies for the Chaplain. On 03/08/22 at 1:50 pm, Staff A stated the Chaplain frequency was not followed as ordered for Patient #8.

Based on record review and interview, the hospice failed to ensure documentation of a QAPI Program was maintained for all 49 patients on service and all personnel employed by the hospice. Findings: A review of agency records showed no documentation of a QAPI Program for 2020 and 2021. On 03/08/22 at 12:50 pm, Staff A stated there was no documentation of the development of the QAPI Program for 2020 and 2021.

Based on a record review and interview, the governing body failed to ensure an agency specific QAPI program was evaluated annually for all 49 patients on hospice services and all agency staff for 2020 and 2021. A review of administrative records showed no governing body review of the agency specific QAPI program for 2020 and 2021. On 03/08/22 at 12:55 pm, Staff A stated the governing body minutes did not show review of the agency specific QAPI for the hospice in 2020 and 2021.

Based on record review and interview, the hospice failed to ensure a hospice aide were ordered for one (Patient #13) of 13 patients. Findings: Patient #13 A review of the plan of care dated 02/17/22 to 05/17/22 and plan of care updates dated 02/23/22 and 03/02/22 showed no hospice aide frequency. A review of the electronic medical record showed hospice aide visits performed on 02/18,22, 02/ 21/22, 02/22/22, 02/28/22, 03/01/22, 03/02/22, 03/03/22, 03/04/22 and 03/07/22. On 03/08/22 at 1:30 pm, Staff A stated Patient #13 had no order for the hospice aide services provided.