Every finding on record at Beyond Hospice & Palliative Care, LLC

It is required that hospice aides are supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days to: assess the quality of care and services provided by the hospice aide; ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. The hospice aide does not need to be present. This standard was not met as evidenced by clinical record review and interview. In 2 of 6 (33%) clinical records reviewed for patients that elected hospice aide services revealed the agency did not ensure that hospice aide services were supervised by a registered nurse no less frequently than every 14 days. Clinical Record 1: The election of the hospice benefit was 06/14/2024. The clinical record was reviewed for benefit period 06/14/2024 to 09/11/2024. The plan of care included an order for aide services for 2 times per week. The patient received aide services as ordered, starting on 06/18/2024. The first aide supervisory visit was completed on 07/06/2024 18 days after the first aide visit. Clinical Record 7: The election of hospice benefit was 04/05/2024. The clinical record review for benefit period 06/04/2024 to 08/02/2024 revealed an order for hospice aide services for 2 times per week. The patient received aide services as ordered starting on 06/05/2024. The first aide supervisory visit was completed on 06/10/2024. The next aide supervisory visit was dated 06/24/2024, which is 14 days, then on 07/11/2024 which is 17 days. There were no additional documented aide supervisory visits completed between 07/11/2024 and the end of the benefit period 08/02/2024. In an interview with the Director of Nurses on 09/25/24 while reviewing the clinical record stated I don't know why those were missed but we are constantly educating and encouraging that aide supervisory visits be done at each visit, so they are not missed.

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, interviews, 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. This standard was not met as evidenced by clinical record review and interview. In 2 of 14 (14%) clinical records reviewed revealed the entries were not complete. Clinical Record 3: The patient elected hospice services on 05/03/2024. Clinical record review revealed that an initial Certification of Terminal Illness for periods 05/03/2024 to 07/01/2024 did not include a physician signature. There was no documented evidence that the physician reviewed the initial CTI. Clinical Record 4: The patient elected hospice services on 02/26/2024. Clinical record review revealed that an initial Certification of Terminal Illness for periods 02/26/2024 to 05/25/2024 did not include a physician signature. There was no documented evidence that the physician reviewed the initial CTI. The Administrator stated in an interview on 09/26/2024 during a joint review of the clinical records that she had previously seen a missing signature on a Certification of Terminal Illness. Still, she thought it was an isolated incident. Also, she stated she did not look any deeper and did not realize it was a problem in multiple charts.

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 and interview. In 3 of 11 (27%) clinical records reviewed for patients requiring a physician's recertification of terminal illness revealed that the agency did not ensure that the hospice medical director completed and signed the recertification of terminal illness. Clinical Record 3: The patient elected hospice services on 05/03/2024. Clinical record review revealed that a recertification of Terminal Illness for periods 07/02/2024 to 08/30/2024, and 08/31/2024 to 10/29/2024 included all required narrative, yet lacked evidence of a physician signature. Clinical Record 4: The patient elected hospice services on 02/26/2024. Clinical record review revealed that a recertification of Terminal Illness for periods 05/26/2024 to 08/23/2024, and 08/24/2024 to 10/22/2024 included all required narrative, yet lacked evidence of a physician signature. Clinical Record 5: The patient elected hospice services on 09/07/2023. Clinical record review revealed that a recertification of Terminal Illness for periods 01/05/2024 to 03/04/2024, 03/05/2024 to 05/03/2024, 05/04/2024 to 07/02/2024, 07/03/2024 to 08/31/2024, and 09/01/2024 to 10/30/2024 included all required narrative, yet lacked evidence of a physician signature. The Administrator stated in an interview on 09/26/2024 during a joint review of the clinical records that she had previously seen a missing signature on a Certification of Terminal Illness. Still, she thought it was an isolated incident. Also, she stated she did not look any deeper and did not realize it was a problem in multiple charts.

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary and the patient's record, if requested. This standard was not met as evidenced by clinical record review and interview. In 5 of 6 (83%) clinical records reviewed for patients discharged revealed that the agency did not ensure a discharge summary was provided to the attending physician. Clinical Record 10: The patient was discharged on 03/04/2024. The clinical record contained no evidence of a documented discharge summary, or a discharge summary sent to the attending physician. Clinical Record 11: The patient was discharged on 12/05/2023. The clinical record contained no evidence of a documented discharge summary, or a discharge summary sent to the attending physician. Clinical Record 12: The patient was discharged on 12/11/2023. The clinical record contained no evidence of a documented discharge summary or a discharge summary sent to the attending physician. Clinical Record 13: The patient was discharged on 10/24/2023. The clinical record contained no evidence of a documented discharge summary or a discharge summary sent to the attending physician. Clinical Record 14: The patient was discharged on 09/30/202. The clinical record contained no evidence of a documented discharge summary or a discharge summary sent to the attending physician. The Registered Nurse/Clinical Manager in an interview during a joint review of the clinical record on 09/26/2024, stated she is new to hospice and was not aware a discharge summary was to be sent to the attending physician.

Based on record review and interview, the comprehensive assessments utilized by the agency failed to include the complications and risk factors that would affect care planning for 1 of 5 (Patient #1) Patients reviewed who was admitted into hospice care and hospitalized with multiple wounds in that: The hospice skilled nurses failed to conduct a full head-to-toe that include skin assessment for patient #1 as part of the initial and recertification comprehensive assessment. The failure to conduct and document wound assessment for patient #1 contributed to the Patient's untreated multiple wounds discovered during hospitalization (as reported by the DFPS as indicated on intake #368465) The failure to conduct a full head-to-toe that include skin assessment for patient #1 resulted in the hospice failing to identify areas of skin breakdown and resulted in a failure to provide necessary interventions to prevent development or worsening of wounds. These failures could have resulted in increased pain and discomfort for the Patient as well as an increased risk of infection to wounds in the event they were not appropriately treated. These failures could have impeded the Patient's ability to experience optimal comfort and well-being throughout the dying process. The finding: Patient #1 Review of Patient #1's records revealed POC with SOC dated 04/09/2022 and period reviewed from 04/09/2022 to 07/07/2022 that listed Heart Failure, Essential Primary hypertension, anxiety disorder, depression, Type 2 diabetes mellitus without complications, and Abnormal weight loss as the diagnosis. Service type/frequency include Physician with 2 PRN visit for face-to-face assessment. SN once a week and 2 PRN visits for assessment observation treatment. Review of the IDG physician orders dated 04/09/2022 and 07/07/2022 revealed in part statement that "this information is to assist in documenting palliative care and services necessary for this Patient. The care and services the residents receive should continue to meet standards of practice for nursing services ..." The Physician order identified that skin break down and/or pressure sores are expected with this Patient. RN initial Assessment revealed Braden Scale for prescribing pressure sore risk as 16; indicating that Patient #1 was at risk for developing pressure ulcers. Integumentary documentation of patient #1 having poor skin turgor, and that the skin was dry and warm. DME include gel mattress. Review of the RN initial comprehensive assessment dated 04/09/2022 failed to accurately describe Patient #1's skin conditions/status related to whether or not there was presence of wounds. The initial comprehensive assessment was signed and dated by RN A. Review of RN A weekly visits dated 04/16/2022, 04/22/2022, 04/29/2022, 05/06/2022, 05/14/2022, 05/20/2022, 05/27/2022, 06/03/2022, 06/10/2022, and 06/16/2022, revealed recurrent check off that Patient #1's skin was dry, warm, with poor skin turgor, while RN A's visit documentation on 06/24/2022, and 07/01/2022 revealed check off that Patient #1's skin was dry, warm, clammy, pallor, with poor skin turgor. Review of the CR revealed wound care worksheet section was blank. There was no documentation that RN A promoted intervention or coordinated with the IDT Patient #1's poor skin turgor as documented. There was no documentation that Patient #1 refused skin assessment. Review of RN recertification assessment dated 07/07/2022 failed to include description of patient #1 skin status related to presence of wounds. The wound care worksheet section was blank. The recertification comprehensive assessment was signed and dated by RN B. Further review of patient #1's record revealed SN/RN A visit dated 07/14/2022 with documentation check off that Patient #1's skin was dry, warm, clammy, pallor, with poor skin turgor. There was no documentation that RN B promoted intervention or coordinated with the IDT Patient #1's clammy, pallor, poor skin turgor as documented. Review of record revealed that Patient #1 was admitted to the hospital on 07/14/2022 due to unresponsive status. DFPS report and indicated on intake 368465 revealed documentation of multiple wounds on patient #1's body, it was indicated that the wounds went from Patient #1's bottom to her back, her stomach, inner thighs, and right breast. In an interview at 11:10 a.m. on 09/08/2022 with RN A in the presence of the Admin., RN A was asked if he had performed skin assessment during admission and subsequent SN visits. RN A stated that he never observed Patient #1 skin because Patient #1 was always fully clothed, and Patient #1 was not compliant in taking off her clothing during RN A's visits. The surveyor asks RN A the reason for not documenting Patient #1's non-compliant or refusal. RN A stated that Patient #1 has right to refuse or not compliant with RN A's request. Surveyor ask RN A if he asked Patient #1's caregiver/paid help regarding Patient #1's skin condition or requested that caregiver present during the assessment. RN A stated he did not request for the caregiver's assistance or asked the caregiver about Patient #1's skin status because he usually asked Patient #1 if there was any wound and Patient #1 usually says "no" and he just went by Patient #1's word. Surveyor asked the admi regarding the hospice's policy for frequency of conducting full head-to-toe skin assessments, the admin said the policy was to do them on admission and during subsequent visits. Admin indicated that asking the Patient if they had wound is not sufficient to base a comprehensive assessment. During telephone interview on 09/08/2022 at 12:30p.m. with personal care home caregiver (Identifier #62), Identifier #62 stated that she was never responsible for Patient #1's bathing, grooming, cooking, and cleaning and that Patient #1 never informed her of the wound. Identifier #62 stated that Patient #1 had lived with her for over 20 years, but Patient #1 did not share that she had those types of the wound all over the body. Identifier #62 stated that it was the Hospice nurses that are responsible for checking the Patient's body for wounds. Identifier #62 stated that when she visited the Patient at the hospital and was showed the graphics of the wounds, she "almost passed out" when she saw the wounds all over Patient #1's body. Identifier #62 stated that she never perceived any odor or observed any blood on the Patient #1's clothing. Identifier #62 added that the only reference Patient #1 made to her was on 06/14/2022 when Patient #1 returned from PCP visit and Patient#1 informed her that the PCP had ordered cream and antibiotics, but Patient #1 did not share where to apply the cream or what the antibiotic was meant to do. Telephone Interview at 12:50p.m on 09/08/2022 with RN B, RN B stated that she saw Patient #1's skin during the assessment on 07/07/2022 and the skin was intact. Surveyor informed RN B regarding the hospital description of the wounds and that caregiver acknowledgment of seeing the picture of the wounds, which might not have developed within one week. RN B denied Patient #1 having any wounds. RN B refrained from responding to the surveyor's question whether Patient #1 removed her clothing for RN B to fully assess skin integrity. RN B kept repeating that the Patient #1's skin was intact. Surveyor asked if the RN B reviewed medications Patient #1 was taken and established the use of antibiotic. RN B stated she was not aware of the antibiotic and cream prescribed by the PCP on 6/14/2022. During telephone interview placed by the admin on 09/09/2022 at 2:57 p.m., with the DON, DON stated she "guessed the nurses never saw the wound." surveyor ask for the effect or impact of the RNs not accurately documenting Patient #1's skin status and basing the documentation on subjective assessment only. DON identified the impact as not having detailed information about the Patient leading to lack of providing quality of care. Admin stated that the impact of not having detail assessment leads to not having a plan of care established and it appears that the agency was not giving total care to the Patients according to law and guidance. Review of the hospice's policy and procedure manual titled, "Assessment" labeled JCC 013115 Hospice-CHAP read in part, "the hospice must conduct and document in writing a patient-specific comprehensive assessment that identified the patient's need for need for hospice care and services, and the patient's need for physical, psychosocial, emotional and spiritual care. Content of the Comprehensive Assessment. 1. The comprehensive assessment will: a. Include all areas of hospice care related to the palliation and management of the patient's terminal illness and related conditions b. Accurately reflect the patient's health status at the time of the comprehensive assessment and include information to establish and monitor a plan of care..." Hospice Nursing Care," dated 1995, which indicted, "The hospice registered nurse performs initial, comprehensive and ongoing comprehensive assessments regarding the impact of the terminal diagnosis on the patient's physical, functional, psychosocial, and environmental needs and activities of daily living."

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 drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by clinical record review and interview. In 1 of 6 (17%) clinical records reviewed it was revealed the records did not have an updated drug profile in accordance with agency policy. Record # 98251: The patient had physician orders written on 9/20/2021 that included the use of Santyl and Zinc Oxide for wound care to the left foot. These medications were not present on the medication profile. The Alternate Administrator and Director of Nursing were interviewed on 11/10/21, and stated the medications within the records identified were not updated on the POC.

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. Includes all services necessary for the palliation and management of the terminal illness, including the following: Intervention to manage pain and symptoms; A detailed statement of the scope and frequency of services necessary to meet specific patient and family needs; Measurable outcomes anticipated from implementing and coordinating the plan of care; Drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. 1 of 3 (33%) clinical records reviewed revealed that the plan of care did not include all required elements. Record # 98251 was reviewed and identified the patient elected hospice care on 9/20/2021. An order was written for wound care on 9/20/2021. Nursing Notes and Plans of Care were reviewed for the time range of 9/20/2021-10/23/2021. In review of the Plans of Care on 9/28/2021 and 10/12/2021, specific wound care interventions were not on the plan of care. The Alternate Administrator and Director of Nurses were interviewed on 11/1020/21, and stated there were no wound care interventions on the plan of care.

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; Information about the medical management of any of the patient's conditions unrelated to the terminal illness. This standard was not met as evidenced by clinical record review and interview. 2 of 6 (33%) clinical records reviewed revealed that the physician evaluation of clinical info for the CTI did not clearly state the patients primary hospice diagnosis. . Record #68973 was reviewed and identified the patient elected hospice care on 9/20/2021. The initial CTI failed to clearly identify the patient's primary hospice diagnosis. The clinical record review revealed information on the CTI that stated the patient was "a 74 yo F with a PMHx significant for severe debilitation with bedbound status as evidenced by chronic sacral decubitus ulcer requiring 24 hour care and supervision". The RN comprehensive nursing assessment dated 9/20/2021 indicated in part "Patient is a 63 year old Male diagnosed with Chronic diastolic (congestive) Heart Failure...". Record #92269 was reviewed and identified the patient elected hospice care on 9/20/2021. The initial CTI failed to clearly identify the patient's primary hospice diagnosis. The clinical record review revealed information on the CTI that stated the patient was "a 63yo male with PMHx significant for Dementia...". The initial assessment from the RNCM on 9/20/2021 stated, "Patient is a 74-year old Female diagnosed Heart Failure...". The Alternate Administrator and Medical Director were interviewed on 11/10/2021 and stated there was no primary hospice diagnosis included in the documented CTI.

It is required that all entries in the patient record are legible, complete, and appropriately authenticated and dated by the person performing the care/service in accordance with hospice policy and with currently acceptable standards of practice. The hospice has a means to authenticate entries or to identify the author of each entry. If the hospice uses electronic records, electronic authentication utilizes a user ID and password protection. This standard was not met as evidenced by clinical record review and interview. In 3 of 6 (50%) clinical records reviewed, the CTI was not signed or dated by the Hospice Medical Director. Record #68973 was reviewed and identified the patient elected hospice care on 9/20/2021. There was no evidence that the CTI was signed or dated by the Hospice Medical Director. Record #92269 was reviewed and identified the patient elected hospice care on 9/20/2021. There was no evidence that the CTI was signed or dated by the Hospice Medical Director. Record #27126 was reviewed and identified the patient elected hospice care on 9/25/2021. There was no evidence that the CTI was signed or dated by the Hospice Medical Director. The Alternate Administrator was interviewed on 11/10/2021, and verified that the CTI was not signed or dated by the Hospice Medical Director.