Every finding on record at Angel Wings Healthcare LLC

Upon patient record review, 2 of 14 (Patient #9,14) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #9 - The medication profile contained Miralax 17 gm daily for constipation. There was no evidence in the directions of a diluent addition to that medication. This was corrected onsite. Patient #14 - The medication profile listed Senna one tab daily as needed for constipation as well as a Bisacodyl suppository one daily prn for constipation. The directions did not include which prn medication to take first. This was corrected onsite.

Upon patient record review, 4 of 14 (Patient #1,2,5,6) 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 medication profile listed patient receiving a Duo neb for treatment of shortness of breath. There were no problems, goals or interventions noted related to respiratory. The medical record also showed an order dated 09/11/25 for Bactrim DS one tablet daily for seven days. There were no problems, goals or interventions outlined for infection. This was corrected onsite. Patient #2 - The medication profile listed patient was on Eliquis daily. There were no problems, goals or interventions noted related to bleeding risk. This was corrected onsite. Patient #5 - The medication profile listed patient was on aspirin daily as a blood thinner. There were no problems, goals or interventions noted related to the bleeding risk. The profile also included that patient was taking Senna one tablet daily for constipation. There were no problems, goals, or interventions related to constipation. These were corrected onsite. Patient #6 - The medication profile listed patient was taking Oxycodone 7.5/325 one tablet every six hours scheduled along with marijuana one unit as needed for his pain regimen. There was no problems, goals, or interventions related to pain management. This was corrected onsite.

Upon patient record review, 2 of 14 (Patient #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 #9 - The physician order contained Miralax 17 gm daily for constipation. There was no evidence in the directions of a diluent addition to that medication. This was corrected onsite. Patient #14 - The physician order listed Senna one tab daily as needed for constipation as well as a Bisacodyl suppository one daily prn for constipation. This was corrected onsite.

Upon patient record review, 1 of 14 (Patient #12) 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 #12 - There was no evidence in the medical record that bereavement services were offered or declined at the time of death. There was no bereavement plan of care or any evidence of correspondents or contact to the bereaved post death.

Upon patient record review 6 of 14 (Patient #2, 3, 4, 5, 6, 7) 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 • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #2 - The aide plan of care dated 08/01/25, documented aide frequency of visits at 5 visits per week with showers to be given on Tuesday and Thursday, and bed baths on Monday, Wednesday and Friday. The aide marked "acknowledged" on the aide note to every task and then marked "completed" regardless of the day the visit was made. Patient #3 - The aide plan of care dated 07/03/25, documented aide frequency of 3 visits per week with bed baths to be given specifically on Tuesdays and Thursdays. The aide completed visits on Monday, Wednesday and Fridays every week and marked the task "acknowledged" and "complete" on all visits made. Patient #4 - The plan of care dated 05/15/25, had an aide frequency order of 2 visits per week. The aide plan of care had the task of patient shower on Monday, Wednesday and Friday. The medical record had evidence that the frequency was met, but the plan of care was not followed as visits were completed on Tuesdays and Thursdays only and the task was marked "acknowledged" and "completed" by the aide on the aide note. Patient #5 - The medical record showed a frequency order for the aide for 2 visits per week. The week of 8/11/25, only one visit was completed on 08/15/25 and there was no evidence of a missed/refused note in the medical record for the other visit. The week of 08/18/25 there was 3 visits completed one of which was done without an order: 08/19/25, 08/21/25, and 08/22/25. In addition, the plan of care dated 08/14/25, had an aide frequency order of 2 visits per week. The aide plan of care had the task of patient shower on Monday, Wednesday and Friday. The medical record had evidence that the frequency was met, but the plan of care was not followed as visits were completed on Tuesdays and Thursdays only and the task was marked "acknowledged" and "completed" by the aide on the aide note. Patient #6 - The medical record showed a frequency order for the aide for 2 visits per week. The week of 08/25/25, there was only one visit completed on 08/28/25 and the week of 09/08/25, only 1 visit was completed on 09/11/25. There was no evidence of a missed/refused note in the medical record for those missing visits. In addition, the plan of care dated 06/23/25, had an aide frequency order of 2 visits per week. The aide plan of care had the task of patient shower on Monday, Wednesday and Friday. The medical record shows evidence the plan of care was not followed as visits were completed on Tuesdays and Thursdays only and the task was marked "acknowledged" and "completed" by the aide on the aide note. Patient #7 - The aide plan of care dated 10/10/24, had an aide frequency order of 2 visits per week. The aide plan of care states patient to receive a bed bath on Monday, Tuesday, Wednesday and Thursday. The medical record shows evidence the frequency order was met, however the plan of care was not followed as visits were only completed on Tuesday and Thursday only and the task was marked "acknowledged" and "complete" by the aide on the aide note.

It is required that the hospice Interdisciplinary Group, in consultation with the individual's attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review and interview. 2 of 3 (67%) clinical records reviewed revealed that the agency did not ensure that an initial comprehensive assessment was performed no later than 5 calendar days after the election of hospice care. Clinical Record 1: The patient elected the hospice benefit on 2/20/2024. The Social worker made a phone call to the patient's brother and on further review of the clinical record there was not documented evidence that the social worker made a visit or spoke with the patient. There was no documented evidence that the psychosocial assessment was completed by the RN. The patient lives in a group home and is alert and oriented with confusion at times. In an interview with the social worker and administrator on 3/8/2024 the social worker stated, "I did not have a contact number for the patient and did not know how to get in touch with him." The administrator stated, " she did not call anyone at the agency to get the contact information for the patient which I could have supplied to her." Clinical Record 2: The patient elected the hospice benefit on 2/6/2024. The social worker attempted to contact caregiver for initial assessment on 2/10/2024, she left a message for the caregiver to call back. On further review of the clinical record there was no documented evidence that the social worker followed up with the patient or family.

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current prescription and over-the-counter (OTC) drugs, supplements, herbal remedies, and other alternative treatments that could affect drug therapy. 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 document review, interview and observation. 3 of 3 (100%) of medication profiles reviewed revealed that the agency did not ensure that all current medications were on the patient's medication profile or that the medication profile was updated at each comprehensive assessment. Clinical Record 1: The patient elected the hospice benefit on 2/20/2024 with a diagnosis of Chronic diastolic congestive heart failure. On the initial RN assessment dated 2/20/2024 the RN documented that the patient was using O2 at 2L for mild dyspnea. RN documented on 2/21/2024 "Pt utilizing oxygen 2L via NC with comfort". Oxygen tank and concentrator was listed on the POC. The agency did not ensure that the oxygen was listed on the patient's medication profile. Clinical Record 2: The patient elected the hospice benefit on 2/6/2024 with a diagnosis of Degenerative disease of nervous system. The patients plan of care dated 2/6/2024 identified that the patient is on oxygen 2-5L as needed. Review of the medication profile revealed that the agency did not ensure that the oxygen was on the patient's medication profile. The initial certification of terminal illness dated and signed by the doctor on 2/6/2024 stated that the patient was currently taking Vancomycin HCL twice a day. Review of the medication profile revealed that the agency did not ensure that the medication was listed on the mediation profile. In an interview with the Administrator and Director of Clinical on 3/8/2024, they confirmed that the patient was on Vancomycin for aspiration pneumonia. Clinical Record 3: The patient elected the hospice benefit on 1/10/2024 with a diagnosis of Alzheimer's Disease. During review of the clinical record, it was revealed that a verbal order obtained by RN from hospice medical director for Vitamin C 500mg, 1 tablet by mouth twice a day for 14 days, Zinc 220mg, 1 capsule by mouth every day for 14 days, and multivitamin 1 tablet by mouth every day for 14 days. There was no documented evidence that these medications had been updated on the medication profile. During joint review of the record and interview with the administrator and Director of Clinical on 3/8/2024, they confirmed that the doctor gave this order, and it was not added to the patient's medication profile. Home Visit 2: Clinical Record #2. A visit was made to the patient on 3/8/2024 with the RN. During review of the skilled nursing facilities patient medication profile, it was found that these medications were not listed on the hospice medication profile. Sucralfate 1gm give four times a day for ulcer, Cholestyramine oral packet 4gm, give 1 packet three times a day for GERD, Reglan 5mg give 1 tablet one time a day for gastrointestinal agent, Ascorbic Acid 250mg give 1 tablet one time a day for immunity, Ferrous Sulfate oral solution 300mg/5ml give 5ml one time a day for supplement, Atorvastatin Calcium 20mg give 1 tablet at bedtime for antilipidemic, Metoprolol tartrate 50mg give 1 tablet two times a day for beta blocker, Lactobacillus oral packet give 1 packet three times a day for anti-diarrhea, and Bisacodyl rectal suppository 10mg insert 1 tablet rectally every 24 hours as needed for constipation.

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. 1. IDG members provide the care and services offered by the organization. 2. The IDG, in its entirety, supervises the care and services provided to the patient and family. This standard was not met as evidenced by clinical record review and interview. 1 of 3 (33%) clinical records reviewed revealed that the agency did not ensure that IDG worked together to meet the patient's needs, Clinical Record 1: The patient elected the hospice benefit on 2/20/2024. It was documented in the initial RN assessment that the patient is awake and alert with occasional confusion, He is ambulatory living in a group home with supervision. In an attempt to make an initial assessment, the social worker made one phone call to the patient's brother who lives out of town. There is no documented evidence found that the social worker followed up with any communication to the brother or the patient. During the home visit with the nurse on 3/8/2024, it was revealed that the patient has financial hardship and has respiratory medications that are not covered by the hospice that he needs assistance with funding for these medications, The RN case manager stated that the social worker was supposed to be working on this issue. The caregiver at the group home stated he was due for refills of these medications. There is no documented evidence that the SW is involved in this process. In an interview with the social worker on 3/82024 she stated that "there was no other contact numbers for the patient in his chart except for the brothers number. I did not know how to contact the group home." The administrator stated the social worker should have called the office to obtain contact numbers if she couldn't find them. When asked about helping the patient with uncovered medications she only stated, "I have not seen the patient."

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: A detailed statement of the scope and frequency of services necessary to meet specific patient and family needs. This standard was not met as evidenced by clinical record review and interview. 2 of 3 (67%) of clinical records reviewed revealed that the agency did not ensure that there was a detailed statement of the frequency of services necessary to meet patient needs. Clinical Record 1: The patient accepted aide services at election of the hospice benefit on 2/20/2024. Aide visits were made to the patient on 2/21/2024, 2/23/2024, 2/27/2024, and 2/29/2024. There was no documented evidence of discipline frequencies on the patient plan of care.  Clinical Record 3: The patient accepted aide services at election of hospice benefit on 1/10/2024. During review of the patient plan of care dated 1/10/2024, it was identified that aide frequency was documented 3 times a week for 2 different aides which totaled aide visits 6 times a week. The aide is only visiting 3 times a week. During an interview with the administrator and assistant administrator they confirmed that the aide was ordered only 3 times a week.

It is required that a hospice aide provides services ordered by the Interdisciplinary Group; included in the plan of care; permitted to be performed under state law and regulation; and consistent with the hospice aide training. This standard was not met as evidenced by clinical record review and interview. 1 of 3 clinical record reviewed for patients that elected aide services revealed the agency did not ensure that the hospice aide provided services only included on the plan of care (POC). Clinical Record 1: The patient elected the hospice benefit on 2/20/2024 and accepted hospice aide services on admission. Visits were made by the hospice aide on 2/21/2024 and 2/23/2024. Aide did not complete tasks listed on the plan of care, nail care each visit, oral care each visit, apply lotion each visit, foot care apply lotion each visit, peri care each visit, apply barrier cream each visit. In an interview with the administrator and assistant administrator it was confirmed that the aides did not follow the aide care plan.

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. 1 of 3 (33%) Clinical Records reviewed revealed that the agency did not ensure the hospice aides documented complete and appropriate records of service, including the report of changes in the patient's needs. Clinical Record 1: The patient elected the hospice benefit on 2/20/2024 and accepted hospice aide services on admission. Visits were made by the hospice aide on 2/21/2024 and 2/23/2024. Aide did not complete tasks listed on the plan of care, nail care each visit, oral care each visit, apply lotion each visit, foot care apply lotion each visit, peri care each visit, apply barrier cream each visit. There was no documented evidence that the aide notified the RN case manager of the change in the patient's needs and tasks not completed. In an interview with the administrator and assistant administrator it was confirmed that the aides are required to notify the RN of tasks not completed.

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: medical supplies (including drugs and biologicals) and medical appliances related to the palliation and management of the terminal illness and related conditions as identified in the care plan. This standard was not met as evidenced by clinical record review and interview. In 2 of 3 (67%) medication profiles reviewed revealed the agency did not ensure that all drugs and biologicals related to the palliation and management of the patients' related conditions were covered by the hospice. Clinical Record 1: The patient elected the hospice benefit on 2/20/2024 with a diagnosis of Chronic Diastolic Obstructive heart failure. The patient's initial nursing assessment dated 2/20/2024 stated the patient had depression and generalized pain. On review of the medication profile, it was found that the agency was not covering Duloxetine HCI 30mg daily for depression or Acetaminophen 325mg 2 tablets every 6 hours as needed for pain. The agency also was not covering Milk of Magnesia for occasional constipation. Clinical Record 2: The patient elected the hospice benefit on 2/6/2024 with a diagnosis of Degenerative Disease of Nervous System and Secondary of Cerebral Palsy. The patient had a gastrostomy tube in which she received feedings and all her medications through. The patient had Omeprazole 20mg daily for GERD ordered and the agency was not covering the medication. In an interview with the administrator and clinical director, the administrator initially did not agree with covering the cost of most medications for the patients. She was provided the NHPCO algorithm for covering medications which she stated she did not agree with as a pharmacist by trade. After discussion, it was agreed by that these medications should be covered.

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. (L670) Each patient’s record includes, at a minimum physician order. This standard was not met as evidenced by clinical record review and interview. In 1 of 3 (33%) of clinical records reviewed revealed that the agency did not ensure that there were appropriate physicians orders. Clinical Record 2: The patient elected the hospice benefit on 2/6/2024. The initial certification of terminal illness dated and signed 2/6/2024, stated the patient was receiving Vancomycin HCL 2 times a day via G-tube. No physician order in the clinical record for Vancomycin HCL twice a day. There was no documented evidence of a physician's order found in the medical record. In an interview with the Administrator and Director of Clinical on 3/8/2024 they confirmed the patient was taking Vancomycin for aspiration pneumonia.

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/IDF 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. 1 of 1 (100%) clinical record reviewed of a patient residing in a skilled nursing facility revealed that the agency did not ensure that the plan of care identified which provider was responsible for performing functions agreed upon. Clinical Record 2: The patient elected the hospice benefit on 2/6/2024 with a diagnosis of degenerative disease of nervous system. The patient has a secondary diagnosis of diabetes. she is currently receiving Lantus 100units/ml take 45 units subcutaneous 1 time a day. Per an RN note made on 2/27/2024 she participated in the SNF patient coordination meeting. In this note she documented that blood glucose readings had been between 160-220. There is no documented evidence on the hospice plan of care or any nursing documentation that states which provider is responsible for obtaining or managing the blood glucose monitoring. An order was written on 2/6/2024 that read "Gastrostomy feeding tube- bolus order Every shift check G-tube residual prior to feeding. If G-tube residual is greater than 100ml hold feeding for one hour an recheck residual. If G-tube residual continues to be greater than 100ml, call MD. Head of Bed 45 degrees with feeding, bolus and 3 to 4 hours after bolus feedings." There is no documented evidence of who is responsible for monitoring these findings.

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. (L523) This standard was not met as evidenced by clinical record review and interview. In 4 of 7 (57%) records reviewed, in which social worker visits were accepted, revealed the agency did not ensure the initial comprehensive assessments were completed by the social worker within five (5) days after the election of hospice care. Clinical Record 1: The patient elected the hospice benefit on 3/31/23, the initial social worker visit was documented on 4/7/23 (day 7). The record did not contain any documentation as to why the visit was made outside the 5-day requirement. Clinical Record 3: The patient elected the hospice benefit on 6/2/23, the initial social worker visit was documented on 6/9/23 (day 7). The record did not contain any documentation as to why the visit was made outside the 5-day requirement. Clinical Record 4: The patient elected the hospice benefit on 2/22/23, the initial social worker visit was documented on 3/1/23 (day 7). The record did not contain any documentation as to why the visit was made outside the 5-day requirement. Clinical Record 6: The patient elected the hospice benefit on 5/4/23, the initial social worker visit was documented on 5/14/23 (day 10). The record did not contain any documentation as to why the visit was made outside the 5-day requirement. Personnel Record 5 [Social Worker]: During an interview, on 1/25/24, the social worker was asked if she was aware of the 5-day comprehensive assessment requirement and she said, "yes, I try to make that, if I can't visibly see the patient, I can make calls to the family first and then go see them." Personnel Record 3 [Administrator]: On 1/25/24 the administrator confirmed that the social worker had not seen the above patients within the 5-day requirement and voiced understanding of the regulation but discussed the challenges of only having one PRN (as needed) social worker and the lack of qualified applicants.

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current: prescription and over-the-counter (OTC) drugs; supplements; herbal remedies; and other alternative treatments that could affect drug therapy. This standard was not met as evidenced by clinical record review, document review, interview and observations. In 1 of 7 (14%) records reviewed revealed the agency did not ensure the patient's drug profiles contained current and accurate prescribed medications. Document 7: Agency policy (PC. 85) Titled, "Medication monitoring will include appropriate date/information to develop an accurate patient medication history and a current, complete medication profile. This data will be available to all hospice staff involved in the patient care." Clinical Record 1: The patient elected the hospice benefit on 3/31/23 with a diagnosis of senile degeneration of the brain. During medication reconciliation, conducted during the home visit observation on 1/24/24 the following discrepancies were identified: Skilled Nursing Facility (SNF) drug profile: Milk of Magnesia Suspension (MOM) 400mg/5ML give 30 ml by mouth every 24 hours as needed for constipation (order date 1/11/21). Hospice drug profile: MOM 400/5ml give 30ml 6 times a day as needed for gas relief (order date 5/5/23). SNF drug profile: Ocuvite-Lutein Capsule (Multiple vitamins-minerals) 1 tablet by mouth one time a day related to unspecified cataract (order date 1/11/21). Hospice drug profile: Listed Ocuvite vitamin was discontinued on 11/14/23. SNF drug profile: Pepcid Tablet 20 mg give 1 tablet by mouth one time a day related to other diseases of stomach (order dated 1/19/21). Hospice drug profile: this medication was not listed. Personnel Record 5: The administrator reviewed the drug profiles and confirmed that the above discrepancies were accurate. The administrator stated, "We send over the order the facility but sometimes they don't do what they are supposed to with them, but we should have caught that."

It is required that the update of the comprehensive assessment is completed by the hospice Interdisciplinary Group, who, in collaboration with the individual’s attending physician, if any, consider the changes that have taken place since the initial assessment. The assessment update is completed as frequently as the condition of the patient requires. This standard was not met as evidenced by clinical record review and interview. 1 of 7 (14%) records reviewed, it was revealed the agency did not ensure the hospice interdisciplinary group updated the comprehensive assessment when changes in the patient condition were identified. Clinical Record 7: The patient elected the hospice benefit on 6/26/23 with a primary diagnosis of senile degeneration of the brain. There was a routine comprehensive nursing assessment documented on 12/18/23. On 12/24/23 the hospice RN documented a phone call to the facility who reported the patient had a blood pressure of 86/30. On 12/25/23 the RN documented a phone call was placed to the facility and stated, "this nurse had to beg the facility charge nurse to get me vital signs on this patient. Facility charge nurse would not give vital signs (VS). Per charge nurse patient had drainage from eye and said (the patient) does not have a comfort kit, this nurse asked facility charge nurse what symptoms were out of control. No answer to my question from facility nurse. Charge nurse to call hospice back with VS and assessment." The hospice RN documented a follow-up call at 2:25 pm with the following vital signs reported: Blood Pressure 136/36, Pulse 85, Temperature 97.9. On 12/27/23 the hospice RN documented a phone call and stated, "anticipatory pain and bowel regimen orders received. See physician order." On 12/28/23 it was documented that phone call was made to the facility to inform them that a pharmacist would deliver the morphine liquid and the Dulcolax. On 1/2/24 a visit was documented by the RN to pronounce the patient at 9:55pm. From 12/18/23 to 1/2/24 there were no documented nursing visits made by the hospice. The ordered visit frequency was for one visit biweekly, and there were no documented changes to update the comprehensive assessment despite the patient's change of condition. Personnel Record 5: The above information was reviewed with the administrator on 1/25/24. It was determined that there were no additional comprehensive assessments completed by the hospice. The administrator stated, "she (the patient) was in a skilled facility and if they need us to visit, they tell us, and we would go."

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. (L539) This standard was not met as evidenced by clinical record review and interview. In 7 of 7 (100%) records reviewed revealed the agency did not ensure that a social worker was included in the interdisciplinary group (IDG) to meet the psychosocial and emotional needs and to participate in supervision of the care and services provided to the patient. Clinical Record 1: Election of benefit 3/31/23, current benefit period started on 11/26/23. The following IDG meetings did not contain evidence of social worker participation; 11/10/23, 11/24/23, 12/8/23, 1/5/24, and 1/19/24. The IDG meetings listed contained notes written by the RN and the Chaplain. Clinical Record 2: Election of benefit 12/26/23. The following IDG meetings did not contain evidence of social worker participation; 1/5/24 and 1/19/24. The IDG meetings listed contained notes written by the RN and the Chaplain. Clinical Record 3: Election of benefit 6/2/23, current benefit period started on 11/29/23. The following IDG meetings did not contain evidence of social worker participation; 11/10/23, 11/24/23, 12/8/23, 1/5/24, and 1/19/24. The IDG meetings listed contained notes written by the RN and the Chaplain. Clinical Record 4: Election of benefit 2/22/23, current benefit period started on 12/19/23. The following IDG meetings did not contain evidence of social worker participation; 11/10/23, 11/24/23, 12/8/23, 1/5/24, and 1/19/24. The IDG meetings listed contained notes written by the RN and the Chaplain. Clinical Record 5: Election of benefit 8/8/21 and discharged on 1/12/24. The following IDG meetings did not contain evidence of social worker participation; 11/10/23, 11/24/23, 12/8/23, and 1/5/24. The IDG meetings listed contained notes written by the RN and the Chaplain. Clinical Record 6: Election of benefit 5/4/23 and discharged on 12/16/23. The following IDG meetings did not contain evidence of social worker participation; 11/10/23, 11/24/23, and 12/8/23. The IDG meetings listed contained notes written by the RN and the Chaplain. Clinical Record 7: Election of benefit 6/26/23 until date of death 1/2/24. The following IDG meetings did not contain evidence of social worker participation; 11/10/23, 11/24/23, and 12/8/23. The IDG meetings listed contained notes written by the RN and the Chaplain. Personnel Record 5 [Social Worker]: A phone call interview was conducted with the social worker (SW) on 1/25/24. During the interview the social worker reported that she is a PRN (as needed) employee and that she is the sole SW employed by the agency. When asked about the SW role in IDG she stated, "I work full time nights, so I am not always able to attend (in person or via phone), but I always make sure my notes are in." Personnel Record 3 [Administrator]: During an interview with the administrator, on 1/25/24, it was confirmed that the SW does not consistently participate in the IDG meetings. The administrator stated, "I am going to have to call and wake her up so that she can join." When asked about the IDG meeting notes the administrator reported, "the RN and Chaplain enter them, but the Social Worker had not been doing so, but they will start." In addition to confirming the SW had not entered notes in the clinical records the administrator also provided the IDG meeting sign-in sheets and noted that the SW had signed as present for any of the above meetings identified.

It is required that each patient’s individualized written plan of care: Medical supplies and appliances necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review, document review, interview and observation. In 4 of 4 (100%) records reviewed of patients currently receiving the hospice services, revealed the agency did not ensure that the plans of care (POC) included the medical supplies and appliances needed for patient care. Document 10: Titled "Plan of Care (POC)" (last reviewed 10/1/21) stated in relevant part, "The POC includes all services necessary for the palliation and management of the terminal illness, and related conditions." Clinical Record 1: Election of hospice benefit on 3/31/23 with a diagnosis of senile degeneration of the brain. Per observation during the home visit on 1/24/24, briefs, wipes, peri-spray, and under pads were noted in patient room and were provided by the hospice. The POC (effective 3/31/23 to current) did include the statement "obtain DME/Supplies as needed for patient support," but did not list the specific supplies. Per an interview with the administrator (personnel record 5) on 1/24/24, it was stated "we were not aware the medical supplies needed to be on the POC, the EMR (electronic medical record) just has a place for DME (durable medical equipment)." It was further reported that the agency kept inventory supply sheets for all active patients, the staff members mark what supplies were taken for that individual patient. Clinical Record 2: Election of hospice benefit on 12/26/23 with a diagnosis of cerebral infarction. According to the inventory supply sheet the following items were provided to the patient: nail clippers, gloves, briefs, under pads, and cuticle sticks. The POC (effective 12/26/23 to current) did not contain the medical supplies. Clinical Record 3: Election of hospice benefit on 6/2/23 with a diagnosis of senile degeneration of the brain. According to the inventory supply sheet the following items were provided to the patient: body wash, clippers, gloves, briefs, and under pads. The POC (effective 6/2/23 to current) did not contain the medical supplies. Clinical Record 4: Election of hospice benefit 2/22/23 with a diagnosis of hemiplegia and hemiparesis following cerebral infarction. According to the inventory supply sheet the following items were provided to the patient: briefs and under pads. The POC (effective 2/22/23 to current) did not contain the medical supplies.

It is required that consistent with current professional standards of practice, licensed professionals actively participate in the coordination of all aspects of patient care including: Hospice “core” services are substantially provided directly by hospice employees in a manner consistent with acceptable standards of practice. “Core” services include nursing services, medical social work, and counseling. The hospice may contract for physician services as specified in paragraph (a) §418.64(a) Standard: Physician services The hospice medical director, physician employees, and contracted physician(s) of the hospice, in conjunction with the patient’s attending physician, are responsible for the palliation and management of the terminal illness and conditions related to the terminal illness. (1) All physician employees and those under contract, must function under the supervision of the hospice medical director. (3) If the attending physician is unavailable, the medical director, contracted physician, and/or hospice physician employee is responsible for meeting the medical needs of the patient. THIS IS A CMS CONDITION LEVEL FINDING This CONDITION was not met as evidenced by a review interviews and document review which revealed the hospice failed to ensure that the medical director provided supervision for all physician employees per L590. {CDT.5.I /L590}. 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 418.64: Core Services. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the agency.

It is required that employed physicians and those under contract practice under the supervision of the hospice medical director. Contract 2: The contract for the medical director (executed 5/1/2019) established the role of the medical director included supervising hospice physicians. Personnel Record 1 {Medical Director): During the phone interview, on 1/25/24 the medical director was asked to describe how he provided oversight to the alternate medical director: "I only have midlevel." When asked what the midlevel meant, and he replied, "midlevel's are PA's or NP's." Asked if the agency provided an alternate medical director and he replied, "that it isn't necessary as I am always available". This site visitor stated the name of the physician listed as the alternate medical director and he replied, "yes, that is a physician that (hospice agency name) know, but I have never spoken to him." The regulation regarding the medical director providing oversight was reviewed and the question posed by this site visitor as to how this was being met, he stated, "that is vague, they (hospice) know they can call me so there isn't a need for communication, but if he needs assistance then the (hospice) would contact me. No need for a run down like in a hospital." Personnel Record 6 [Alternate Medical Director]: During the phone interview, on 1/25/24 this site visitor asked what the role of the alternate medical director entailed, he reported, "my role is alternate medical director, I don't do anything routine but am there if they can't reach the medical director." He was able to state the name of the medical director. When asked how the medical director provided oversight he said, "there is no oversight, that isn't necessary." He further said, "the hospice contacts me if I need to provide any coverage or if they need something. I have been working in hospice for years, so I know what I need to do." Personnel Record 3 [Administrator]: During an interview on 1/25/24 the content of the medical director and alternate medical director interviews were presented to the administrator who confirmed that there was no process in place for the medical director supervision to be conducted. When asked by this site visitor how the alternate medical director obtained direction or clinical information she stated, "he would call here, and we will tell him what he needs to know." It was further stated, "We will send (name of alternate medical director) a list of patients plans of care if the medical director. He (the alternate medical director will call the office and ask for more information if needed." The administrator was unable to provide evidence that the alternate medical director functioned under the supervision of the hospice medical director.

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 1 of 7 (14%) records reviewed, in which aide services were accepted, revealed the agency did not ensure the RN provided the hospice aide with specific care instructions thus leaving the aide to make decisions which is outside of the scope of practice. Clinical Record 2: The patient elected the hospice benefit on 12/26/23 with a diagnosis of Cerebral Infarction. The initial nursing assessment (12/26/23) documented four wounds covered with dressings. The aide plan of care, effective from 12/26/23 to current, listed the relevant task of showering, every visit. The care plan did not include instructions on what the aide should do regarding the wound dressings (i.e.: cover them, report to RN if they become wet, etc). Personnel Record 3: During the interview, on 1/25/24, the administrator agreed that the RN should have included specific instructions in regard to the wound dressings.

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: Medical supplies (including drugs and biologicals) and medical appliances related to the palliation and management of the terminal illness and related conditions as identified in the care plan. This standard was not met as evidenced by clinical record review, document review and interview. In 6 of 6 (100%) records in which the patient drug profiles were reviewed, revealed the agency did not ensure that all drugs and biologicals related to the palliation and management of the patients' related conditions were covered by the hospice. Document 10: Agency policy titled "Plan of Care (POC)" (last reviewed 10/1/21) stated in relevant part, "The POC includes all services necessary for the palliation and management of the terminal illness, and related conditions." Clinical Record 1: On the initial certification of terminal illness (CTI) (3/31/23) and the most recent CTI for benefit period 11/26/23-1/24/24, the hospice medical director reported the primary hospice diagnosis was dementia with comorbidities of schizoaffective disorder, bipolar disorder, hypothyroidism, weakness, muscle weakness, and type 2 diabetes. The drug profile, effective from 3/31/23 to current, listed the following medications as “covered” by hospice: Ativan, Benadryl, and Haldol. The following medications, prescribed for conditions identified within the plans of care (3/31/2023 to current) were listed as “not covered” by hospice: Acetaminophen for pain, Gaviscon for gas relief, Metformin for hypoglycemia, Milk of Magnesia for gas relief/constipation, Risperdal for agitation, and Tradjeta for diabetes. Clinical Record 2: On the initial certification of terminal illness (12/26/23), the hospice medical director reported the primary hospice diagnosis was cerebral infarction with comorbidities of hemiplegia and hemiparesis, dysphagia, acute respiratory failure without hypoxia, pleural effusion, chronic obstructive pulmonary disease (COPD), anemia, hypertension (HTN), protein-calorie malnutrition, and cognitive communication deficit. The drug profile, effective from 12/26/23 to current, listed the following medications as “covered” by hospice: Norco. The following medications, prescribed for conditions identified within the plan of care (12/26/2023 to current) were listed as “not covered” by hospice: Hydroxyzine for anxiety, Losartan Potassium Hydrochlorothiazide for HTN, Milk of Magnesia for constipation, and Pantoprazole Sodium for heartburn. Clinical Record 3: On the initial certification of terminal illness (6/2/23) and the current CTI for benefit period 11/29/23-1/27/24, the hospice medical director reported the primary hospice diagnosis was cerebral infarction with comorbidities of atrial fibrillation, hypertension (HTN), anxiety, depression, hyperlipidemia, and cardiac pacemaker. The drug profile, effective from 6/2/23 to current, listed the following medications as “covered” by hospice: Ativan, Benadryl, Haldol, and Dulcolax. The following medications, prescribed for conditions identified within the plans of care (6/2/2023 to current) were listed as “not covered” by hospice: Acetaminophen for pain, and Xarelto for anticoagulant therapy. Clinical Record 4: On the initial certification of terminal illness (2/22/23), the hospice medical director reported the primary hospice diagnosis was Alzheimer’s disease with comorbidities of atrial fibrillation, and benign prostatic hyperplasia (BPH). The drug profile, effective from 2/22/23 to current, listed the following medications as “covered” by hospice: Aspirin, Lorazepam, and Quetiapine Fumarate. The following medications, prescribed for conditions identified within the plans of care (2/22/2023 to current) were listed as “not covered” by hospice: Digoxin for arrhythmias, Finasteride for BPH, Memantine HCL for dementia, Montelukast for allergies, and Robitussin for cough/congestion. Clinical Record 5: On the initial certification of terminal illness (8/8/21) and on the current benefit period certificate of terminal illness (11/22/23-1/20/24, the hospice medical director reported the primary hospice diagnosis was Senile degeneration of the brain with comorbidities of atherosclerotic cardiovascular disease, myocardial infarction, hypertension (HTN), hyperlipidemia, type 2 diabetes, and benign prostatic hypertrophy (BPH). The drug profile, effective from 8/8/21 to discharge on 1/12/24, listed the following medications as “covered” by hospice: Melatonin, Phenergan, and Tramadol. The following medications, prescribed for conditions identified within the plans of care (8/8/2021 to current) were listed as “not covered” by hospice: Acetaminophen for pain, Artificial tears for dry eyes, Aspirin for anticoagulation, Esomeprazole Magnesium for acid reflux, Finasteride for BPH, Gabapentin for neuropathy, Hydrocortisone for allergies, Isosorbide Mononitrate ER for angina prevention, Lactulose for constipation, Metoprolol Succinate ER for HTN, Nitro-glycerine for angina, Paroxetine HCL for depression, Silodosin for enlarged prostate, and Zyrtec for allergies. Clinical Record 6: On the initial certification of terminal illness (5/4/23) the hospice medical director reported the primary hospice diagnosis was Hemiplegia and hemiparesis following cerebral infarction. The drug profile, effective from 5/4/23 to discharge on 12/16/23, listed the following medications as “covered” by hospice: Aspirin and Plavix. The following medications, prescribed for conditions identified within the plans of care (5/4/2023 to current) were listed as “not covered” by hospice:: Amlodipine for hypertension, Jevity 1.5 Cal/Fiber for nutrition, Pantoprazole Sodium for gastroesophageal reflux disease, and Sertraline HCL for depression. Personnel Record 1 [Medical Director]: During the phone interview with the medical director, on 1/24/24, the physician, when asked how the agency determines covered versus not covered medications he stated, "Depends on the diagnosis they are coming on for and if they have a PCP (primary care physician). If they have a PCP then we let them deal with the medications that aren't pertaining to the diagnosis. If no PCP then we take over and talk about what (medications) to leave on and what to take off because they aren't beneficial, with the patient/family input." When the regulatory language regarding covering medications for palliation of the terminal diagnosis as well as those comorbidities contributing to the prognostic picture he replied, "Is that something new? We look solely at the primary diagnosis." Personnel Record 3 [Administrator]: The administrator confirmed, during the interviews on 1/24/24 and 1/25/24, that the practice has been to cover only those medications related to the primary diagnosis. The administrator reported that the hospice works with a consulting pharmacist, who attends the interdisciplinary team (IDT) meetings and assists with recommending medications that are on formulary and/or deprescribing and said they will have this individual assist with reviewing all covered versus not covered medications.

It is required that a clinical record containing past and current findings is maintained for each hospice patient. The clinical record must contain correct clinical information that is available to the patient's attending physician and hospice staff. The clinical record may be maintained electronically. THIS IS A CMS CONDITION LEVEL FINDING This CONDITION was not met as evidenced by a review of clinical records, interviews, document review and interviews which revealed the hospice failed to ensure that the initial certification of terminal illness documents were signed by the selected attending physician{HSIM.3.I/L676}; Failed to ensure that the discharge summary was forwarded to the patient’s attending physician{HSIM.3.I/L683}; and Failed to ensure the discharge summary included the patient's current plan of care {HCDT.40/L684}. 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 418.104: Clinical Records. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the agency.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record may be maintained electronically or on paper. (L670) Each patient’s record includes, at a minimum: Physician certification and recertification of terminal illness as required. This standard was not met as evidenced by clinical record review, document review and interview. In 2 of 2 (100%) records reviewed, in which an attending physician was selected, it was revealed the hospice did not ensure the initial certification of terminal illness documents were signed by the selected attending physician. Document 11: The following regulation within the Condition of Participations requires the attending physician (if the individual has one) to sign the initial certification of terminal illness:  § 418.22 Certification of terminal illness. (c) Sources of certification. (1) For the initial 90-day period, the hospice must obtain written certification statements (and oral certification statements if required under paragraph (a)(3) of this section) from— (i) The medical director of the hospice or the physician member of the hospice interdisciplinary group; and (ii) The individual's attending physician, if the individual has an attending physician. The attending physician must meet the definition of physician specified in § 410.20 of this subchapter. Clinical Record 1: On the election of benefit document (dated 3/31/23), the patient's guardian elected the "facility physician" to act as the attending physician for hospice, this individual was an MD. The initial certification of terminal illness (CTI) document was signed by the medical director on 3/31/23 in both the medical director section and the attending physician section. The patient had a state Medicaid certification of terminal illness form that was signed by the medical director on 3/31/23 and by the attending physician on 4/7/23. The clinical record did not contain evidence that a change of the designated attending physician had been requested. Clinical Record 6: On the election of benefit document (dated 5/4/23), the patient's sister/representative elected an MD to act as the attending physician for hospice. The initial certification of terminal illness (CTI) document was signed by the medical director on 5/4/23 in both the medical director section and the attending physician section. The clinical record did not contain evidence that a change of the designated attending physician had been requested. Personnel Record 1 [Medical Director]: During an interview, on 1/25/24, the medical director was questioned about the regulatory requirement that the attending physician (if the patient has one) sign the initial CTI, he stated, "I sign where they tell me, if they say there is no PCP (attending physician) I sign it, I don't always know." Personnel Record 3 [Administrator]: During an interview with the office manager, and administrator, on 1/25/24 it was reported that "with the EMR (electronic medical record) the attending physicians did not have any way to sign them (CTI's), so we have (name of medical director) sign them." When asked if the CTI document could be printed and sent to the attending physician for a signature the administrator reported "it could, but we haven't done that."

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. In 1 of 2 (50%) records reviewed, in which a discharge summary was required to be sent to the attending physician, it was revealed the agency did not ensure the record contained evidence the discharge summary had been provided. Clinical Record 5: The patient elected the hospice benefit on 8/8/2021 with a diagnosis of senile degeneration of the brain. Discharge from hospice occurred on 1/12/2024 for no longer meeting the hospice criteria. The record did not contain evidence that the discharge summary was provided to the attending physician.   Personnel Record 3 [Administrator]: Joint record review was completed with the office manager who was unable to locate documentation that the discharge summary was sent to the attending physician. The administrator was interviewed on 1/25/24 and reported that there was no additional information to provide on this.

It is required that the hospice discharge summary provided to a facility receiving a hospice patient for care—or to the patient’s community attending physician upon hospice discharge—includes at least the following: a summary of the patient’s hospice stay, including treatments, symptoms, and pain management and the patient’s current plan of care. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) records reviewed, in which a discharge summary was required, revealed the agency did not ensure the discharge summary included the patient's current plan of care. Clinical Record 5: The patient elected the hospice benefit on 8/8/2021. The discharge summary dated 1/12/24, did not include the current and complete plan of care as it was missing the medication list. Clinical Record 6: The patient elected the hospice benefit on 5/14/23. The discharge summary dated 12/16/23, did not include the current and complete plan of care as it was missing the medication list. Personnel Record 3 [Administrator]: During the joint clinical record reviews conducted on 1`/25/24, with the office manager, it was reported that the electronic medical record (EMR) did not automatically include the medications on the discharge summary and there was no additional documentation identified indicating the medication list was attached to the discharge summary. On 1/25/24 the administrator confirmed that there was no additional information available to show that the discharge summary contained all required elements.

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/IDF 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. (L774) This standard was not met as evidenced by clinical record review and interview. In 4 of 4 (100%) records reviewed, in which the patient resided in a skilled nursing facility (SNF), it was revealed the agency did not ensure the plans of care identified which provider was responsible for providing the care and services needed by the patient. Clinical Record 1: At the time of the election of hospice services (3/31/23) to current the clinical record documented that the patient resided in a skilled nursing facility (SNF). The plans of care effective from 3/31/23 to current did not delineate responsibilities. There was a statement "collaborate with referral source/facility/institution" without further details. Clinical Record 3: [Record 3]: At the time of the election of hospice services (6/2/23) to current the clinical record documented that the patient resided in a skilled nursing facility (SNF). The plans of care effective from 6/2/23 to current did not delineate responsibilities. There was a statement "collaborate with referral source/facility/institution" without further details. Clinical Record 6: At the time of the election of hospice services (5/4/23) to date of discharge (12/16/23) the clinical record documented that the patient resided in a skilled nursing facility (SNF). The plans of care effective from throughout the hospice stay did not delineate responsibilities. There was a statement "collaborate with referral source/facility/institution" without further details. Clinical Record 7: At the time of the election of hospice services (6/26/23) to date of discharge (1/2/24) the clinical record documented that the patient resided in a skilled nursing facility (SNF). The plans of care effective from throughout the hospice stay did not delineate responsibilities. There was a statement "collaborate with referral source/facility/institution" without further details. Personnel Record 3 [Administrator] : The records were reviewed jointly with the office manager, on 1/24/24 and 1/25/24, who reported that the electronic medical records (EMR) did not "have any way to do this." The administrator confirmed (on 1/15/24) that they (hospice staff) talk with the SNF staff and if needed will write the responsible party in the physician order and provided the example of wound care. The administrator agreed that with the current practice the responsible provider was not noted in the plans of care.

It is required that the designated IDG member provides the SNF/NF or ICF/IDF with the following information for each patient/resident: Hospice election form. This standard was not met as evidenced by clinical record review, interview and observation. In 1 of 1 (100%) home visits made to a skilled nursing facility (SNF), it was revealed the agency did not ensure that the SNF had been provided with a copy of the hospice election form. Home Visit 1: During the home visit observation, on 1/24/24, the facility clinical record was reviewed for regulatory compliance. This reviewed was completed with the assistance of the SNF medical records personnel and the hospice RN (personnel record 9). The medical records staff member was knowledgeable about what paperwork was required and said that "they (hospice) are always bringing me papers that I have to scan in," which was confirmed on the review as all plans of care updates and visit notes were present. The medical records staff member was unable to locate a copy of the hospice election form and said, "I can't believe I didn't catch that; I know what I need." Personnel Record 3 [Administrator]: On 1/24/24 the administrator was informed that the election form was not present within the facility records and stated, "we send it to them, we try to give them a binder which they don't want, but we fax it or email it and anytime they call saying they don't have it we resend whatever they need." The administrator reported that there was no documented proof that the document had been provided.

Based on record review and interview the agency failed to designate in writing a similarly qualified registered nurse who would serve as the agency's Supervising Nurse in the absence of the Supervising Nurse. The failed practice of the agency not having an Alternate Supervising Nurse placed the agency patients at risk of inadequate or inappropriate care when the Supervising Nurse was unavailable. --- Findings Include: During the entrance conference on 05/30/2023 at approximately 9:50 AM, with the surveyor Alternate Administrator (via phone), and the Office Assistant A, the Alternate Administrator stated, ";The Administrator is out of the country. Im at a doctors appointment and will come to the agency after the appointment. The Office Assistant A can assist anything you need for the survey. I should be there within the hour." The surveyor asked if the Supervising Nurse or the Alternate Supervising Nurse, would be available to assist during the survey. The Alternate Administrator answered, ";The Supervising Nurse was out doing visits, but can be called with any questions." The surveyor asked the Alternate Administrator, if the agency had an Alternate Supervising Nurse. The Alternate Administrator stated, "No." At approximately 10:40 AM, the Alternate Administrator arrived at the agency. The surveyor asked how long the agency have been without an Alternate Supervising Nurse. The Alternate Administrator confirmed the agency have been looking for an Alternate Supervising Nurse for a since June or July 2022. At approximately 10:20 AM, on 05/30/2023, Office Assistant A provided an active employee roster. The roster did not include an alternate supervising nurse. During an interview on 05/31/2023 at approximately 9:30 AM, with the Alternate Administrator and Office Assistant A, the surveyor reviewed the findings and confirmed the agency did not currently have an alternate Supervising Nurse. The Office Assistant A stated, ";We have placed online job postings, attended job fairs, and word of mouth." The Alternate Administrator stated, "We have been looking. We will find a nurse, but then they dont want to do visits. They only want to work in the office." The agency policy titled "Responsibilities of the Supervising Nurse...LD.6" with a revision date of 01018, read in part: "Purpose...To define the responsibilities of the Supervising Nurse to ensure safe, appropriate delivery of patient care...Definition... Supervising Nurse is the registered nurse responsible for supervising skilled services provided by the Agency and who meets the qualifications defined by regulation...Policy...The Supervising Nurse, appointed by the Administrator, will be responsible for the daily direction of patient care...The Supervising Nurse and Alternate Supervising nurse must each be a registered nurse...Procedure...IV. The Administrator will designate, in writing, the appropriate qualified alternate to serve as the Supervising Nurse in the absence of the Supervising Nurse..."

It is required that the written Patient Bill of Rights includes the right to choose his or her attending physician. This standard was not met as evidenced by a review of clinical records and interviews. 4 of 11 (36%) records reviewed revealed the hospice did not ensure the patients had the right to choose his or her attending physician as required at time of admission. Record # 0 was reviewed and identified that the patient elected hospice care on 2/2/2021. The caregiver signed the election statement on 2/2/2021.There was no documented evidence identifying a choice of an attending physician. Record # 6 was reviewed and identified that the patient elected hospice care on 5/18/2022.The record contained the election statement signed by the caregiver on 5/18/2022. There was no documented evidence identifying a choice of an attending physician. Record #8 was reviewed and identified that the patient elected hospice care on 6/17/2022. The caregiver signed the election statement on 6/17/2022.There was no documented evidence identifying a choice of an attending physician. Record #5 was revieweed and identified that the patient elected hospice care on 6/24/2021. The caregiver signed the election statement on 6/24/2021. There was no documented evidence identifying a choice of an attending physician. During an interview on 8/18/2022, the Administrator (Staff # 4) stated the team will be educated on the requirements of the patients and family rights to choose an attending physician for this to be identified on the election statements. reviewed revealed the agency did not ensure the patient had the right to choose his or her attending physician as is required at time of admission on the election statement form.

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 and interviews. 2 of 11 (18%) clinical records reviewed revealed the agency did not ensure that the spiritual counselor and hospice social worker did not complete a comprerhensive assessment within 5 days after the patient elected the hospice benefit. Record # 7 was reviewed and identified the patient elected hospice care on 3/15/2022. The psychosocial assessment not completed until 3/21/2022, 6 days after the election of hospice care.There is no documentation to support a delay in completing this assessment. Record #1 was reviewed and identified that the patient elected hospice care on 7/19/2021.The spiritual assessment was not completed until 7/28/2021, 9 days after the election of hospice care. There is no documentation to support a delay in completing this assessment. During an interview on 8/18/2022, the DCS/RN (Staff record # 1) stated it was unknown as to why these assessments were not completed within 5 days of hospice election. it was revealed the agency did not ensure a psychosocial and spiritual assessment were completed within 5 days after the election of hospice care.

It is required that the update of the comprehensive assessment is completed by the hospice Interdisciplinary Group, who, in collaboration with the individual’s attending physician, if any, 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; reassessment of the patient’s response to care. The assessment update is completed as frequently as the condition of the patient requires; and no less frequently than every 15 days. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 3 (33%) patient files revealed the comprehensive assessment was not updated to include a change in condition that occurred. In 1 of 3 (33%) home visit with interviews and clinical record review the agency did not ensure a fall that was reported to the nurse over a weekend was documented in the clinical record. Clinical Record # 1 was reviewed and identified the patient elected the hospice benefit on 7/19/2021. During the home observation visit #1 on 8/17/2022 with RN #1 the caregiver stated the patient had a fall "last Sunday,” and that he called hospice to report the fall. Review of the clinical record revealed the phone call and report of the fall were not documented in the clinical record. There was no evidence that the fall was documented in the after-hours report. During an interview on 8/18/2022, the DCS/RN (Staff record # 1) stated, that the fall was not documented in the medical record or in the after-hours report. the agency did not ensure a fall that was reported to the nurse over a weekend was documented in the clinical record.

It is required that the hospice uses quality indicator data, including patient care data and other relevant data, in the QAPI program. The data elements abstracted and aggregated from comprehensive patient assessments are used in quality assessment and improvement. This standard was not met as evidenced by a review of clinical records, interviews and observations. 1 of 1 (100%) clinical records of patients with known falls. The agency failed to ensure a patient fall was collected and used in the in the QA program. Record #1 Patient elected the hospice benefit on 7/19/2021. During the home observation visit #1 on 8/17/2022 with RN #1 the caregiver stated the patient had a fall "last Sunday," and that he called hospice to report the fall. Review of the clinical record revealed the phone call and report of the fall was not documented as patient care data for the QAPI program. The Director of Clinical Services stated, during an interview on 8/18/2022 that the fall was not documented in QAPI data documents. Record #1 Patient elected the hospice benefit on 7/19/2021. During the home observation visit #1 on 8/17/2022 with RN #1 the caregiver stated the patient had a fall "last Sunday," and that he called hospice to report the fall. Review of the clinical record revealed the phone call and report of the fall was not documented as patient care data for the QAPI program. The Director of Clinical Services stated, during an interview on 8/18/2022 that the fall was not documented in QAPI data documents.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. he record contains correct clinical information that is available to the patient’s attending physician and hospice staff. including signed copies of the hospice election statement. This standard was not met as evidenced by a review of clinical records and interviews. In 3 of 11 (27%) records reviewed revealed the agency did not ensure election statements included the effective date of election of the Medicare hospice benefit. Clinical Record # 0 was reviewed and identified the patient elected the hospice benefit on 2/2/2021. The record contains the election statement signed by the caregiver on 2/2/2021. The signed election statement did not include the election date. Clinical Record # 8 was reviewed and identified the patient elected the hospice benefit on 6/17/2022. The record contains the election statement signed by the caregiver on 6/17/2022. The signed election statement did not include the election date. Clinical Record # 1 was reviewed and identified the patient elected the hospice benefit on 7/19/2021. The record contains the election statement signed by the caregiver on 7/19/2022. The signed election statement did not include the election date. During an interview on 8/18/2022, the Administrator (Staff # 1) stated the team did not consistently have the patient or caregiver enter the date of election on the election forms and will be educated on the requirements of election dates. the agency did not ensure election statements included the effective date of election of the Medicare hospice benefit.

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. 2 of 5 (40%) clinical records with live discharged patients revealed the hospice did not ensure a discharge summary was sent to the attending physician. Clinical Record # 0 was reviewed and identified that the patient was discharged on 10/29/2021 to non-contracted facility. Review of the record revealed there was no evidence that a discharge summary was sent to the attending physician. Clinical Record # 3 was reviewed and identified that the patient was transferred to another hospice on 10/7/2021. Review of the record revealed there was no documented evidence that a discharge summary was sent to the attending physician or the receiving hospice. During an interview and joint record review on 8/18/2022, the Director of Clinical Services (DCS) stated she did not see documentation to support that the discharge summaries were forwarded to the attending physicians as required. it was revealed the agency did not ensure a discharge summary was sent to the attending physician.