Every finding on record at Atwell Hospice & Pj Home Health Services, Inc

It is required that medical social services are provided by a qualified social worker based on a psychosocial assessment, according to the patient’s and family’s needs and acceptance of these services, per the plan of care, under the direction of a physician. The psychosocial assessment is revised as new information is acquired and as progress toward goals is made. This standard was not met as evidenced by document review and interview. In 1 of 4 (25%) clinical records reviewed that accepted social work visits revealed that the agency did not ensure that medical social services were being provided per the plan of care. THIS IS A CONTINUED REQUIRED ACTION Clinical Record 4: The patient elected the hospice benefit on 08/05/2024. Clinical record review of certification period 09/28/2024-11/26/2024 revealed that the plan of care dated 10/15/2024 ordered social work visits 1 time a month. There was no documented evidence that the social worker completed a visit in the month of October. In an interview with the director of nursing she agreed that the social worker was ordered, and no visit was made. She stated she thought they could start in November. This is a continued required action

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. The hospice advises the patient and family of spiritual counseling services and documents the acceptance or refusal of services. The hospice also makes all reasonable efforts to facilitate visits by local clergy, pastoral counselors, or others who can support the patient’s spiritual needs. This standard was not met as evidenced by clinical record review and interview. In 1 of 4 (25%) clinical records reviewed that accepted chaplain visits revealed that the agency did not ensure that spiritual counseling was being provided per the plan of care. Clinical Record 2: The patient elected the hospice benefit on 08/23/2023. Clinical record review of certification period 10/16/2024-12/14/2024 revealed that the plan of care dated 10/15/2024 ordered chaplain visits 1 time a month. There was no documented evidence that the chaplain completed a visit in the month of October. In an interview with the director of nursing she agreed that the social worker was ordered, and no visit was made. She stated she thought they could start in November.

It is required the patient has a right to the following: be involved in developing his or her hospice plan of care. This standard was not met as evidenced by clinical record review and interview. In 2 of 14 (28%) clinical records reviewed revealed the agency did not ensure the patient was involved in the development of their individualized plan of care. Clinical Record 3: The patient elected their hospice benefit on 10/22/2023 with a terminal diagnosis of Alzheimer’s disease. The RN completed the initial comprehensive assessment on 10/22/2023 and reported the patient had symptoms of incontinence, shortness of breath, and a fall risk. There was no documented evidence, in the clinical record, of a written plan of care until 03/01/2024 (this was 131 days following the election of the hospice benefit). There was no documented evidence in the clinical record that the patient was involved in developing their plan of care. Clinical Record 10: The patient elected their hospice benefit on 01/08/2024 with a terminal diagnosis of chronic heart failure. The RN completed the initial comprehensive assessment on 01/08/2024 and reported the patient had symptoms of constipation. There was no documented evidence, in the clinical record, of a written plan of care until 08/19/2024 (this was 224 days following the election of the hospice benefit). There was no documented evidence in the clinical record that the patient was involved in developing their plan of care. During an interview on 09/25/2024, the Director of Nursing (Personnel Record 2) agreed there were no written plans of care.

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 FINDING This CONDITION was not met as evidenced by a review of clinical records, interviews, and document review which revealed the hospice: Failed to ensure that the registered nurse that is a member of the interdisciplinary group provided coordination of care and ensured continuous assessment of each patient's and family's needs and implementation of the interdisciplinary plan of care {HCPC.19. I/L540}; Failed to ensure that each patient's individualized written Plan of Care included identified problems and planned interventions based upon assessment data from the comprehensive and updated comprehensive assessments {HCPC.21. I/L545}; Failed to ensure that the Plan of Care included all services necessary for the palliation and management of the terminal illness and related conditions, including the following: medical supplies and appliances necessary to meet the needs of the patient {HCPC.21.I/L550}; and Failed to ensure that the hospice interdisciplinary group reviewed, revised, and documented the individualized Plan of Care as frequently as the patient’s condition requires, but no less frequently than every 15 calendar days {HCPC.22.I/L552}. 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 418.56: IDG, Care Planning, Coordination of 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 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. This standard was not met as evidenced by clinical record review and interview. In 10 of 14 (71%) records reviewed revealed that the agency did not ensure the registered nurse (RN) implemented individualized plans of care required to ensure coordination of care and ongoing assessments of the patient’s and family’s needs. Clinical Record 1: The patient elected their hospice benefit 01/26/2024 with a terminal diagnosis of congestive heart failure (CHF). The registered nurse initial comprehensive assessment dated 01/26/2024 reported the patient had symptoms of anxiety, decreased appetite, bowel and bladder incontinence, constipation, and a fall risk. The written plan of care effective for the benefit period dated 01/26/2024 to 03/25/2024 did not include any problems, goals, or planned interventions related to anxiety, decreased appetite, bowel and bladder incontinence, constipation, or fall precautions, medical equipment (Hoyer lift and wheelchair) and medical supplies (wipes, briefs, gloves, and pads) used by the patient. There was no documented evidence in the clinical record that the RN provided coordination of care or implementation of the interdisciplinary plan of care. Clinical Record 2: The patient elected their hospice benefit on 08/05/2023 with a terminal diagnosis of cirrhosis of the liver. The RN completed the initial comprehensive assessment on 08/05/2023 and reported the patient had symptoms of bladder incontinence, shortness of breath, decreased appetite, fall risk, and hypertension. The written plan of care effective for the benefit period dated 08/05/2023 to 11/02/2023 did not include any problems, goals, or planned interventions related to bladder incontinence, shortness of breath, decreased appetite, fall risk, or hypertension, and medical supplies (pull-ups and wipes) used by the patient. There was no documented evidence in the clinical record that the RN provided coordination of care or implementation of the interdisciplinary plan of care. Clinical Record 3: The patient elected their hospice benefit on 10/22/2023 with a terminal diagnosis of Alzheimer’s disease. The RN completed the initial comprehensive assessment on 10/22/2023 and reported the patient had symptoms of incontinence, shortness of breath, and a fall risk. There was no documented evidence, in the clinical record, of a written plan of care until 03/01/2024 (this was 131 days following the election of the hospice benefit). There was no documented evidence in the clinical record that the RN provided coordination of care or implementation of the interdisciplinary plan of care. Clinical Record 4: The patient elected their hospice benefit 06/22/2024 with a terminal diagnosis of chronic obstructive pulmonary disease (COPD). The RN completed the initial comprehensive assessment on 06/22/2024 and reported the patient had symptoms of angina, edema, incontinence, and a fall risk. The written plan of care effective for the benefit period dated 06/22/2024 to 09/19/2024 did not include any problems, goals, or planned interventions related to angina, edema, incontinence, or fall precautions, and medical equipment (walker and oxygen concentrator) used by the patient. There was no documented evidence in the clinical record that the RN provided coordination of care or implementation of the interdisciplinary plan of care. Clinical Record 5: The patient elected their hospice benefit on 05/24/2024 with a terminal diagnosis of hemiplegia and hemiparesis following cerebral infarction. The RN completed the initial comprehensive assessment on 05/24/2024 and reported the patient had symptoms of pain, incontinence, shortness of breath, and dysphagia. The written plan of care effective for the benefit period dated 05/24/2024 to 07/22/2024 did not include any problems, goals, or planned interventions related to pain, incontinence, shortness of breath, dysphagia, medical equipment (walker) and medical supplies (wipes, diapers, and incontinence pads) used by the patient. There was no documented evidence in the clinical record that the RN provided coordination of care or implementation of the interdisciplinary plan of care. Clinical Record 6: The patient elected their hospice benefit on 08/23/2023 with a terminal diagnosis of chronic ischemic heart disease. The RN completed the initial comprehensive assessment on 08/23/2023 and reported the patient had symptoms of seizures, hypertension, and heartburn with reflux. The written plan of care effective for the benefit period dated 08/23/2023 to 11/20/2023 did not include any problems, goals, or planned interventions related to seizures, hypertension, or heartburn with reflux, and medical equipment (walker) used by the patient. There was no documented evidence in the clinical record that the RN provided coordination of care or implementation of the interdisciplinary plan of care. Clinical Record 7: The patient elected their hospice benefit on 04/06/2024 with a terminal diagnosis of COPD. The RN completed the initial comprehensive assessment on 04/06/2024 and reported the patient had symptoms of shortness of breath and pain. The written plan of care effective for the benefit period dated 04/06/2024 to 07/04/2024 did not include any problems, goals, or planned interventions related to shortness of breath or pain, and medical equipment (wheelchair and an oxygen concentrator) used by the patient. There was no documented evidence in the clinical record that the RN provided coordination of care or implementation of the interdisciplinary plan of care. There was no documented evidence in the clinical record that the RN provided coordination of care or implementation of the interdisciplinary plan of care. Clinical Record 8: The patient elected their hospice benefit and was admitted as a transfer from another hospice on 01/19/2024 with a terminal diagnosis of cerebral infarction. The RN completed the initial comprehensive assessment on 01/19/2024 and reported the patient had symptoms of anxiety. The written plan of care effective for the benefit period dated 01/19/2024 to 01/27/2024 did not include any problems, goals, or planned interventions related to anxiety, and medical equipment (cane, shower bench, bedside commode, and walker) used by the patient. There was no documented evidence in the clinical record that the RN provided coordination of care or implementation of the interdisciplinary plan of care. Clinical Record 9: The patient elected their hospice benefit on 05/30/2024 with a terminal diagnosis of alcohol dependence with alcohol-induced persisting dementia. The RN completed the initial comprehensive assessment on 0105/30/2024 and reported the patient had symptoms of shortness of breath on moderate exertion and bladder incontinence. The written plan of care effective for the benefit period dated 05/30/2024 to 07/28/2024 did not include any problems, goals, or planned interventions related to shortness of breath or bladder incontinence and medical equipment (walker) used by the patient. There was no documented evidence in the clinical record that the RN provided coordination of care or implementation of the interdisciplinary plan of care. Clinical Record 10: The patient elected their hospice benefit on 01/08/2024 with a terminal diagnosis of chronic heart failure. The RN completed the initial comprehensive assessment on 01/08/2024 and reported the patient had symptoms of constipation. There was no documented evidence, in the clinical record, of a written plan of care until 08/19/2024 (this was 224 days following the election of the hospice benefit). There was no documented evidence in the clinical record that the RN provided coordination of care or implementation of the interdisciplinary plan of care. During an interview on 09/25/2024, the Director of Nursing (Personnel Record 2) agreed that the patient's written plans of care did not have identified planned interventions to manage the patient's symptoms related to the terminal illness and related conditions.

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, document review and interview. In 10 of 14 (71%) clinical records reviewed revealed that the hospice agency did not ensure that each patient's individualized written plan of care identified planned interventions based on problems identified in the initial and updated comprehensive assessments. Clinical Record 1: The patient elected their hospice benefit on 01/26/2024 with a terminal diagnosis of congestive heart failure. The RN completed the initial comprehensive assessment on 01/26/2024 and reported the patient had symptoms of anxiety, decreased appetite, bowel and bladder incontinence, constipation, and a fall risk. The written plan of care effective for the benefit period dated 01/26/2024 to 03/25/2024 did not include any problems, goals, or planned interventions related to anxiety, decreased appetite, bowel and bladder incontinence, constipation, or fall precautions. Clinical Record 2: The patient elected their hospice benefit on 08/05/2023 with a terminal diagnosis of cirrhosis of the liver. The RN completed the initial comprehensive assessment on 08/05/2023 and reported the patient had symptoms of bladder incontinence, shortness of breath, decreased appetite, fall risk, and hypertension. The written plan of care effective for the benefit period dated 08/05/2023 to 11/02/2023 did not include any problems, goals, or planned interventions related to bladder incontinence, shortness of breath, decreased appetite, fall risk, or hypertension. Clinical Record 3: The patient elected their hospice benefit on 10/22/2023 with a terminal diagnosis of Alzheimer’s disease. The RN completed the initial comprehensive assessment on 10/22/2023 and reported the patient had symptoms of incontinence, shortness of breath, and a fall risk. There was no documented evidence, in the clinical record, of a written plan of care until 03/01/2024 (this was 131 days following the election of the hospice benefit). As of the date of the survey the plan of care did not include any problems, goals, or planned interventions related to incontinence, shortness of breath, or fall precautions. Clinical Record 4: The patient elected their hospice benefit on 06/22/2024 with a terminal diagnosis of chronic obstructive pulmonary disease (COPD). The RN completed the initial comprehensive assessment on 06/22/2024 and reported the patient had symptoms of angina, edema, incontinence, and a fall risk. The written plan of care effective for the benefit period dated 06/22/2024 to 09/19/2024 did not include any problems, goals, or planned interventions related to angina, edema, incontinence, or fall precautions. Clinical Record 5: The patient elected their hospice benefit on 05/24/2024 with a terminal diagnosis of hemiplegia and hemiparesis following cerebral infarction. The RN completed the initial comprehensive assessment on 05/24/2024 and reported the patient had symptoms of pain, incontinence, shortness of breath, and dysphagia. The written plan of care effective for the benefit period dated 05/24/2024 to 07/22/2024 did not include any problems, goals, or planned interventions related to pain, incontinence, shortness of breath, and dysphagia. Clinical Record 6: The patient elected their hospice benefit on 08/23/2023 with a terminal diagnosis of chronic ischemic heart disease. The RN completed the initial comprehensive assessment on 08/23/2023 and reported the patient had symptoms of seizures, hypertension, and heartburn with reflux. The written plan of care effective for the benefit period dated 08/23/2023 to 11/20/2023 did not include any problems, goals, or planned interventions related to seizures, hypertension, or heartburn with reflux. Clinical Record 7: The patient elected their hospice benefit on 04/06/2024 with a terminal diagnosis of COPD. The RN completed the initial comprehensive assessment on 04/06/2024 and reported the patient had symptoms of shortness of breath and pain. The written plan of care effective for the benefit period dated 04/06/2024 to 07/04/2024 did not include any problems, goals, or planned interventions related to shortness of breath or pain. Clinical Record 8: The patient elected their hospice benefit and was admitted as a transfer from another hospice on 01/19/2024 with a terminal diagnosis of cerebral infarction. The RN completed the initial comprehensive assessment on 01/19/2024 and reported the patient had symptoms of anxiety. The written plan of care effective for the benefit period dated 01/19/2024 to 01/27/2024 did not include any problems, goals, or planned interventions related to anxiety. Clinical Record 9: The patient elected their hospice benefit on 05/30/2024 with a terminal diagnosis of alcohol dependence with alcohol-induced persisting dementia. The RN completed the initial comprehensive assessment on 0105/30/2024 and reported the patient had symptoms of shortness of breath on moderate exertion and bladder incontinence. The written plan of care effective for the benefit period dated 05/30/2024 to 07/28/2024 did not include any problems, goals, or planned interventions related to shortness of breath or bladder incontinence. Clinical Record 10: The patient elected their hospice benefit on 01/08/2024 with a terminal diagnosis of chronic heart failure. The RN completed the initial comprehensive assessment on 01/08/2024 and reported the patient had symptoms of constipation. There was no documented evidence, in the clinical record, of a written plan of care until 08/19/2024 (this was 224 days following the election of the hospice benefit). As of the date of the survey the plan of care did not include any problems, goals, or planned interventions related to constipation. During an interview on 09/25/2024, the Director of Nursing (Personnel Record 2) agreed that the patient's written plans of care did not have identified planned interventions to manage the patient's symptoms related to the terminal illness and related conditions.

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 medical supplies and appliances necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review, and interview. In 4 of 9 (44%) clinical records reviewed, for patients that received medical supplies, revealed the hospice agency did not ensure that each patient's individualized written plan of care included all services necessary for the palliation and management of the terminal illness, including medical supplies necessary to meet the patient's needs. Clinical Record 1: The patient elected their hospice benefit on 01/26/2024. The RN completed the initial comprehensive assessment on 01/26/2024 and reported the patient had symptoms of bowel and bladder incontinence. The Director of Nursing confirmed the hospice agency provided wipes, briefs, gloves, and pads to the patient. The medical supplies related to the palliation of the patient's terminal illness and related conditions were not identified on the plan of care effective as of 01/26/2024. Clinical Record 2: The patient elected their hospice benefit and was admitted to the hospice agency services on 08/05/2023. The RN completed the initial comprehensive assessment on 08/05/2023 and reported the patient had symptoms of bladder incontinence. The Director of Nursing confirmed the hospice agency provided pull-ups and wipes to the patient. The medical supplies related to the palliation of the patient's terminal illness and related conditions were not identified on the plan of care effective as of 08/05/2023. Clinical Record 3: The patient elected their hospice benefit on 10/22/2023. The second benefit period was from 10/22/2023 to 01/19/2024. The RN completed the initial comprehensive assessment on 10/22/2023 and reported the patient had symptoms of incontinence. The Director of Nursing confirmed the hospice agency provided the patient with wipes and briefs. There was no documented evidence, in the clinical record, of a written plan of care until 03/01/2024 (this was 131 days following the election of the hospice benefit). As of the date of the survey the plan of care did not include the medical supplies related to the palliation of the patient's terminal illness and related conditions. Clinical Record 5: The patient elected their hospice benefit on 05/24/2024. The third benefit period was from 05/24/2024 to 07/22/2024. The RN completed the initial comprehensive assessment on 05/24/2024 and reported the patient had symptoms of incontinence. The Director of Nursing stated that the hospice agency provided wipes, diapers, and incontinence pads to the patient. The medical supplies related to the palliation of the patient's terminal illness were not identified on the plan of care effective as of 05/24/2024. During an interview on 09/26/2024, the Director of Nursing (Personnel Record 2) stated she was not sure how to get the supplies to populate onto the plan of care in the agency's electronic medical record. The Director of Nursing agreed that the patient's medical supplies were not listed on the patient's individualized plans of care.

It is required that the Interdisciplinary Group, in collaboration with the individual's attending physician (if any), reviews, revises, and documents the individualized care plan as frequently as the patient's condition requires and no less frequently than every 15 calendar days. This standard was not met as evidenced by clinical record review, document review and interview. In 5 of 14 (36%) clinical records reviewed for patients admitted to the hospice agency's services revealed that the hospice agency did not ensure that the interdisciplinary group, in collaboration with the patient's attending physician, reviewed, revised, and documented the individualized care plans as frequently as the patient's condition required and no less frequently than every fifteen calendar days. Agency policy 013115 Hospice-CHAP, titled, Interdisciplinary Group (IDG), stated in part, that the IDG Members will meet every, at a minimum, every fifteen (15) days to review and update the written plan of care for each patient. Clinical Record 1: The patient elected their hospice benefit on 01/26/2024. The documented initial comprehensive assessment was completed on 01/26/2024 by the registered nurse. There was no documented evidence the patient had the care plan reviewed during an IDG meeting until 06/19/2024 (this was 145 days following the election of the hospice benefit). Clinical Record 2: The patient elected their hospice benefit on 08/05/2023. The initial comprehensive assessment was completed on 08/05/2023 by the registered nurse. The first documented IDG meeting that reviewed the patient's individualized care plan was dated 09/20/2023 (46 days), the next documented IDG meeting was on 10/18/2023 (28 days) and then not again until 11/09/2023 (22 days). Clinical Record 3: The patient elected their hospice benefit on 10/22/2023 in their second benefit period. The initial comprehensive assessment was completed on 10/22/2023 by the registered nurse. The first documented IDG meeting that reviewed the patient's individualized care plan was dated 02/07/2024 (108 days). The clinical record did not include evidence that a plan of care had been implemented until 03/01/2024. Clinical Record 6: The patient elected their hospice benefit on 08/23/2023. The initial comprehensive assessment was completed on 08/23/2023 by the registered nurse. The first documented IDG meeting that reviewed the patient's individualized care plan occurred 09/20/2023 (28 days). Clinical Record 10: The patient elected their hospice benefit on 01/08/2024. The initial and comprehensive assessment was completed by the registered nurse on 01/08/2024. The clinical record did not include evidence IDG met to review this patient’s care plan between 02/21/2024 and 03/20/2024 (28 days). The clinical record did not include evidence that a plan of care had been implemented until 08/19/2024. During an interview on 09/26/2024, the Director of Nursing (Personnel Record 2) stated the process for documenting interdisciplinary group meetings was previously done on paper and had gradually been transitioned to the electronic medical record. The Director of Nursing agreed that there was no documented evidence that all interdisciplinary group meetings had been completed every fifteen days.

It is required that medical social services are provided by a qualified social worker 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. The psychosocial assessment addresses the patient’s and the family’s adjustment to the terminal illness, the social and emotional factors related to the terminal illness, the presence or absence of adequate coping mechanisms, family dynamics, and communication patterns, financial resources and any constraints, the caregiver’s ability to function effectively, obstacles and risk factors that may affect compliance with the plan of care, and family support systems to facilitate coping with end-of-life issues. The psychosocial assessment is revised as new information is acquired and progress toward goals is made. This standard was not met as evidenced by clinical record review, document review and interview. In 3 of 11 (27%) clinical records reviewed, for patients that accepted social worker services, revealed that the hospice agency did not ensure that medical social worker services were provided according to the patient's and family's needs and acceptance of these services. Agency policy 013115 Hospice-CHAP, titled, Comprehensive Assessment, stated in part, the patient's comprehensive assessment would be completed within five days of the admission by the interdisciplinary group upon acceptance of services. Clinical Record 1: The patient elected their hospice benefit on 01/26/2024 in their third benefit period. The initial comprehensive assessment dated 01/26/2024 stated the patient and family accepted social worker services. As of the date of the survey there was no documented evidence of attempted or completed social worker assessments or visits. Clinical Record 5: The patient elected their hospice benefit on 05/24/2024. The initial comprehensive assessment dated 05/24/2024 stated the patient and family accepted social worker services. The plan of care dated 05/24/2024 listed the social worker frequency at one time a month. As of the date of the survey there was no documented evidence of attempted or completed social worker assessments or visits. Clinical Record 6: The patient elected their hospice benefit on 08/23/2023. The initial comprehensive assessment dated 08/23/2023 stated the patient and family accepted social worker services. As of the date of the survey there was no documented evidence of attempted or completed social worker assessments or visits. During an interview on 09/26/2024, the Director of Nursing (Personnel Record 2) stated the social worker was not always used because most patients declined the services. When asked about the patients that accepted social worker services per documentation in the comprehensive assessment, the Director of Nursing stated it must have been an error. The Director of Nursing agreed that the patients and families had not received medical social worker services.

The hospice must use volunteers to the extent specified in paragraph (e) of this section. These volunteers must be used in defined roles and under the supervision of a designated hospice employee. THIS IS A CMS CONDITION LEVEL DEFICIENCY This CONDITION was not met as evidenced by document review and interview. Review of administrative documents, and interviews with leadership revealed the hospice: Failed to ensure that the hospice provided care and services in a manner consistent with accepted standards of practice: volunteer services {HCDT.1.I/L652}; Failed to ensure that volunteers were used in day-to-day administrative and/or direct patient care roles {HCDT.21.I/L644}; and Failed to ensure that volunteers provided day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff {HSLG.7.I/L647}. 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 418.78: Volunteers. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the agency.

It is required that volunteers are used in day-to-day administrative and/or direct patient care roles. This standard was not met as evidenced by document review and interview. A review of the volunteer program revealed the hospice agency did not ensure that volunteers were used in day-to-day administrative and/or direct patient care roles. Agency policy 013115 Hospice-CHAP, titled, Volunteer Services, stated in part, “the hospice must provide volunteer services in a manner consistent with accepted standards of practice. Volunteers will be used in day-to-day direct patient care or administrative roles.” The hospice agency volunteer program binder did not have any documented volunteer administrative and/or direct patient care hours for the calendar years 2023 or 2024. During an interview on 09/26/2024, the Director of Nursing/Volunteer Coordinator (Personnel Record 2) stated she was not aware that volunteer hours were required due to the (Public Health Emergency) waiver. The Volunteer Coordinator was informed the waiver had ended in December 2023. The Volunteer Coordinator stated a new volunteer had been hired on 09/24/2024 and was scheduled for orientation and training. The Volunteer Coordinator agreed there were no documented or accumulated volunteer hours thus far in 2024.

It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This standard was not met as evidenced by document review and interview. A review of the volunteer program binder revealed the hospice agency did not ensure that volunteers were used in day-to-day administrative and/or direct patient care services in an amount that, at a minimum, equaled five percent (5%) of the total patient care hours of all paid employees and contract staff. During an interview on 09/26/2024, the Director of Nursing/Volunteer Coordinator (Personnel Record 2) stated she hired a volunteer the other day. The new volunteer start date is anticipated 10/03/2024. When asked if there were any documented volunteer hours for 2024, the Volunteer Coordinator stated there were no hours and no volunteers during that time that she is aware of.

It is required that the hospice must provide hospice care that is consistent with patient and family needs and goals, with patient needs and goals as priority. This standard was not met as evidenced by clinical record review and interview. In 2 of 14 (28%) clinical records reviewed revealed the agency did not ensure the plans of care were developed timely and were consistent with the patient and family needs and goals. Clinical Record 3: The patient elected their hospice benefit on 10/22/2023 with a terminal diagnosis of Alzheimer’s disease. The RN completed the initial comprehensive assessment on 10/22/2023 and reported the patient had symptoms of incontinence, shortness of breath, and a fall risk. There was no documented evidence, in the clinical record, of a written plan of care until 03/01/2024 (this was 131 days following the election of the hospice benefit). Clinical Record 10: The patient elected their hospice benefit on 01/08/2024 with a terminal diagnosis of chronic heart failure. The RN completed the initial comprehensive assessment on 01/08/2024 and reported the patient had symptoms of constipation. There was no documented evidence, in the clinical record, of a written plan of care until 08/19/2024 (this was 224 days following the election of the hospice benefit). During an interview on 09/25/2024, the Director of Nursing (Personnel Record 2) agreed there were no written plans of care.

It is required that a hospice must be primarily engaged in providing the following care and services and must do so in a manner that is consistent with accepted standards of practice: volunteer services. The standard was not met as evidenced by document review and interview. A review of the volunteer program document binder revealed that the agency did not ensure that volunteers services were utilized and available per the accepted standards of practice. During an interview on 09/26/2024, the Director of Nursing/Volunteer Coordinator (Personnel Record 2) stated she was not aware that volunteer hours were required due to the (Public Health Emergency) waiver. The Volunteer Coordinator was informed the waiver had ended in December 2023. The Volunteer Coordinator agreed there were no documented or accumulated volunteer hours thus far in 2024.

It is required that the hospice medical director, physician employees, and contracted physician(s), in conjunction with the patient’s attending physician, are responsible for the palliation and management of the terminal illness as well as conditions related to the terminal illness. THIS IS A CMS CONDITION LEVEL FINDING This CONDITION was not met as evidenced by a review of clinical records, document review and interviews which revealed the hospice: Failed to ensure that the hospice medical director or physician designee provided written certification of terminal illness, including the primary terminal diagnosis, 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{HCPC.4. I/L667}; and Failed to ensure that the hospice medical director or physician-designee provided written and signed recertification of the terminal illness (CTI) to meet the hospice care benefit requirement {HCPC. 6. IL668}. The cumulative effect of these deficiencies has resulted in the hospice organization's inability to ensure the provision of quality of care for the Condition of Participation CFR 418.102: Medical Director. The collective deficient practice illustrated systemic process failures that had the potential to affect all patients receiving hospice care and services from the agency.

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, document review and interview. In 3 of 14 (21%) Clinical records revealed that the hospice 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. Agency policy 013115 Hospice-CHAP, titled, Certification of Terminal Illness, stated in part, the hospice must obtain a written certification of terminal illness for each patient and admit the patient only on the recommendation of the Medical Director and the patient's Attending Physician, if any. Clinical Record 1: The patient elected their hospice benefit on 01/26/2024. The documented initial comprehensive assessment was completed on 01/26/2024 by the registered nurse. There was no documented evidence that the medical director or physician designee provided a written certification of terminal illness for the benefit period dated 01/26/2024 to 03/25/2024. Clinical Record 11: The patient elected their hospice benefit on 09/12/2023. The documented initial comprehensive assessment was completed on 09/12/2023 by the registered nurse. There was no documented evidence that the medical director or physician designee provided a written certification of terminal illness for the benefit period dated 09/12/2023 to 11/10/2023. Clinical Record 12: The patient elected their hospice benefit on 01/30/2024. The documented initial comprehensive assessment was completed on 01/30/2024 by the registered nurse. There was no documented evidence that the medical director or physician designee provided a written certification of terminal illness for the benefit period dated 01/30/2024 to 03/29/2024. During an interview on 09/25/2024, the Director of Nursing (Personnel Record 2) agreed that the clinical records did not include evidence that medical director or physician designee had completed written certifications of terminal illness for the patients. When the Director of Nursing was asked why the written certifications were not in the electronic medical record, the Director of Nursing stated the written certifications were previously completed on paper and later the medical director began completing them in the electronic medical record. The Director of Nursing attempted to locate the written certifications that had been completed on paper but was unable to locate them.

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. This standard was not met as evidenced by clinical record review, document review and interview. In 7 of 14 (50%) clinical records reviewed revealed that the hospice agency did not ensure the hospice medical director or physician designee provided a written and signed recertification of the terminal illness to meet the hospice care benefit requirement. Document 2: 013115 Hospice-CHAP, titled, Recertification of Terminal Illness, stated in part the hospice must obtain a written recertification of terminal illness for each patient and recertify the patient only on the recommendation of the Medical Director. Clinical Record 1: The patient elected their hospice benefit on 01/26/2024. There was no documented evidence that the medical director or physician designee completed the written and signed recertification of terminal illness for the following benefit periods: fourth benefit period (03/26/2024-05/24/2024), fifth benefit period (05/25/2024-07/23/2024), sixth benefit period (07/24/2024-09/21/2024), and the seventh benefit period (09/22/2024-11/20/2024). Clinical Record 2: The patient elected their hospice benefit services on 08/05/2023. There was no documented evidence that the medical director or physician designee completed the written and signed recertification of terminal illness for the following benefit periods: second benefit period (11/03/2023-01/31/2024), third benefit period (02/01/2024-03/31/2024), fourth benefit period (04/01/2024-05/30/2024), fifth benefit period (05/31/2024-07/29/2024), and the sixth benefit period (07/30/2024-09/27/2024). Clinical Record 4: The patient elected their hospice benefit on 06/22/2024. There was no documented evidence that the medical director or designee completed the written and signed recertification of terminal illness to meet the hospice care benefit requirement for the second benefit period (09/20/2024 to 12/18/2024). Clinical Record 5: The patient elected their hospice benefit on 05/24/2024. There was no documented evidence that the medical director or designee completed the written and signed recertification of terminal illness to meet the hospice care benefit requirement for the fourth benefit period (07/23/2024 to 09/20/2024). Clinical Record 6: The patient elected their hospice benefit on 08/23/2023. There was no documented evidence that the medical director or designee completed the written and signed recertification of terminal illness to meet the hospice care benefit requirement for the second benefit period (11/21/2023 to 02/18/2024), fifth benefit period from (06/18/2024 to 08/16/2024), and the sixth benefit period from (08/17/2024 to 10/15/2024). Clinical Record 7: The patient elected their hospice benefit on 04/06/2024. There was no documented evidence that the medical director or designee completed the written and signed recertification of terminal illness to meet the hospice care benefit requirement for the second benefit period (07/05/2024 to 10/02/2024). Clinical Record 9: The patient elected their hospice benefit on 05/30/2024. There was no documented evidence that the medical director or designee completed the written and signed recertification of terminal illness to meet the hospice care benefit requirement for the fifth benefit period (07/29/2024 to 09/26/2024) and sixth benefit periods (09/27/2024 to 11/25/2024). During an interview on 09/25/2024, the Director of Nursing (Personnel Record 2) agreed that the clinical records did not contain evidence that medical director or physician designee had completed written recertifications of terminal illness for the patients. When the Director of Nursing was asked why the written recertifications were not in the electronic medical record, the Director of Nursing stated the written recertifications were previously completed on paper and later the medical director began completing them in the electronic medical record. The Director of Nursing attempted to locate the written recertifications that had been completed on paper but was unable to locate them.

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current over-the-counter (OTC) drugs. This standard was not met as evidenced by interview and clinical record review. In 1 of 3 (33%) of patient visits it was revealed that the drug profile does not contain the patient's current over-the-counter drugs. Clinical Record #71609: During a home visit observation on 11/16/2021, the patient stated Tylenol is administered for pain. Review of the drug profile revealed Tylenol is not identified on the drug profile. The Alternate Administrator and DCS confirmed this finding and acknowledged that the drug profile did not contain the patient's current over-the-counter drug.

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 and Safe handling of equipment in the patient’s care environment if it is likely to have been contaminated with body fluids; This standard was not met as evidence by home visit observation and interview. In 1 of 3 (33%) home visit observations safe handling of equipment in the patient’s care environment did not occur. Clinical Record #16648; During a patient observation visit on 11/16/21, with a skilled nurse, this surveyor witnessed the nurse use a blood pressure cuff, clean the blood pressure cuff with alcohol-based sanitizer while turning and resting the blood pressure cuff on their lap, then place the cuff in the clean section of the bag. In 1 of 3 (33%) home visit observations adherence to proper hand hygiene as defined in hospice policy IC.12 Bag Technique was not performed in accordance with agency policy. Clinical Record #93153: During a home observation visit on 11/16/2021 the nurse removed items from the bag, completed hands-on care with the patient then proceeded to reach back into the bag without donning a clean set of gloves on hands. Agency policy states, in part, "hands are cleaned any time prior to entering bag or returning clean equipment to bag". Interview with the Alternate Administrator and DCS confirmed this finding.

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 observation and clinical record review. In 1 of 3 (33%) home observation visits the patient received interventions without physician orders. Clinical Record #16648: During a home observation visit on 11/16/2021 the nurse completed a blood sugar test and used a pulse-ox to receive O2 saturations. Review of the clinical record revealed that there are no orders for blood sugar testing or pulse oximetry. During an interview with the Alternate Administrator and DCS they stated they were "not aware that the patient clinical record requires physician orders for blood sugar tests and measuring pulse oximetry".

It is required that the plan of care identifies the IDG’s finding regarding safe self-administration and/or family administration of drugs and biologicals. If the patient and/or family cannot administer drugs or biologicals, it is noted in the plan of care, as well as how it is addressed by the IDG. This standard was not met as evidenced by clinical record review and interview. In 10 of 10 (100%) clinical records reviewed of patients who reside at home, it was revealed the records did not contain the IDG determination of ability of the patient/family to safely self-administer drugs and biologicals to the patient in the home [Clinical Record #s 71609; 16648; 87993; 30472; 59899; 71498; 66119; 39252; 53800; 44398]. The DCS confirmed this finding and agreed the IDG did not document on the plan of care the determination of the patient/family to safely self-administer drugs and biologicals to the patient in the home.