Every finding on record at Angelic Grace Hospice and Palliative Care LLC

It is required that the hospice maintains a written comprehensive emergency preparedness program that demonstrates compliance with applicable federal, state, and local emergency preparedness requirements, uses an “all hazards” approach, describes the hospice’s approach to meeting the health, safety, and security of the staff, the patient population, with attention to their mobility, [and] describes how the hospice coordinates with other healthcare facilities, as well as the community, during an emergency or disaster situation. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This standard was not met as evidenced by document review and interview which revealed the agency: Failed to ensure to develop and implement an EP plan that was based on a hospice-based and community-based risk assessment, using an “all-hazards” approach {HSEP.2.D/E6}; Failed to ensure that the EP plan was reviewed and updated at least every two (2) years{HSEP.2. D/E4}; Failed to ensure that the agency maintained an emergency preparedness training program that is based on the emergency preparedness plan, risk assessment, policies and procedures, and the communication plan. The training program is reviewed and updated at least every two (2) years. The last emergency plan training program was last reviewed in 2019 {HSEP.5. D/E37} and Failed to ensure agency maintained an emergency preparedness training and testing program that is based on the emergency preparedness plan, risk assessment, policies and procedures, and the communication plan. The training program is reviewed and updated at least every two (2) years {HSEP.5. D/E36}. 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 418.113: Emergency Preparedness. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the agency.

It is required that the hospice develops and maintains an emergency preparedness (EP) plan that is reviewed and updated at least every two (2) years. This standard was not met as evidenced by interview and document review. A review of the agency emergency preparedness (EP) plan revealed the agency reviewed the EP for 2019 and 2023, however, there was no documented evidence that the plan was reviewed and updated for 2021. Upon reviewing the emergency preparedness (EP) plan, the documentation lacked evidence of the emergency plan reviewed for 2021, 2022, and 2023. The most recent emergency plan review was 02/12/2023. The previous emergency plan review was in 2019.

It is required that the hospice develops and maintains an emergency preparedness (EP) plan that is reviewed and updated at least every two (2) years. The plan is based on and includes a documented hospice-based and community-based risk assessment, using an “all-hazards” approach specific to the geography and population served. This standard was not met as evidenced by interview and document review. A review of the agency emergency preparedness (EP) plan revealed the documentation lacked evidence of a documented hospice-based and community-based risk assessment, using an “all-hazards” approach specific to the geography and population served for the years 2021, 2022, 2023, and 2024. During an interview on 05/02/2024, the Alternate Administrator/Executive Director/Volunteer Coordinator confirmed that a documented hospice-based and community-based risk assessment was not completed every two years using an “all-hazards” approach specific to the geography and population served. Upon reviewing the emergency preparedness (EP) plan, the documentation lacked evidence of a documented hospice-based and community-based risk assessment, using an “all-hazards” approach specific to the geography and population served for the years 2021, 2022, 2023, and 2024.

It is required that the hospice maintains an emergency preparedness training and testing program that is based on the emergency preparedness plan, risk assessment, policies and procedures, and the communication plan. The training program is reviewed and updated at least every two (2) years. This standard was not met as evidenced by document review and interview. A review of the agency emergency preparedness (EP) plan revealed the documentation lacked evidence that the training program was based on the emergency preparedness plan, risk assessment, policies and procedures, and the communication plan. The document lacked evidence of a risk assessment for the years 2021, 2022, 2023, and 2024. The documentation lacked evidence that the training program was updated for 2021, 2022, and 2023. The most recent emergency plan review was 02/12/2024. The previous emergency plan review was in 2019. During an interview on 05/02/2024, the Alternate Administrator/Executive Director/Volunteer Coordinator confirmed that a documented emergency preparedness training program was not based on a current risk assessment and was not reviewed and updated at least every two (2) years. Upon reviewing the emergency preparedness (EP) plan, the documentation lacked evidence that the training program was based on the emergency preparedness plan, risk assessment, policies and procedures, and the communication plan. The document lacked evidence of a risk assessment for the years 2021, 2022, 2023, and 2024. The documentation lacked evidence that the training program was updated for 2021, 2022, and 2023. The most recent emergency plan review was 02/12/2024. The previous emergency plan review was in 2019.

It is required that the hospice maintains an emergency preparedness training program that is based on the emergency preparedness plan, risk assessment, policies and procedures, and the communication plan. The training program is reviewed and updated at least every two (2) years. The hospice EP training program includes the following for all new hospice employees and those providing services under arrangement: initial training in EP policies and procedures consistent with their expected roles, demonstration of staff knowledge of emergency procedures, EP training of all hospice employees and individuals providing services under arrangement at least every two (2) years, more frequent training occurs if there is a significant update of EP policies and procedures, a periodic review and rehearsal of the hospice’s EP plan with hospice employees (including non-employee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others, and documentation of each training including the date(s), participants, and content. This standard was not met as evidenced by document review and interview. Upon reviewing the emergency preparedness (EP) plan, the documentation lacked evidence that the training program was based on the emergency preparedness plan, risk assessment, policies and procedures, and the communication plan. The documentation lacked evidence that the training program was updated for 2021, 2022, and 2023. The most recent emergency plan review was 02/12/2024. The previous emergency plan review was in 2019. During an interview on 05/02/2024, the Alternate Administrator/Executive Director/Volunteer Coordinator confirmed that a documented emergency preparedness training program was not based on a current risk assessment and was not reviewed and updated at least every two (2) years. Upon reviewing the emergency preparedness (EP) plan, the documentation lacked evidence that the training program was based on the emergency preparedness plan, risk assessment, policies and procedures, and the communication plan. The document lacked evidence of a risk assessment for the years 2021, 2022, 2023, and 2024. The documentation lacked evidence that the training program was updated for 2021, 2022, and 2023. The most recent emergency plan review was 02/12/2024. The previous emergency plan review was in 2019.

It is required that the hospice designates a registered nurse member of the IDG to provide coordination of care, ensure continuous assessment of each patient’s and family’s needs, and ensure the implementation of the interdisciplinary plan of care. Hospice care and services provided to patients and families follow the individualized plan of care established by the hospice IDG in collaboration with the attending physician (if any), the patient or patient representative, and the primary caregiver in accordance with the patient’s needs. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed revealed that the agency did not ensure that the RN ensured the implementation of the interdisciplinary plan of care. Clinical Record 11: The patient’s date of election was 07/19/2023. The patient's hospice diagnosis was Parkinsonism. The initial comprehensive assessment dated 07/19/2023 documented that the patient had Parkinson's Disease, tremors, multiple CVAs, dementia, paraplegia, anxiety, cardiac disease, confusion, constipation, fatigue, forgetfulness, depression, insomnia, multiple falls, bowel and bladder incontinence, w/c dependent, a fair to poor appetite, and a full code. The Plan of Care (POC) dated 07/19/2023-09/16/2023, 09/17/2023-11/15/2023, and 11/16/2023-01/14/2024 did not contain nursing or psychosocial interventions or goals for the identified problems. The Plan of Care (POC) dated 09/17/2023-11/15/2023 and 11/16/2023-01/14/2023 lacked discipline frequency orders for skilled nursing, hospice aide, medical social worker, and spiritual counseling services. There was no documented evidence that the RN ensured the implementation of the interdisciplinary plan of care. During a joint review of the record and an interview on 10/5/2023, the Director of Nursing confirmed that the RN did not ensure the implementation of the interdisciplinary plan of care.

It is required that each patient’s individualized written plan of care: reflects patient and family goals and identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed revealed the hospice did not ensure the plan of care (POC) included planned interventions and goals based on problems identified in the initial and updated comprehensive assessments. Clinical Record 11: The patient’s date of election was 07/19/2023. The patient's hospice diagnosis was Parkinsonism. The initial comprehensive assessment dated 07/19/2023 documented that the patient had Parkinson's Disease, tremors, multiple CVAs, dementia, paraplegia, anxiety, cardiac disease, confusion, constipation, fatigue, forgetfulness, depression, insomnia, multiple falls, bowel and bladder incontinence, w/c dependent, a fair to poor appetite, and a full code. The Plan of Care (POC) dated 07/19/2023-09/16/2023, 09/17/2023-11/15/2023, and 11/16/2023-01/14/2024 did not contain nursing or psychosocial interventions or goals for the identified problems. During a joint review of the record and an interview on 10/5/2023, the Director of Nursing confirmed that there was no documented evidence the plans of care were individualized to include planned interventions and goals based on the problems identified in the initial and updated comprehensive assessments.

It is required that each patient’s individualized written plan of care reflects 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. In 1 of 14 (7%) clinical records reviewed revealed that the agency did not ensure that the patient's individualized written plan of care reflected a detailed statement of the scope and frequency of services necessary to meet specific patient and family needs. Clinical Record 11: The patient’s date of election was 07/19/2023. The Plan of Care (POC) dated 09/17/2023-11/15/2023 and 11/16/2023-01/14/2023 lacked discipline frequency orders for skilled nursing, hospice aide, medical social worker, and spiritual counseling services. During a joint review of the record and an interview on 10/5/2023, the Director of Nursing confirmed that the patient's individualized written plan of care did not reflect a detailed statement of the scope and frequency of services necessary to meet specific patient and family needs.

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as hand hygiene. This standard was not met as evidenced by document review, interview, and observation. In 1 of 3 (33%) home visit observations revealed the agency did not ensure the staff followed the hand hygiene policy. Agency Policy: Hand Hygiene IC.15 dated 12/15/2022, stated in part, "Hand Hygiene with Soap and Water. Staff will identify and gather appropriate supplies. Staff will wet hands and wrists with water using temperature that is comfortable. Staff will apply the amount of product recommended by the manufacturer to hands and rub hands together vigorously for at least 15 seconds (with the recommendation of 20 seconds, but either time is acceptable), covering all surfaces of the hands and fingers. Staff will rinse hands and wrists thoroughly with water. With hands held upright, staff will dry hands and wrists thoroughly with a clean paper towel. They will use a paper towel to turn of the faucet." Home Visit 1: During the home visit (Clinical Record 2) on 05/01/2024 with the Certified Nurse Aide (CNA) Personnel Record 8), the CNA was observed washing hands with soap and water then proceeded to turn off faucet with wet hands. After turning off the faucet she dried her hands with the paper towel, then turned the faucet on and off with the same paper towel. During an interview on 05/01/2024, the Director of Nursing confirmed that the staff did not follow the hand hygiene policy.

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 clinical record review and interview. In 6 of 14 (43%) clinical records reviewed revealed that the agency did not ensure that the hospice medical director or physician designee reviewed the clinical information for each patient being evaluated for admission and provided a written certification that anticipated the patient's life expectancy would be six months or less if the illness ran its normal course. Clinical Record 1: The patient's date of election was 05/01/2023. The Certification of Terminal Illness lacked evidence of a physician certification statement. Clinical Record 2: The patient's date of election was 12/09/2023. The Plan of Care and Certification of Terminal Illness document dated 12/09/2023-03/07/2024 lacked evidence of a physician certification statement. Clinical Record 9: The patient's date of election was 03/22/2023. The Plan of Care and Certification of Terminal Illness document dated 03/22/2023-04/06/2023 lacked evidence of a physician certification statement. Clinical Record 11: The patient's date of election was 07/19/2023. The Plan of Care and Certification of Terminal Illness document dated 07/19/2023-09/16/2023 lacked evidence of a physician certification statement. Clinical Record 13: The patient's date of election was 04/06/2023. The Certification of Terminal Illness dated 04/06/2023-06/16/2023 lacked evidence of a physician certification statement. Clinical Record 14: The patient's date of election was 04/21/2023. The Certification of Terminal Illness dated 04/21/2023-05/19/2023 lacked evidence of a physician certification statement. During a joint record review and interview on 05/02/2024, the Director of Nursing (DON) confirmed that the hospice medical director or physician designee reviewed the clinical information for each patient being evaluated for admission and did not provide a written certification statement that anticipated the patient's life expectancy would be six months or less if the illness ran its normal course. During a joint record review and interview on 05/02/2024, the Alternate Administrator/Executive Director/Volunteer Coordinator stated that the Hospice Medical Director responsible for completing the physician certification statement no longer worked with the agency. A new Hospice Medical Director started in March 2024 and completed the physician certification statements during the Interdisciplinary Team meeting.

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. In 1 of 11 (9%) clinical records reviewed revealed the hospice did not ensure the hospice medical director or physician-designee provided written and signed recertification of the terminal illness to meet the hospice care benefit requirement. Clinical Record 11: The patient’s date of election was 07/19/2023. There was no documented evidence the recertification was completed for the benefit period starting 11/16/2023. During a joint record review and interview on 05/02/2024, the Director of Nursing (DON) confirmed that the hospice medical director or physician-designee did not provide written and signed recertification of the terminal illness to meet the hospice care benefit requirement. During a joint record review and interview on 05/02/2024, the Alternate Administrator/Executive Director/Volunteer Coordinator stated that the Hospice Medical Director responsible for completing the physician certification statement no longer worked with the agency. A new Hospice Medical Director started in March 2024 and completed the physician certification statements during the Interdisciplinary Team meeting.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum physician orders. This standard was not met as evidenced by clinical record review and interview. In 3 of 14 (21%) clinical records reviewed revealed the organization did not ensure the patient’s record includes physician orders. Clinical Record 11: The patient’s date of election was 07/19/2023. The Plan of Care (POC) dated 09/17/2023-11/15/2023 and 11/16/2023-01/14/2023 lacked discipline frequency orders for skilled nursing, hospice aide, medical social worker, and spiritual counseling services. During a joint review of the record and an interview on 05/01/2024, the Director of Nursing confirmed that there is no documented evidence of plan of care physician orders for the frequencies identified. Clinical Record 4: The patient’s date of election was 12/08/2021. The Plan of Care (POC) dated 11/28/2023-01/26/2024 lacked discipline frequency orders for skilled nursing, hospice aide, medical social worker, and spiritual counseling coordinator. Clinical Record 5: The patient’s date of election was 09/28/2023. The Plan of Care (POC) dated 12/02/2023-01/30/2024 lacked visit discipline frequency orders for skilled nursing, hospice aide, medical social worker, and spiritual counseling coordinator. During a joint review of the record and an interview on 05/02/2024, the Director of Nursing confirmed that there is no documented evidence of plan of care physician orders for the frequencies identified.

It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid certified facility, the hospice forwards to the receiving facility a copy of the hospice discharge summary described in HCDT 40.I and the patient’s record, if requested. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records for discharged patients reviewed revealed that the agency did not ensure the discharge summary was sent to the receiving Medicare/Medicaid certified facility. Clinical Record 12: The patient's care was transferred to another Hospice provider on 10/26/2023. The record lacked evidence that the discharge summary was forwarded to the receiving hospice. During a joint record review and interview on 05/01/2024, the Director of Nursing confirmed that the record lacked evidence that the discharge summary was sent to the receiving Medicare/Medicaid-certified facility.

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary and the patient's record, if requested. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records for discharged patients reviewed revealed that the agency did not ensure the discharge summary was forwarded to the patient’s attending physician. Clinical Record 11: The discharge summary dated 01/14/2023 lacks documentation that the discharge summary was forwarded to the patient's attending physician. During a joint record review and interview on 05/01/2024, the Director of Nursing confirmed that the record lacked evidence that the discharge summary was forwarded to the patient’s attending physician.

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, the patient’s current plan of care, the patient’s latest physician orders, and any other documentation that will assist in the post-discharge continuity of care or that is requested by the receiving facility or the attending physician. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records for discharged patients reviewed revealed that the agency did not ensure the discharge summary was forwarded to the 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; the patient’s current plan of care; the patient’s latest physician orders; and any other documentation that will assist in the post-discharge continuity of care or that is requested by the receiving facility or the attending physician. Clinical Record 12: The date of the transfer was 10/23/2023. The record lacked evidence of a completed discharge summary that included a summary of the patient’s hospice stay, including treatments, symptoms, and pain management. The record also lacked evidence that the patient’s current plan of care, the patient’s latest physician orders, and any other documentation that will assist in the post-discharge continuity of care or that is requested by the receiving facility or the attending physician were included in the discharge summary. During a joint record review and interview on 05/01/2024, the Director of Nursing confirmed that the record lacked evidence of a completed discharge summary that included a summary of the patient’s hospice stay, including treatments, symptoms, and pain management; the patient’s current plan of care; the patient’s latest physician orders; and any other documentation that will assist in the post-discharge continuity of care or that is requested by the receiving facility or the attending physician.

It is required that the hospice obtains a criminal background check on all hospice employees who have direct patient contact or access to patient records. Hospice contracts require that all contracted employees who have direct patient contact or access to patient records obtain criminal background checks. Criminal background checks are obtained in accordance with state requirements. In the absence of state requirements, criminal background checks are obtained within three (3) months of the date of employment for all states in which the individual has lived or worked during the past three (3) years. This standard was not met as evidenced by interview and personnel record review. In 1 of 10 (10%) personnel records reviewed revealed that the agency did not ensure that the criminal background checks were obtained within three months of the date of employment. Personnel Record 5: The employee's date of hire was 11/02/2022. The criminal background check was dated 05/02/2024. The record lacked a criminal background check within three months of the date of employment. During a joint personnel record review and interview on 05/02/2024, the Alternate Administrator/Executive Director/Volunteer Coordinator confirmed that the record lacked a criminal background check within three (3) months of the date of employment.