Every finding on record at Ardent Hospice of the Valley

Based on observation, interview, and record review, the agency failed to ensure one of three sampled home visit patient's (Patient 13) medication supply was filled and provided. This failure had the potential for Patient 13 not getting the treatment required per physician's order and potential for adverse health outcomes. --- Findings: During a concurrent observation and interview on 5/14/24, at 10:54 a.m., with Registered Nurse (RN), in Patient 13's home, RN was asking Caregiver (CG) 13 for Patient 13's medication box. RN was reconciling the current medication order with the available medications. RN stated the Robitussin (medication for cough) was an active order but was not available on hand. RN stated the cough medication should be available for use but was not. RN stated the agency failed to follow the physician's order. During a review of Patient 13's "Current Ordered Medications (COM)," dated 5/13/24, the COM indicated, "Robitussin [cough medicine] Cough-Chest Congestion DM 5 MG [milligram]-100 MG/5 ML [milliliter] Oral Liquid, 10 ML every 6 hours/PRN [as needed]." During an interview on 5/14/24, at 11:26 a.m., with CG 13, CG 13 stated the cough medicine (Robitussin) was not available and they never had it. During a review of Patient 13's "Hospice Recertification Plan of Care Update (HRPOCU)," dated 4/29/24, the HRPOCU indicated, "Goals: Patient will receive medications as prescribed." During an interview on 5/15/24, at 10:11 a.m., with Administrator/Director of Patient Clinical Services (ADPCS), ADPCS reviewed Patient 13's drug profile and stated the medication was discontinued (5/14/24 - during the home visit). Requested a policy and procedure for refilling medications and none was provided.

Based on interview and record review, the facility failed to ensure one of 14 sampled patients (Patient 1) had an Interdisciplinary Group (IDG-a group comprised of the Physician, Registered Nurse, Social Worker, Chaplain, and patient or caregiver) meeting at least every 15 days to discuss the Plan of Care (POC). This failure had the potential for Patient 1s POC to not be updated, resulting in unmet needs for Patient 1. --- Findings: During a concurrent interview and record review on 5/16/24 at 2:27 p.m. with Administrator/Director of Patient Care Services (ADPCS), Patient 1s Medical Record (MR), dated 2/16/24 was reviewed. The MR indicated, Patient 1 was admitted on 2/16/24, and Patient 1 should have had her first IDG meeting by 2/28/24 and did not.

Based on observation, interview, and record review, the agency failed to ensure one of three sampled home visit patient's (Patient 13) Caregiver (CG) 13 was educated on medication administration and pain management. This failure had the potential for Patient 13's suffering from unrelieved pain due to not receiving the correct medication dose. --- Findings: During a concurrent observation and interview on 5/14/24, at 10:32 a.m., in Patient 13's room, Registered Nurse (RN) was asking Patient 13 what his pain level was. Patient 13 reported having pain at a level 5 out of 10 (Pain scales are used to rate the intensity of a patient's pain. Pain scales ranges from 0 [no pain] to 10 [sever pain] with a level 5 considered moderate pain). Patient 13 stated, "Its [pain] all over. I have pain on my back and on my legs. It's all over my body." During a review of Patient 13's "Current Ordered Medications (COM)," dated 3/11/24, the COM indicated, "Hydrocodone [strong pain medication] 10 MG [milligram] Acetaminophen 325 MG tablet, 1 tablet every 4 hours." During an interview on 5/14/24, at 11:26 a.m., with CG 13, CG 13 stated she was giving Patient 13 his pain medicine (Hydrocodone) four times a day, after each meal and before going to bed. CG 13 stated, "First dose [given] after breakfast at 8 a.m., second dose after lunch at 1 p.m. [five hours later], third dose after dinner at 6 p.m. [fiver hours later], and fourth dose before going to sleep at 9 p.m." CG 13 stated Patient 13 was always in pain and they give it (pain medication) to him four times a day. During an interview on 5/14/24, with RN, RN stated, "The pain medication was not given [to Patient 13] according to the physician's order. Patient [13] was only receiving four tablets daily since 4/19/24, it should be six tablets daily and every four hours routinely." RN stated the agency failed to meet Patient 13's goal of managing his pain. RN stated the medications should be reconciled every visit and it was not done. During an interview on 5/14/24 at 1:34 p.m., with Administrator/Director of Patient Care Services (ADPCS), ADPCS stated, "Hospice is comfort based and we [hospice agency] failed to meet the hospice goal for this patient [13]." During a review of Patient 13's "Hospice Recertification Plan of Care Update (HRPOCU)," dated 4/29/24, the HRPOCU indicated, "Goals: Patient/Caregiver will understand the pain scale, how to manage pain and report changes to hospice. Orders: Skilled Nurse to review medication profile and reconcile medications as needed. Skilled Nurse may instruct and reinforce medication teaching related to use of medications to treat disease processes." During a review of agency's policy and procedure (P&P) titled, "Pain Management Education" dated 5/2022, the P&P indicated, "Patients and family/caregiver will receive information regarding pain and the management of pain as an integral part of hospice care. 2. The patient and family/caregiver will receive verbal or written instructions, as appropriate, regarding: D. The importance of effective pain management."

Based on interview and record review, the agency failed to provide social work services for two of 14 sampled patients (Patient 13 and Patient 14). This failure had the potential for not meeting Patient 13 and Patient 14's psychosocial needs during their end of life. --- During a review of Patient 13's "Hospice Recertification Plan of Care Update (HRPOCU)", dated 4/24/24, the HRPOCU indicated, "Orders: Patient [13] will have an increased sense of security, peacefulness, ability to express love/forgiveness. Plans for funeral/memorial will be completed." During a concurrent interview and record review on 5/15/24, at 10:11 a.m. with Administrator/Director of Patient Care Services (ADPCS), Patient 13's Social Worker Notes were reviewed. ADPCS stated, "I can't find any Social Worker (SW) Notes for this patient [13]." There was no documentation of MSW visit notes and there were no documented plans for funeral/memorial according to the plan of care. During an interview on 5/16/24, at 9:15 a.m. with Medical Social Worker (MSW), MSW stated he did not complete his coordination notes within five days. MSW stated, "That's [provision of social work services] my delinquent." MSW stated he is the only MSW of the agency and all patients should receive social work services and Patient 13 did not receive social work services. During a review of the agency's job description titled, "Medical Social Worker (MSW)," undated, the job description indicated, "Job Summary: The medical social worker is responsible for the implementation of standards of care for medical social work services. Duties and Responsibilities: 1. Assumes responsibility for the ongoing interdisciplinary assessment and development of the individualized plan of care in partnership with the patients, representative (if any), and caregiver(s). 5. Providing services that are ordered by the physician as indicated in the plan of care. 8. Prepares clinical notes on all patients referred to social work." Findings: During a concurrent interview and record review on 5/16/24 at 9:50 a.m. with Clinical Resource (CR), Patient 14's medical record was reviewed. There was no MSW's psychosocial assessment noted. CR stated, "I don't see a Social Worker note on the Initial Assessment. I don't see a note from the Social Worker for any decline or anything [from the patient or family]. It should have been documented. I'm not seeing it."

Based on interview and record review, the agency failed to ensure one of 14 sampled patients (Patient 14's) home visit was completed according to the plan of care. This failure had the potential for the patient not reaching her established goal. --- Findings: During a review of Patient 14's "Hospice Certification And Plan Of Care (HCPOC)," dated 3/11/24 to 6/8/24, the "HCPOC" indicated, "HHA [Home Health Aide] effective 3/17/24 2WK12 [two times a week for 12 weeks]." During a concurrent interview and record review on 5/16/24 at 9:50 a.m. with Clinical Resource (CR), Patient 14's HHA home visits for Patient 14 were reviewed. The HHA conducted a home visit for Patient 14 one time during the week starting 3/31/24. CR stated, "I did not see documentation for the missed visit." CR stated the HHA for Patient 14 should have conducted two home visits as indicated in the "HCPOC."

Based on interview and record review, the agency failed to ensure a Registered Nurse (RN) conducted an onsite supervisory home visit no less frequently than every 14 days for one of three sampled home visit patients (Patient 14's) who was receiving Home Health Aide (HHA) services. This failure had the potential for unmet HHA care needs for Patient 14. --- Findings: During a review of Patient 7's "Hospice Recertification Plan of Care Update (HRPOC)," dated 3/28/24, the "HRPOC" indicated, "HHA effective 4/14/24 3WK8 [three times a week for eight weeks], 1WK1 [one time a week for one week]." During a concurrent interview and record review on 5/16/24 at 12:05 p.m. with Clinical Resource (CR), RN 1's onsite supervisory visits were reviewed. HHA did the home visits for Patient 7 three times a week on 4/15/24, 4/17/24, and 4/19/24, and the week after on 4/22/24, 4/24/24, and 4/26/24. CR stated there was no documented evidence RN 1 conducted any onsite supervisory visit in the two week period starting 4/14/24. CR stated the RN should have conducted onsite supervisory HHA visit for Patient 7 every two weeks. The policy and procedure for RN supervisory visits was requested and none was provided.

Based on interview and record review, the agency failed to ensure volunteer staff were available to be utilized for 14 of 14 sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14) in patients' care with terminal illness (a disease that cannot be cured or adequately treated and is expected to result in the death of the patient within a short period of time) as per the agency's policy and procedure. This had the potential for patients' needs with terminal illness and their families not to receive the optimal support and services they need from the volunteer services. --- Findings: During an interview on 5/14/24 at 3:30 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated the hospice agency had no volunteer services since the agency opened approximately two years ago in 2022. LVN 1 stated the agency had no hired volunteers. LVN 1 stated no volunteers were available and the agency was unable to provide volunteer services for Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, Patient 14 to help with the patients' care needs and their families' care needs (companionship, household chores, and shopping). During an interview on 5/15/24 at 10:42 a.m. with Patient 14, Patient 14 stated she lived alone. Patient 14 stated she had to pay somebody to do her grocery shopping and her laundry. Patient 14 stated she wanted to have somebody to talk to and she liked the staff coming to her house to assist her and talk to her. During a review of the facility's policy and procedure (P&P) titled, "Volunteer Services," dated 5/22, the P&P indicated, "Policy [Name of the Hospice Agency) will provide volunteer services under the direction of a Volunteer Coordinator and with assistance of trained hospice volunteers. . . Volunteers may work in a variety of capacities, including: 1. Patient care volunteers provide a personal care or emotional support and practical assistance, which enhance the comfort and quality of life for patients and families/caregivers. These services include being available for companionship, listening, simply "being there," and preparing meals. Patient care volunteers may also provide relief for caregivers or assist them with household chores. . . 3. Errands and transportation volunteers offer a type of practical support often needed by hospice patients and families/caregivers. These duties may include picking up needed prescriptions or supplies, or grocery shopping."

Based on interview and record review, the agency failed to ensure the agency demonstrated an ongoing effort to recruit volunteers. This failure had the potential for patients' needs with terminal illness and their families not to receive the needed support from the volunteer services. --- Findings: During a concurrent interview and record review on 5/15/24 at 3:45 p.m. with Clinical Resource (CR), CR stated the agency had no volunteer staff available who can provide companionship [and other volunteer services like household chores and shopping] to the terminally ill patients.. CR stated the Volunteer Coordinator was the Administrator/Director of Patient Care Services (ADPCS). The agency was unable to provide documentation an ongoing volunteer recruitment process was in place to hire volunteers who can provide services to the terminally ill patients. During an interview on 5/14/24 at 11:30 a.m. with Human Resource Manager (HRM), HRM stated the agency did not have any hired volunteer staff. HRM stated there were no volunteer personnel files to review. During a review of the agency's policy and procedure (P&P) titled, "Volunteer Coordinator," dated 3/14/24, the P&P indicated, "To maintain and coordinate the volunteer program for Hospice. Responsible for the orientation, training, and coordination of all Hospice volunteers, for volunteer program administration and development in all service areas. . . B. Duties & Responsibilities. . . 4. Recruit, interview and select volunteers. 5. Design and supervise the orientation and training of volunteers."

Based on observation, interview, and record review, the agency failed to ensure patient medical records (MR) were stored in a secure area. This failure had the potential for unauthorized personnel to access the MR. --- Findings: During a concurrent observation and interview on 5/13/24 at 11:02 a.m. with Administrator/Director of Patient Care Services (ADPCS) and Licensed Vocational Nurse (LVN) 1 in the supply room, one unlocked vertical file cabinet was observed. The file cabinet contained two drawers of paper MR. LVN 1 stated the current MR are all digital, and these were old MR. LVN 1 stated she did not have a key to the file cabinet. ADPCS stated she did not have the key. During a review of the agencys policy and procedure (P&P) titled, ";RECORD RETENTION," dated 2003, the P&P indicated, ";Paper records will be stored by type of record first and record date second in a secure area with access by authorized personnel only."

Based on observation, interview, and record review, the agency failed to ensure one of three sampled home visit patient's (Patient 14's) expired medication (Senna tablet - used to relieve constipation) was not available for use at the patient's home. This failure had the potential for the medication to be ineffective. --- Findings: During a review of Patient 14's "Hospice Certification And Plan Of Care (HCPOC)," dated 3/11/24 to 6/8/24, the "HCPOC" indicated, "Medications. . . Senna Plus 8.6 mg [milligram]-50 mg tablet 1 tablet daily. Reason: Bowel Management." During a concurrent observation and interview on 5/15/24 at 10:50 a.m. with Patient 14 and Home Health Aide (HHA) in Patient 14's home in the living room, Patient 14's medications stored inside a plastic bag container were reviewed. There was a bottle of Senna tablets 8.6 mg with an expiration date (the time period during which the medication is known to remain stable, retain its strength, quality, and purity) of 2/2024. Patient 1 stated, "I used Senna tablet as a back-up to Lactulose (used to treat constipation)." HHA verified the expiration date for Senna was dated 2/2024. During an interview on 5/15/24 at 2:35 p.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated and acknowledged the Senna 8.6 mg medication with an expiration date of 2/2024 "has been awhile" and should not be available for use by Patient 14. During a review of the facility's policy and procedure (P&P) titled, "STORAGE OF MEDICATIONS AND NUTRITIONAL PRODUCTS," dated 5/22, the P&P indicated, "PURPOSE To ensure that medications and nutritional therapy solutions are properly handled and stored."

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 measurable outcomes anticipated from implementing and coordinating the plan of care. CONTINUING PRIOR REQUIRED ACTION This standard was not met as evidenced by a review of clinical records and interview. 3 of 5 (60%) clinical records reviewed revealed the hospice did not ensure plans of care included outcomes that were defined and measurable. Record #36569: Start of Care (SOC) 9/19/2019, POC reviewed by IDT on 3/29/2022, Diagnosis Congestive Heart Failure: Goals: Pain will be relieved or reduced. Disorientation will be minimized. The Administrator was interviewed on 4/11/2022. She agreed with the finding that the patient's acceptable pain level was not identified or documented and the signs/symptoms of disorientation exhibited by the patient were not documented. Record #35879: Start of Care (SOC) 1/7/2021, POC reviewed by IDT on 3/29/2022, Diagnosis Senile Degeneration of the Brain: Problem: Stress Management Goals: Pt/caregiver will be supported in dealing with stressors. The Administrator was interviewed on 4/11/2022. She agreed with the finding that the patient’s definition of stressors was not documented. Record #47895: Start of Care (SOC) 3/21/2022, POC reviewed by IDT on 3/29/2022, Diagnosis Malignant Neoplasm of other specified ill-defined sites. Problem: Wounds/impaired tissue integrity: Pt will remain comfortable. Problem: Long Term Care Facility, hospice patient in: Pt will remain as comfortable as possible. The Administrator was interviewed on 4/11/2022. She agreed with the finding that the patient's acceptable pain level was not identified or documented.

It is required that the written Patient Bill of Rights includes the right to receive information about the services covered under the hospice benefit. This standard was not met as evidenced by review of clinical records and interview. In 8 of 8 (100%) clinical records with start of care dates after 10/1/2020, there was no documentation to support that patients were notified of their right to receive information regarding the medications and services that were covered under the hospice benefit and those that were not, as required by the CMS Hospice Election Statement Addendum, effective October 1, 2020 "Patient Notification of Non-covered Items, Services, and Drugs." Record #31915, Start of Care (SOC) 5/4/21, 1st Benefit Period, Diagnosis Heart Disease, Continuous Care/Date of Revocation 5/28/21: Record #29180, Start of Care (SOC) 5/4/21, 5th Benefit Period effective 12/30/21, Diagnosis Heart Disease: Record #66770, Start of Care (SOC) 2/9/22, 1st Benefit Period, Diagnosis Alzheimer’s Disease: Record #13759, Start of Care (SOC) 5/14/21, 4th Benefit Period effective 1/9/22, Diagnosis Cerebrovascular Disease: Record #20868, Start of Care (SOC) 12/29/21, 1st Benefit Period, Diagnosis Hypoxemia: Record #54748, Start of Care (SOC) 1/7/21, 6th Benefit Period effective 1/2/22, Diagnosis Senile Degeneration of the Brain: Record #47596, Start of Care (SOC) 10/22/21, 1st Benefit Period, Diagnosis Senile Degeneration of the Brain, Date of Revocation 10/31/21 Record#58950, Start of Care 11/4/2020, 7th Benefit Period effective 12/29/21, Diagnosis Senile Degeneration of the Brain, Date of Death 1/27/22. The Administrator/DPCS/owner stated that she was not aware that the "Patient Notification of Non-covered Items, Services, and Drugs" was to be provided with required verbiage as an addendum to the written Patient Bill of Rights, and confirmed that following patients did not receive information contained in the CMS Hospice Election Statement Addendum as required:

It is required that the hospice designates an Interdisciplinary Group or groups who, in consultation with the patient's attending physician, prepare a written plan of care (POC) for each patient. The plan of care specifies the hospice care and services necessary to meet the specific needs of the patient and family identified in the comprehensive assessment, relative to the terminal illness and associated conditions. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This CONDITION was not met as evidenced by clinical record review and interview, the hospice failed as follows: to include on the plan of care (POC) specific hospice care and services necessary to meet the patient and family-specific needs identified in the comprehensive assessment [418.56/L538]; to include on the POC patient and family goals and interventions based on problems identified in the comprehensive assessment [418.56(c)/L545]; to document a statement of the scope and frequency of social work services necessary to meet the specific patient and family needs [418.56(c)(2)/L547] and the hospice did not include on the POC measurable outcomes anticipated from implementing and coordinating the plan of care [418.56(c)(3)/L548]. The cumulative effect of these deficiencies could negatively impact the organization's ability to provide safe and effective quality patient care services.

It is required that the hospice designates an Interdisciplinary Group or groups who, in consultation with the patient's attending physician, prepare a written plan of care (POC) for each patient. The plan of care specifies the hospice care and services necessary to meet the specific needs of the patient and family identified in the comprehensive assessment, relative to the terminal illness and associated conditions. This standard was not met as evidenced by a review of clinical records and interview. In 1 of 11 (10%) clinical records reviewed there were needs of the patient and family identified in skilled nursing and social work visit notes, communication notes, and an IDG meeting narrative that were not documented as a problem with interventions and goals in the plan of care or plan of care updates. Record #47596, Start of Care (SOC) 10/22/21, 1st Benefit Period, Diagnosis Senile Degeneration of the Brain, Date of Revocation 10/31/21. Skilled nursing visit notes, the initial social work assessment (10/24/21) and the initial spiritual care assessment (10/24/21) included information that the patient was expressing fear of being “held hostage” by her husband/DPOA with a stated desire to “escape” from the home and her husband. The IDG documented in meeting notes dated 10/26/21 that the patient’s concerns were not valid and that the patient was experiencing extreme emotional distress and anxiety because of her terminal diagnosis and contributing co-morbidities. On 10/31/21 the patient eloped from her home, her husband contacted police, and the patient was picked up and taken to a medical psychiatric hospital where she was placed on a 72-hour safety hold. The patient’s husband/DPOA revoked the hospice benefit. The plan of care/plan of care updates documented in the clinical record did not include the problem(s) related to the patient’s elopement risk nor were there any interventions or goals documented to mediate or prevent the patient’s elopement. This finding was confirmed by the Administrator/DPCS/owner during joint clinical record review.

It is required that each patient’s individualized written plan of care identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by a review of clinical records and interview. In 3 of 11 (27%) clinical records reviewed the hospice did not ensure that services needed were provided to patients, to address problems identified in the initial and/or updated comprehensive assessments. Record #54748, Start of Care (SOC) 1/7/21, 6th Benefit Period effective 1/2/22, Diagnosis Senile Degeneration of the Brain: During joint clinical record review, the Administrator/DPCS/owner confirmed that a resolved Problem/Goal of Funeral Planning remains on the latest POC update by the IDG dated 2/15/22. Record #47596, Start of Care (SOC) 10/22/21, 1st Benefit Period, Diagnosis Senile Degeneration of the Brain, Date of Revocation 10/31/21: During joint clinical record review, the Administrator/DPCS/owner confirmed that the documented problem of "incontinence" and the goal that "patient will remain free from Injury" did not include any interventions intended to achieve these goals. Record #23218, Start of Care (SOC) 4/9/2020, 10th Benefit Period effective 10/1/21, Diagnosis Parkinson’s, Date of Death 10/2/21: During joint clinical record review, the Administrator/DPCS/owner confirmed that there was no documented goal for an unspecified problem that was identified only as "knowledge deficit." The Administrator/DPCS/owner confirmed that none of the goals or interventions identified on the initial plan of care dated 1/1/21 had been resolved, and agreed there were no revisions by the IDG through the last meeting date of 2/15/22.

It is required that each patient’s individualized written plan of care include 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. 1 of 11 (9% ) clinical records reviewed revealed the hospice did not ensure that the plan of care included the scope and frequency for medical social services to meet the specific patient and family needs. Record#58950, Start of Care 11/4/2020, 7th Benefit Period effective 12/29/21, Diagnosis Senile Degeneration of the Brain, Date of Death 1/27/22. There was documentation in the clinical record of a COVID positive test during the week prior to the patient's death. The record contained a social worker telephone visit performed with the patient’s daughter/DPOA on 1/26/22. There were no physician's orders for the planned interventions of patient and family bereavement support/care needs related to the death of the patient's son.

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 measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by a review of clinical records and interview which revealed 5 of 11 (45%) clinical records did not include outcomes that were defined and measurable. Record #31915, Start of Care (SOC) 5/4/21, 1st Benefit Period, Diagnosis Heart Disease, Continuous Care/Date of Revocation 5/28/21: Problem identified: Cognitive/Neurological. Goal: Function at maximum cognitive level. The Administrator/DPCS/owner stated the patient’s maximum cognitive level was not documented. Record #66770, Start of Care (SOC) 2/9/22, 1st Benefit Period, Diagnosis Alzheimer’s Disease: Goals: Patient will have minimal episodes of agitation; Patient experiences spiritual comfort. The Administrator/DPCS/owner stated signs of agitation exhibited or feelings of agitation as expressed by the patient were not documented, nor was the patient’s stated definition of spiritual comfort. Record #86405, Start of Care (SOC) 10/29/2019, 12th Benefit Period effective 9/18/21, Diagnosis COPD, Date of Revocation 11/16/21: Goal: Patient experiences spiritual comfort. The Administrator/DPCS/owner stated the patient’s definition of spiritual comfort was not documented. Record #54748, Start of Care (SOC) 1/7/21, 6th Benefit Period effective 1/2/22, Diagnosis Senile Degeneration of the Brain: Problem: Stress Management Goals: Pt/caregiver will be supported in dealing with stressors. The Administrator/DPCS/owner stated the patient’s definition of stressors was not documented. Record #73409, Start of Care (SOC) 9/19/2019, 14th Benefit Period effective 1/6/22, Diagnosis Congestive Heart Failure: Goals: Pain will be relieved or reduced. Disorientation will be minimized. The Administrator/DPCS/owner agreed the patient/caregiver’s acceptable pain level was not identified or documented and the signs/symptoms of disorientation exhibited by the patient were not documented.

It is required that the hospice maintains a coordinated, agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases. This standard was not met as evidenced by review of clinical records and interview. In 2 of 2 (100%) of clinical records reviewed in which patients were documented as testing positive for COVID-19 infection, the agency did not identify patients with confirmed COVID-19 infection and include the presence of these COVID-19 infected patients as an integral part of the hospice's quality assessment and performance improvement (QAPI) program. When interviewed on 2/22/2022, the Administrator/DPCS/owner stated that there were no COVID exposures and no COVID positive patients had been served by the agency since the inception of the COVID-19 pandemic. During home visit observations on 2/23/2022, interview with agency staff and during joint clinical record review with the Administrator/DPCS/owner, 2 patients were confirmed in clinical record documentation to have tested positive for COVID-19 infection. The Administrator/DPCS/owner confirmed that these infections were not documented in the agency’s infection tracking logs or included in the agency’s QAPI program. Record#58950, Start of Care 11/4/2020, 7th Benefit Period effective 12/29/21, Diagnosis Senile Degeneration of the Brain, Date of Death 1/27/22: There was documentation in the clinical record of a COVID positive test during the week prior to dying. [The patient’s family members living in the same residence tested positive. The patient’s son died the day before the patient from documented COVID complications.] Record #73409, Start of Care (SOC) 9/19/2019, 14th Benefit Period effective 1/6/22, Diagnosis Congestive Heart Failure: There was documentation of the patient having COVID after moving from a private residence to an assisted living facility permanently; patient recovered after exhibiting mild cold symptoms. The Administrator/DPCS/owner stated that she was unaware that these two patients had tested positive for COVID-19 infection and confirmed that these infections were not logged on the agency's infection control log and were not included in the agency's QAPI reports.

Medical social services are provided based on a psychosocial assessment, according to the patient's and family's needs and acceptance of these services, per the plan of care, and under the direction of a physician. This standard was not met as evidenced by a review of clinical records and interview. In 1 of 11 (10%) clinical records reviewed reviewed the hospice failed to ensure that the plan of care included physician’s orders for medical social services to be provided to patient. Record#58950, Start of Care 11/4/2020, 7th Benefit Period effective 12/29/21, Diagnosis Senile Degeneration of the Brain, Date of Death 1/27/22. During joint clinical record review with the Administrator/DPCS/owner, the record contained a social worker telephone visit performed with the patient’s daughter/DPOA on 1/26/22. Interventions offered were for patient and family bereavement support/care needs related to the death of her son, with plans to contact the daughter weekly. There were no social work services provided for the prior 3 benefit periods. There were no physician's orders for these planned interventions. The Administrator/DPCS/owner confirmed that there was no documented plan of care with social work identified problems, interventions or goals, and no documented request for physician orders by the medical social worker.

It is required that short-term inpatient care is available for pain control, symptom management, and respite purposes. Inpatient care is provided in a participating Medicare or Medicaid/MediCal facility. This standard was not met as evidenced by a review of clinical records and interview. In 1 of 1 (100%) clinical record that included respite services, the inpatient care was not provided in a participating Medicare or Medicaid facility. Record #73409: Start of Care (SOC) 9/19/2019, 14th Benefit Period effective 1/6/22, Diagnosis Congestive Heart Failure: The Administrator/DPCS/owner confirmed that a patient in need of respite services was transported by the Hospice to an assisted living facility for 5 days as the patient’s wife/primary caregiver was exhausted and in need of a break from primary care. The Administrator/DPCS/owner stated that this was done as no contracted facilities "close enough for the patient's wife to visit every day would accept the patient". She stated that contracted Medicare/Medicaid facilities that were contacted refused to accept the patient for respite services citing COVID restrictions. The medical record contained a signed physician order stating that the patient would be placed into an assisted living facility to receive respite care per the patient’s wife/primary caregiver request. The Administrator/DPCS/owner stated the hospice paid for 5 days in the assisted living facility (including room, board, medications, equipment needed and supplies) and for all the pre-admission exams/tests/CXRs required by the assisted living facility. She stated that the assisted living staff was provided with the hospice plan of care and the hospice continued to provide skilled nurse, aide, social work and chaplain visits with the same frequencies as when the patient was in his private residence. In an interview, the Administrator/DPCS/owner stated that she did not believe the care provided in and by assisted living facility staff “counted” as respite care as the agency did not bill Medicare or Medicaid for respite level of care.