Every finding on record at Anodyne Hospice Care LLC

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 document review, clinical record review, and interview. In 6 of 14 (43%) clinical records reviewed, the agency did not ensure the initial comprehensive assessment was completed within 5 calendar days after the election of hospice care. Agency policy No. 1-014 Comprehensive Assessment, dated November 2023, stated in part "A comprehensive patient assessment will be performed by the interdisciplinary group no later than 5 calendar days after the election of hospice care in consultation with attending physician. During the comprehensive patient assessment, all baseline data and other relevant information will be documented in the patient's clinical record, including at least the following information as relevant: The patient's psychosocial status, including emotional barriers to treatment, cognitive limitations, memory and orientation, family relationships, social history, source of adequacy of environmental and other resources, coping mechanisms, and the patient's and family/caregiver's reaction to illness. An assessment of the patient's and family/caregiver's spiritual orientation, including, as appropriate, any involvement in a religious group such as a church or synagogue or a support group such as Alcoholics Anonymous and spiritual concerns or needs such as despair, suffering, guilt, etc." Clinical Record 4: The patient elected the hospice benefit on 11/22/2023, with a terminal diagnosis of unspecified dementia. Clinical record review revealed the Medical Social Worker (MSW) completed the initial psychosocial assessment on 12/17/2023, 25 days after the patient’s election of hospice care, and 20 days outstanding. The clinical record did not include documentation to explain why the psychosocial assessment was not completed within 5 calendar days of the patient’s election of benefit as part of the comprehensive assessment. Clinical Record 6: The patient elected the hospice benefit on 01/24/2024, with terminal diagnosis of Prostate Cancer. Clinical record review revealed the MSW completed the initial psychosocial assessment on 02/02/2024, 9 days after the patient’s election of hospice care, and 4 days outstanding. The clinical record did not include documentation to explain why the psychosocial assessment was not completed within 5 calendar days of the patient’s election of benefit as part of the comprehensive assessment. Clinical Record 7: The patient elected the hospice benefit on 11/30/2023, with a terminal diagnosis of senile degeneration of the brain. Clinical record review revealed the MSW completed the initial psychosocial assessment on 12/15/2023, 15 days after the patient’s election of hospice care, and 10 days outstanding. The clinical record did not include documentation to explain why the psychosocial assessment was not completed within 5 calendar days of the patient’s election of benefit as part of the comprehensive assessment. Clinical Record 9: The patient elected the hospice benefit on 04/27/2023 with a terminal diagnosis of hemiplegia. Clinical record review revealed the MSW completed the initial psychosocial assessment on 06/30/2023, 64 days after the patient’s election of hospice care, and 59 days outstanding. The clinical record did not include documentation to explain why the psychosocial assessment was not completed within 5 calendar days of the patient’s election of benefit as part of the comprehensive assessment. Clinical Record 10: The patient elected the hospice benefit on 05/31/2023 with a terminal diagnosis of Alzheimer’s disease. Clinical record review revealed the MSW completed the initial psychosocial assessment on 06/06/2023, 6 days after the patient’s election of hospice care, and 1 day outstanding. The clinical record did not include documentation to explain why the psychosocial assessment was not completed within 5 calendar days of the patient’s election of benefit as part of the comprehensive assessment. Clinical Record 13: The patient elected the hospice benefit on 05/05/2023 with a terminal diagnosis of progressive multifocal leukoencephalopathy. Clinical record review revealed the MSW completed the initial psychosocial assessment on 05/12/2023, 7 days after the patient’s election of hospice care, and 2 days outstanding. The clinical record did not include documentation to explain why the psychosocial assessment was not completed within 5 calendar days of the patient’s election of benefit as part of the comprehensive assessment. During a joint record review and interview on 02/21/2024, the Director of Patient Care Services confirmed the psychosocial assessments were not performed within 5 days after the election of hospice care as part of the comprehensive assessment.

It is required that the comprehensive assessment includes an initial bereavement assessment of the needs of the patient's family and other individuals, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and considered in the bereavement plan of care. This standard was not met as evidenced by document review, clinical record review, and interview. In 4 of 14 (29%) clinical records reviewed, the agency did not ensure that an initial bereavement assessment was completed as part of the comprehensive assessment. Agency policy No. 1-014 Comprehensive Assessment, dated November 2023, stated in part "During the comprehensive patient assessment, all baseline data and other relevant information will be documented in the clinical record, including at least the following information, as relevant: A bereavement assessment of the needs of the patient's family and other individuals." Agency policy No. 1-021 Bereavement Assessment, dated November 2023, stated in part, "On admission, the social worker or hospice registered nurse will complete a bereavement risk assessment that is given to the Bereavement Coordinator." Clinical Record 4: The patient elected the hospice benefit on 11/22/2023, with a terminal diagnosis of unspecified dementia. Clinical record review revealed the bereavement assessment was completed on 12/17/2023. There was no documented evidence that the initial bereavement assessment was completed as part of the start of care comprehensive assessment. Clinical Record 9: The patient elected the hospice benefit on 04/27/2023 with a terminal diagnosis of hemiplegia. Clinical record review revealed no documented evidence that the initial bereavement assessment was completed as part of the start of care comprehensive assessment. Clinical Record 10: The patient elected the hospice benefit on 05/31/2023 with a terminal diagnosis of Alzheimer’s disease. Clinical record review revealed the bereavement assessment was completed on 09/06/2023. There was no documented evidence that the initial bereavement assessment was completed as part of the start of care comprehensive assessment. Clinical Record 11: The patient elected the hospice benefit on 05/28/2023. Clinical record review revealed no documented evidence that the initial bereavement assessment was completed as part of the start of care comprehensive assessment. During joint record review and interview on 02/21/2024, the Director of Patient Care Services confirmed the start of care comprehensive assessments did not include an initial bereavement assessment.

It is required that the hospice provides nursing care under the supervision of a registered nurse. This standard was not met as evidenced by document review, clinical record review, and interview. In 3 of 11 (27%) clinical records reviewed with nursing services provided by a Licensed Vocational Nurse, the agency did not ensure nursing care was provided under the supervision of a Registered Nurse. Agency policy No. 1-031 Responsibilities/Supervision of Clinical Services, dated November 2023, stated in part, "A monthly patient visit will be completed by a Registered Nurse (RN) to supervise licensed practical/vocational nursing services. More frequent supervision may be required per state regulations." Clinical Record 1: The patient elected the hospice benefit on 07/23/2023. The plan of care dated 07/23/2023 included an order for skilled nursing visits two to three times per week. The Licensed Vocational Nurse (LVN) provided weekly visits beginning 07/25/2023 through the date of record review on 02/21/2024. The clinical record revealed one LVN supervisory visit was completed by the Registered Nurse (RN) on 08/12/2023. The clinical record contained no documented evidence that further LVN supervisory visits were completed at least every 30 days as required by agency policy. Clinical Record 5: The patient elected the hospice benefit on 01/03/2024. The plan of care dated 01/03/2024 included an order for skilled nursing visits two times per week. The LVN provided weekly visits beginning 01/03/2024 through the date of record review on 02/21/2024. The clinical record contained no documented evidence that LVN supervisory visits were completed at least every 30 days as required by agency policy. Clinical Record 9: The patient elected the hospice benefit on 04/27/2023. The plan of care dated 04/27/2023 included an order for skilled nursing visits two to three times per week. The LVN provided weekly visits beginning 05/02/2023 through the date of discharge on 07/25/2023. An LVN supervisory visit was documented by the RN on 5/27/2023 but no further supervisory visits were documented. The clinical record contained no documented evidence that LVN supervisory visits were completed at least every 30 days as required by agency policy. During a joint record review and interview on 02/21/2024, the Director of Patient Care Services confirmed findings that clinical records did not contain evidence that the nursing care provided by a Licensed Vocational Nurse was under the supervision of a Registered Nurse.

It is required that counseling services include spiritual counseling. The hospice provides an assessment of the patient’s and family’s spiritual needs. Spiritual counseling to meet spiritual needs is provided in accordance with the patient’s and family’s acceptance of the services and in a manner consistent with the patient and family beliefs and desires. This standard was not met as evidenced by document review, clinical record review, and interview. In 2 of 14 (14%) clinical records reviewed with spiritual counseling services accepted, the agency did not ensure that an assessment of the patient's and family's spiritual needs was performed. Agency policy No. 1-020 Spiritual Assessment, dated November 2023, stated in part "On admission, the hospice registered nurse will conduct an initial spiritual assessment. The chaplain will contact the patient/family by a home visit or by telephone based on the patient's and family's needs and acceptance of these services. If the patient and/or family/caregiver refuse these services, the refusal will be documented." Clinical Record 9: The patient elected the hospice benefit on 04/27/2023 with a terminal diagnosis of hemiplegia. The hospice plan of care dated 04/27/2023 included an order for Chaplain visits once a month. The initial comprehensive assessment dated 04/27/2023 included documentation that the patient/family accepted spiritual counseling services. Clinical record review revealed no documented evidence that the patient /family was contacted after the acceptance of spiritual counseling services and no documentation that a spiritual assessment was completed. Clinical Record 11: The patient elected the hospice benefit on 05/28/2023. The hospice plan of care dated 05/28/2023 included an order for Chaplain visits once a month. The initial comprehensive assessment dated 05/28/2023 included documentation that the patient/family accepted spiritual counseling services. Clinical record review revealed no documented evidence that the patient /family was contacted after the acceptance of spiritual counseling services and no documentation that a spiritual assessment was completed. During a joint record review and interview on 02/21/2024, the Director of Patient Care Services confirmed that the clinical records did not include a spiritual assessment or documentation that contact was made to the patient/family after acceptance of services.

It is required that hospice aides are supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. This standard was not met as evidenced by document review, clinical record review, and interview. In 2 of 13 (15%) clinical records reviewed with hospice aide services provided, the agency did not ensure that a Registered Nurse made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the Hospice Aide. Agency policy No. 1-031 Responsibilities/Supervision of Clinical Services, dated November 2023, stated in part, "Hospice aide supervisory visits will be conducted on site at least every two (2) weeks by a hospice registered nurse. Supervisory visits can be made in conjunction with the hospice aide or in his/her absence. A direct observation supervisory visit will be made at least annually." Clinical Record 5: The patient elected the hospice benefit on 01/03/2024. The plan of care dated 01/03/2024 included an order for hospice aide visits three times a week. Clinical record review revealed hospice aide visits were provided three times a week beginning 01/07/2024 through date of record review on 02/21/2024. The clinical record included documentation of a hospice aide supervisory visit dated 02/16/2024, 41 days after the initial hospice aide visit. The clinical record contained no documented evidence that hospice aide supervision visits were completed no less frequently than every 14 days as required by agency policy. Clinical Record 8: The patient elected the hospice benefit on 04/06/2023. The plan of care dated 04/06/2023 included an order for hospice aide visits two times a week. Clinical record review revealed hospice aide visits were provided two times a week beginning 04/14/2023 through 05/25/2024. The clinical record contained no documented evidence that hospice aide supervision visits were completed no less frequently than every 14 days as required by agency policy. During a joint record review and interview on 02/21/2024, the Director of Patient Care Services confirmed the clinical records did not include documentation that supervisory visits were performed by the Registered Nurse no less frequently than every 14 days as required by agency policy.

It is required that hospice nursing services, physician services, drugs, and biologicals are made routinely available on a 24-hour basis, seven (7) days per week, and all covered services are available on a 24-hour basis when reasonable and necessary to meet the needs of the patient and family. This standard was not met as evidenced by document review and interview. The agency did not ensure that hospice services were available to the patient and family 24-hours a day, seven (7) days a week. Agency policy No. 1-012 On-Call/Weekend Services, dated November 2023, stated in part, "There will be on-call staff available after office hours, Monday through Friday, and 24 hours a day on weekends." The patient handbook provided to patients at the start of care stated in part "Our office hours are Monday through Friday from 9:00 AM to 5:00 PM except during company holidays. Patient care needs are the highest priority; therefore, weekend and evening staffing will be scheduled accordingly. We provide 24 hours a day, 7 days a week on-call service." The site visitor called the agency’s after-hours phone number provided to patients and families in the patient handbook at 06:47 AM on 02/22/2024, and there was no answer. The site visitor left a message for a return call, a return call was not received by 8:30 AM. The Alternate Administrator confirmed the finding during an interview on 02/22/2024 and stated in part "I received the call; I didn't answer because I thought it was a spam call." A review of the patient handbook, interview with the alternate administrator, and home visit by site visitor revealed that the agency did not ensure hospice nursing services were available on a 24-hour basis, seven days a week to meet the needs of the patient and family.

It is required that each patient’s record includes, at a minimum: the initial plan of care, updated plans of care, initial assessment, comprehensive assessment, updated comprehensive assessments, and clinical notes including the care and services provided. This standard was not met as evidenced by document review, clinical record review, and interview. In 3 of 14 (21%) clinical records reviewed, the agency did not ensure staff followed agency policy and completed visit notes on the day the care or service was provided to the patient. Agency policy No. 6-022 Clinical/Service Data Collection, dated November 2023, stated in part "Entries into the clinical/service record will be made on the day care/service is provided to the patient. All documentation will be turned into the office at the end of the workday, and clinical notes, dictated or written, will be incorporated into the patient's health record at least every seven working days." Clinical Record 1: The hospice plan of care dated 07/23/2023 included an order for Chaplain visits one time per month. Clinical record review revealed the Chaplain completed a visit on 01/17/2024. The Chaplain entered the documentation of the 01/17/2024 visit into the clinical record on 02/21/2024, 35 days after the visit was completed. Clinical Record 2: The hospice plan of care dated 10/02/2023 included an order for Chaplain visits one time per month. Clinical record review revealed the Chaplain completed a visit on 01/17/2024. The Chaplain entered the documentation of the 01/17/2024 visit into the clinical record on 02/21/2024, 35 days after the visit was completed. Clinical Record 4: The hospice plan of care dated 11/22/2023 included an order for Chaplain visits one time per month. Clinical record review revealed the Chaplain completed a visit on 01/04/2024. The Chaplain entered the documentation of the 01/04/2024 visit into the clinical record on 02/21/2024, 48 days after the visit was completed. During a joint record review and interview on 02/21/2024, the Director of Patient Care Services confirmed the findings and stated, "Timely documentation is an issue for us, we have a performance improvement project that we started last quarter."

It is required that each patient’s record contains at a minimum physician orders. This standard was not met as evidenced by document review, clinical record review, and interview. In 3 of 14 (21%) clinical records reviewed, the agency did not ensure that the clinical record included physician orders for visits provided. Agency policy No. 6-022 Clinical/Service Data Collection, dated November 2023, stated in part "A clinical/service record will be initiated and maintained for each patient receiving care or services according to organization policies found in this manual and will include at a minimum: physician orders." Clinical Record 7: The hospice plan of care dated 11/30/2023 included an order for Hospice Aide visits two times a week beginning 11/30/2023. Clinical record review revealed Hospice Aide visits were provided three times a week for the weeks of 12/10/2023 to 12/16/2023, 12/17/2024 to 12/23/2023, and 01/07/2024 to 01/13/2024. The clinical record contained no documented evidence that physician orders were obtained for the additional Hospice Aide visits provided. Clinical Record 12: The plan of care dated 05/01/2023 included orders for Skilled Nursing two to three times a week, Medical Social Worker one time a month, and Hospice Aide three times a week. Clinical record review revealed the Chaplain provided a visit on 05/04/2023. The clinical record contained no documented evidence that a physician order was obtained for the Chaplain visit provided on 05/04/2023. Clinical Record 13: The plan of care dated 05/05/2023 included orders for Skilled Nursing two times a week, Medical Social Worker one time a month, and Hospice Aide two times a week. Clinical record review revealed the Chaplain provided a visit on 05/10/2023. The clinical record contained no documented evidence that a physician order was obtained for the Chaplain visit provided on 05/10/2023. During a joint record review and interview on 02/21/2024, the Director of Patient Care Services confirmed findings that the clinical records did not contain evidence that a physician order was obtained for the additional hospice aide visits and the chaplain visits provided.