Every finding on record at Belle Vie Hospice, LLC

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current prescription and over-the-counter (OTC) drugs. The medication review process includes the identification of the following: The effectiveness of drug therapy; Drug side effects; Actual or potential drug interactions; Duplicate drug therapy; and, Drug therapy associated with laboratory monitoring. This standard was not met as evidenced by clinical record review and interview. 1 of 6 (16%) applicable clinical records of patients admitted after the previous site visit review that ended on 3/3/2022 revealed the drug profile did not include documentation of all the patients' medications for inclusion in the medication regimen review. Clinical record #74331 was reviewed and identified the patient elected the hospice benefit on 3/7/2022. The admission assessment completed on 3/7/2022 identified that the patient was using oxygen at 5 L per minute. Oxygen was not documented on the medication profile. The Administrator was interviewed on 6/1/2022 and agreed that the oxygen was missing from the medication profile. The hospice had identified this as a problem and has a performance improvement plan in place to work on correcting the issue. He had no additional information to provide.

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; but no less frequently than every 15 calendar days. A revised plan of care includes information from the patient’s updated comprehensive assessment and a record of the patient’s progress toward the outcomes and goals specified in the plan of care. This standard was not met as evidenced by clinical record review and interview. 3 of 12 (25%) clinical records reviewed revealed that the POC was not reviewed and updated by the IDG. Clinical Record #74331 was reviewed and identified that the patient elected the hospice benefit on 3/7/2022 and died on 3/7/2022. There was no evidence that the patient's admission and death were reviewed in an IDG team meeting. Clinical Record #98399 was reviewed and identified that the patient elected the hospice benefit on 4/21/2022 and died on 4/29/2022. There was no evidence that the patient's admission and death were reviewed in an IDG team meeting. Clinical Record #85875 was reviewed and identified that the patient elected the hospice benefit on 4/21/2022 and died on 5/2/2022. There was no evidence that the patient's admission and death were reviewed in an IDG team meeting. The Administrator was interviewed on 6/1/2022 and agreed that there was no documentation in the patient records of the IDG review of the admission or discharge of these patients. He stated that the patients were discussed but the EMR did not generate the template for documentation as the patients had already been discharged. He will work with the EMR system to determine how to ensure this documentation is captured for future patients.

It is required that each patient’s individualized written plan of care reflects patient and family goals identify planned interventions based on problems identified in the initial and updated comprehensive assessments, includes all services necessary for the palliation and management of the terminal illness including intervention to manage pain and symptoms and measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review and interview. 3 of 7 (42%) records reviewed did not include documented evidence that the plan of care was individualized, reflecting problems identified in the assessments, with measurable outcomes. Record #69536: A comprehensive assessment was completed on 11/12/2021. The documentation revealed the patient’s pain at 6/10, an acceptable level would be 2/10, taking Tramadol 50mg twice daily as needed for pain. The plan of care dated 11/12/2021 which identified pain as a problem included the goal “Family/CG/IDT To be able to manifest understanding of pain management as evidenced by following and administering pharmacological regimen safely.” There was no evidence of a measurable outcome or pain medication interventions to address the patient’s pain. Record #10385: A comprehensive assessment was completed on 10/15/2021. The documentation revealed “LLE wound continues to be open requiring wound care. SN cleansed site with NS, Steri striped areas that were able to be closed, applied bordered dressing.” The plan of care dated 10/15/2021 which identified skin integrity as a problem, included the goal “Pt/IDT to demonstrate competency in the care of the patient with impaired skin integrity as evidenced by identifying signs and symptoms of skin breakdown and wound occurrence.” There was no evidence of a measurable outcome or wound care interventions to address the patient’s wound. Record #14915: A comprehensive assessment was completed on 11/17/2021. The documentation revealed the patient’s pain at 8/10, an acceptable level would be 2/10 taking Tramadol 50mg twice daily and Morphine as needed for pain. The plan of care dated 12/15/2021 which first identified pain as a problem did not include evidence of pain medication interventions. The Administrator was interviewed on 3/3/2022 and confirmed these findings.

It is required that the hospice documents and maintains an effective infection control program that protects patients, families, visitors, and hospice staff by preventing and controlling infections and communicable diseases. The infection control program includes: Identifying risk for acquiring and transmitting infectious agents where the patient resides. THIS IS A CONDITION LEVEL DEFICIENCY. This CONDITION was not met as evidenced by document review, personnel record review, and interview with Administrator. This CONDITION was not met as evidenced by document review and interview with the Administrator, and identified the agency failed to ensure the agency policy: 1. Established the individuals eligible to be fully vaccinated for COVID-19. [HIPC.11/L900] 2. Defines: the process for an individual to request: a medical or spiritual exemption from being fully vaccinated for COVID-19 per state and federal law and regulation. [HIPC.13/L900] 3. States a temporary delay in receipt of a COVID-19 primary vaccination series may be accepted, per CDC guidelines, upon receipt of documented clinical precautions and considerations, including, but not limited to: Individuals with an acute illness secondary to COVID-19; and Individuals who received monoclonal antibodies or convalescent plasma treatment. [HIPC.14/L900]. 4. States two (2) exceptions to being fully vaccinated for COVID-19 due to job responsibilities, per federal regulation. These are individuals who provide exclusively telehealth or telemedicine services outside of the settings where hospice services are directly provided to patients/families and who do not have any direct contact with patients, families, and caregivers, or other individuals eligible to be fully vaccinated for COVID-19, individuals who provide support services for the hospice that are performed exclusively outside of the settings where hospice services are directly provided to patients/families and who do not have any direct contact with patients, families, and caregivers, or other individuals eligible to be fully vaccinated for COVID-19. [HIPC.15/L900] 5. States the requirements for a medical or a spiritual exemption to being fully vaccinated for COVID-19 per state and federal law and regulation. A medical exemption from being fully vaccinated for COVID-19 includes documentation of information specifying which of the authorized COVID-19 vaccines is clinically contraindicated for the individual to receive, and the recognized clinical reasons for the contraindications and a documented statement by the authenticating practitioner recommending that the individual be exempted from the hospice requirement to be fully vaccinated for COVID-19 based on the recognized clinical contraindications and a statement signed and dated by a licensed practitioner, who is not the individual requesting the exemption, and who is acting within their respective scope of practice as defined by, and in accordance with, all applicable state and local law and regulation. A spiritual exemption from being fully vaccinated for COVID-19 includes documentation of the Organization’s defined criteria of an individual’s sincerely held religious belief, practice, or observance per federal law and regulation. [HIPC.16/L900]. 6. Defines a process to ensure that nationally recognized infection prevention and control guidelines intended to mitigate the transmission and spread of COVID-19 are implemented and followed. HIPC.18/L900.] and Additionally failed to ensure a process for all employees to be screened and documented vaccination status for COVID-19.[HIPC.17/L900]. The cumulative effect of this issue has resulted in the home health agency’s inability to ensure the provision of quality health care in a safe environment for the condition of participation CFR 418.60: Infection Control. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the agency. 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.

It is required that contributing to patient and family counseling and education. Hospice “core” services are substantially provided directly by hospice employees in a manner consistent with acceptable standards of practice. “Core” services include nursing services, medical social work, and counseling. THIS IS A CONDITION LEVEL DEFICIENCY. This CONDITION was not met as evidenced by personnel record review and interview with the Administrator. The agency failed to ensure that medical social work core services were provided directly by hospice employees [HCDT.2.I/L588]. The cumulative effect of this issue has resulted in the home health agency’s inability to ensure the provision of quality health care in a safe environment for the condition of participation CFR 418.65: Core Services. The deficient practice illustrated process failures that had the potential to affect all patients cared for by the agency.

It is required that consistent with current professional standards of practice, licensed professionals actively participate in the coordination of all aspects of patient care including conducting ongoing interdisciplinary comprehensive assessments, developing and evaluating the plan of care, contributing to patient and family counseling and education. Hospice “core” services are substantially provided directly by hospice employees in a manner consistent with acceptable standards of practice. “Core” services include nursing services, medical social work, and counseling. This standard was not met as evidenced by personnel record review and interview. 1 of 9 (11%) records reviewed revealed the hospice did not ensure that medical social work core services were provided directly by hospice employees. Record #12543: (LCSW): hire date 8/18/2021. A review of the personnel file revealed the social worker was contracted to provide social work services to the hospice. The Administrator was interviewed on 3/2/2022 and stated, “we didn’t realize the social worker had to be a direct employee.”

It is required that the hospice provides an initial orientation for each employee that addresses the employee’s specific job duties, including infection control and organization procedures and policies and procedures on advance directives. Orientation on the hospice philosophy is also provided to all employees and contracted staff who have patient and family contact. Orientation includes the following, as appropriate to the employee’s specific job duties, the needs and concerns of patients and families coping with a terminal illness and education regarding the hospice’s policies and procedures on advance directives. This standard was not met as evidenced by personnel record review and interview. 2 of 9 (22%) records reviewed revealed the hospice did not ensure that an initial employee orientation was provided. Record #84551: (Hospice Medical Director (HMD)): hire date 10/26/2021. A review of the personnel file revealed there was no evidence that orientation was provided upon hire. Record #92189: (Alternate HMD): hire date 7/21/2021. A review of the personnel file revealed there was no evidence that orientation was provided upon hire. The Administrator was interviewed on 3/3/2022 and stated, “we didn’t realize it was required for contract staff.”

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum physician orders. This standard was not met as evidenced by clinical record review and interview. 1 of 7 (14%) records reviewed revealed the hospice did not ensure the clinical record included a physician’s order for the wound care. Record #10385: A comprehensive assessment was completed on 10/15/2021. The documentation revealed “LLE wound continues to be open requiring wound care. Skilled Nurse cleansed site with NS, Steri striped areas that were able to be closed, applied bordered dressing.” There was no evidence of a physician’s order for wound care. The Administrator was interviewed on 3/2/2022 and stated, there were no documented wound orders within the records identified.

It is required that organization policy and procedure states the requirements for a medical or a spiritual exemption to being fully vaccinated for COVID-19 per state and federal law and regulation. A medical exemption from being fully vaccinated for COVID-19 includes: documentation of information specifying which of the authorized COVID-19 vaccines is clinically contraindicated for the individual to receive, and the recognized clinical reasons for the contraindications; and a documented statement by the authenticating practitioner recommending that the individual be exempted from the hospice requirement to be fully vaccinated for COVID-19 based on the recognized clinical contraindications; and a statement signed and dated by a licensed practitioner, who is not the individual requesting the exemption, and who is acting within their respective scope of practice as defined by, and in accordance with, all applicable state and local law and regulation. A spiritual exemption from being fully vaccinated for COVID-19 includes documentation of the Organization’s defined criteria of an individual’s sincerely held religious belief, practice, or observance per federal law and regulation. This standard was not met as evidenced by document review and interview. A review of the vaccination policy revealed the hospice did not include the requirements for a medical or spiritual exemption to being fully vaccinated. Agency policy "Mandatory Vaccination Policy" stated, in part: “All exception requests are initiated by the employee via writing and reviewed for approval, deferral, or denial.” A review of agency policy “Mandatory Vaccination Policy” revealed there was no evidence that the policy included the requirements for a medical or a spiritual exemption to being fully vaccinated for COVID-19 per state and federal law and regulation. The Administrator was interviewed on 3/3/2022 and confirmed this finding.