Every finding on record at Big Bend Hospice, Inc.

It is required that the hospice Interdisciplinary Group, in consultation with the individual's attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review and interview. In 2 of 30 (7%) records reviewed revealed the agency did not ensure that the social worker completed the initial psychosocial assessment within the five-day requirement. Clinical Record 13: Patient elected the hospice benefit on 8/11/23. In the interdisciplinary team meeting notes, held on 8/17/23, the social worker (SW) documented "pending assessment." The initial SW visit was completed on 8/22/23 which was day 11. The record did not contain documentation as to why the initial SW visit was conducted outside of the 5-day requirement. Clinical Record 14: Patient elected the hospice benefit on 8/15/22. Clinical note from 8/22/23 documented "SW returned back from vacation leave today. Request made by Social Services Supervisor for this SW to complete the initial comprehensive assessment. SW spoke with patient via phone regarding SW & his role & schedule visit." Patient requests this writer meet with him tomorrow (8/23/23)." SW visit was documented as completed on 8/23/23 which was day 8. The record did not contain documentation that attempts had been made to complete the SW assessment within the 5-day requirement. Personnel Record 4: The chief compliance officer and the RN coding compliance specialist reviewed the two clinical records above and confirmed that the psychosocial/SW initial visits were not completed within the five-day requirement. They also reported that there was no further evidence to present to support why the visits were delayed.

It is required that the comprehensive assessment includes an initial bereavement assessment of the needs of the patient's family and other individuals, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. This standard was not met as evidenced by clinical record review and interview. In 2 of 30 (7%) records reviewed revealed the agency did not ensure that the bereavement needs were assessed within the five-day initial comprehensive assessment period. Clinical Record 13: Election of hospice benefit was 8/11/23. Initial social work (SW) assessment that was completed on 8/22/23 (day 11) contained the bereavement risk assessment; however, every question was answered "unknown." The clinical record included multiple notes where hospice team members had been in contact with the primary care giver however there was no documentation that attempts were made to complete the bereavement risk assessment. The plan of care contained the problem "anticipatory grief" with a start date of 8/22/23, there was no documentation to support how this was determined to be a problem. Clinical Record 14: Election of benefit was 8/15/23. Initial social work assessment that was completed on 8/23/23 (day 8) contained the bereavement risk assessment; however, every question was answered "unknown" with an additional comment, "SW will follow up with primary care giver." As of the date of the record review 9/14/23 there was no documentation showing that follow up attempts had been made. The plan of care contained the problem "anticipatory grief" with a start date of 8/29/23, there was no documentation to support how this was determined to be a problem. Personnel Record 4: On 9/14/23 the chief compliance officer and RN coding and compliance specialist confirmed that neither of these records contained evidence the initial bereavement risk assessments were completed.

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 clinical record review, interview and observation. In 3 of 30 (10%) records reviewed revealed the agency did not ensure the plans of care contained individualized interventions based on problems identified within the comprehensive assessments. Clinical Record 2: Patient elected the hospice benefit on 10/26/22. Nursing comprehensive assessment, dated 7/25/23, documented the patient "tells the writer she fell on the floor and landed on left shoulder. No deformity or bruising noted." Plan of care, effective for the benefit period 6/23/23 to 8/21/23 and the current benefit period, effective from 8/22/23 to current, did not include any problems, goals, or interventions related to fall prevention or safety. Clinical Record 5: Clinical record review revealed a hospice admission date of 3/17/23 with a diagnosis of Alzheimer's disease and comorbidity of dysphagia. RN comprehensive assessment, dated 8/29/23 stated, "He is on a mechanical soft diet with thickened liquids." The nurse also documented, "His skin is fragile often has at least 1 skin tear on extremities. He has 2 lesions on left upper back that are non-healing." The plan of care effective as of 8/29/23 listed "diet as tolerated" and did not include any problems, goals, or interventions to address the dietary needs, wounds, or skin issues. Furthermore, during the home visit observation on 9/12/23, with the hospice agency chaplain (staff 20) the wife mentioned the patient had suffered a fall shortly after admission and they were now using pillows as bolsters to help keep him from falling out of bed. Record review revealed documentation of patient falls on 4/20/23 and on 5/23/23. Plan of care, effective 3/17/23 to current, did not include any problems, goals, or interventions related to fall precautions or safety. Clinical Record 20: Initial comprehensive assessment dated 9/1/23 documented the patient had a chest tube intact to left lung. Nursing visit note on 9/6/23 revealed to the tube remained in place and drained serosanguinous fluid. The plan of care, effective from 9/1/23 to current, did not include any problems, goals, or interventions related to the chest tube. Personnel Record 4: The chief compliance officer and RN coding and compliance specialist, confirmed during the interview on 9/14/23 that the plans of care should have included interventions related to the above problems identified within the comprehensive assessments.

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 1 of 17 (6%) records reviewed, in which aide services were accepted, revealed the agency did not ensure the RN provided the aide with specific instructions thus leaving the aide to make decisions which was outside the scope of practice. Clinical Record 19: Hospice aide plan of care, effective from 3/27/23 to current, listed the following relevant tasks: float heals, elevate legs, elevate arms for comfort and elevate head of bed, all of these tasks included the modifier "per need" and did not provide the aide with further instructions on how to define "per need." Furthermore, the aide care plan did not indicate rather or not the patient was a decision maker to provide the instruction to the aide. Personnel Record 4: During the joint interview, conducted on 9/13/23, with the chief compliance officer and the RN coding and compliance specialist, it was confirmed that using "per need" on the aide care plan was not acceptable and they reported they "already had the RN fix it."

It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. This standard was not met as evidenced by clinical record review and interview. In 2 of 17 (12%) records reviewed, in which aide services were accepted, revealed the agency did not ensure that the aide reported changes in the patient's condition to the RN and that the communication was documented within the clinical records. Clinical Record 6: Hospice aide visit note dated 7/12/23 documented, "patient yelled out during repositioning in bed." The hospice aide visit note dated 7/14/23 documented, "patient had some pain during repositioning. Patient's family stated next bath visit they will administer the patient pain medication before my arrival." The record did not contain documentation the RN was notified during nor after either visit. Clinical Record 19: Hospice aide visit note dated 9/5/23 documented, "patient stated she did not feel good, her legs hurt." This same visit note included the task "report patient condition changes and/or concerns to Hospice Nurse - per visit." For this task the aide documented, "no concerns/issues noted." The record did not contain any additional documentation to indicate the RN was notified. Personnel Record 4: During the joint interview with the chief compliance officer and the RN coding and compliance specialist, on 9/14/23, it was confirmed that the aide should have contacted the RN, but they were unable to locate any documentation that this had occurred. No additional information was provided prior to the end of the site visit.

It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services and, as necessary, provides in-service training and education programs where required. This standard was not met as evidenced by interview and personnel record review. In 1 of 17 (6%) personnel records reviewed, in which assessment of skills and competencies were required, revealed the agency did not ensure that the records contained documented evidence of completion. Personnel Record 15: Personnel record review revealed this staff member was hired on 3/21/22 for the role of RN/Team Manager for one of the alternate delivery sites. Personnel record was missing the initial skills competency. Per the interview with the human resources manager on 9/15/23, the employee is currently out on medical leave but "probably has a copy of this." Personnel Record 4: At the time of the exit conference, on 9/15/23, the chief compliance officer reported that they were still unable to locate a copy of the initial competency for this individual.