Every finding on record at Big Hittters, LLC

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. Agency policy "Interdisciplinary Group (IDG) Plan of Care" stated in part, "The IDG plan of care is developed, reviewed, and revised based on the findings of the initial comprehensive assessments, as well as updated comprehensive assessments conducted through the patient's family's care." In 1 of 14 (7%) clinical records reviewed, the agency did not ensure that the plan of care included planned interventions based on problems identified in the initial and updated comprehensive assessments. Clinical Record 14: The patient elected the hospice benefit on 01/ 21/2025. The updated nursing assessment dated 04/04/2025 documented that the patient had increased difficulty with constipation. Physician orders were written for Senna (laxative for constipation) and Dulcolax (laxative). The updated plans of care dated 04/11/2025, 04/25/2025, and 05/09/2025 did not include an intervention or goal for the patient's identified problem with constipation. During an interview and a joint record review on 05/22/2025, the Vice President of Quality, who reviewed the records, stated that the plans of care had not been updated with the intervention and goal for the problem identified in the updated assessments.

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] 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. In 3 of 14 (21%) clinical records reviewed, the agency did not ensure that the patient's updated plan of care included progress toward the outcomes and goals specified in the plan of care. Clinical Record 2: The patient elected hospice care on 05/16/2024. Occupational therapy was ordered. The Occupational Therapist (OT) evaluated the patient on 05/23/2024. OT visits were ordered one (1) time a week through 07/12/2024 for the right upper extremity range of motion, ADLS (activities of daily living), and adaptive equipment needs. On 06/03/2024, the physician ordered physical therapy (PT) for evaluation and treatment with weekly visits through 07/12/2024. The interdisciplinary team meetings dated 06/07/2024 and 07/05/2024 documented an update in the patient's progress toward OT goals, but no documentation of progress in the PT goals. The interdisciplinary team (IDG) meeting dated 06/21/2024 did not document an update in the patient's progress toward goals from PT or OT. The PT had goals for gait training and strengthening, as well as balance. The last PT visit was 07/01/2024. Clinical Record 11: The patient elected hospice care on 03/27/2025. On 04/02/2025, the physician ordered PT to evaluate and treat. PT services were ordered weekly for 4 weeks. A Physical Therapist Assistant (PTA) provided the visits with strengthening exercises, walking safety, and strengthening. The IDG meeting on 04/11/2025 documented the PT order. The IDGs dated 04/25/2025 and 05/09/2025 did not document an update in the patient's progress toward goals for PT. The last PTA visit was dated 04/23/2025 and documented the education to the caregivers for: safety in transfer and walking, the need to continue exercises for strength and balance, and to engage their core for maintaining strength and balance. Home exercises were provided. None of the updates or progress toward PT goals were documented at the IDG meetings dated 04/25/2025 or 05/09/2025. Clinical Record 14: The patient elected hospice care on 01/21/2025. On 02/17/2025, the physician ordered PT services with the first PT visit note dated 02/21/2025. PT services were ordered weekly through 03/13/2025 for strengthening and safety, with a home exercise program provided. No progress toward the PT goals or updates were documented during the IDGs dated 02/28/2025 or 03/14/2025. During the interview on 05/21/2025, the Vice President of Quality stated that the goals and updates had not been documented on the IDG (interdisciplinary meeting) documents.

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; use of gloves, mask, eye protection, or face shield depending on anticipated exposure. This standard was not met as evidenced by document review, interview, and observation. Agency policy "Engineering Control and Work Practices" stated in part, "Employees who encounter patients or regulated biohazardous waste practice the following good hand-washing behaviors to reduce exposure and prevent the spread of bloodborne pathogens and other infections. Employees wash their hands immediately before gloves and other PPE and immediately after removing gloves and other PPE." In 1 of 3 (33%) home visits observed, the agency did not ensure that hand hygiene was performed when indicated per the agency policy. Home Visit 3: During the home visit with the Registered Nurse (RN) [Personnel Record 5] on 05/21/2025, the RN set up their field to provide wound care on the patient's left foot, performed hand hygiene and donned gloves, and the old dressing was removed and discarded. The RN doffed the gloves, sanitized their hands, and donned new gloves. The draining wound was cleaned and patted dry, gloves were doffed, and new gloves donned. The RN did not sanitize their hands between glove changes. The foot was re-dressed per the physician's orders, and gloves were removed and hands sanitized. During the interview on 05/21/2025, the Vice President of Quality stated that hand sanitizing between glove changes was expected.

It is required that volunteers be used in day-to-day administrative and/or direct patient care roles. Volunteer services provided to patients/families are in a defined role and under the supervision of a designated hospice employee. Volunteer services are: noted in the plan of care; [and] documented in the patient record, including the time spent. This standard was not met as evidenced by clinical record review and interview. In 2 of 9 (22%) clinical records reviewed of patients with an identified need for volunteer services, the agency did not ensure that the volunteer services were provided. Clinical Record 1: The patient elected the hospice benefit on 04/20/2025. The initial nursing comprehensive assessment, dated 04/29/2025, documented that the patient would enjoy having a volunteer. The initial psychosocial assessment dated 05/05/2025 documented that the patient and family were responsive to having a volunteer for socialization and card playing. The interdisciplinary team (IDG) dated 05/09/2025 did not document volunteer services or progress toward the identified patient need. A clinical record review on 05/21/2025 revealed no coordination related to the plan for the volunteer or documentation from the volunteer coordinator. Clinical Record 12: The patient elected the hospice benefit on 03/04/2024. The IDG meeting dated 03/29/2024 documented that a volunteer had been requested, and the placement of a volunteer was being worked on. The next IDG, dated 04/11/2024, did not document an update as to whether a volunteer had been found or that there was any follow-up with this request. A clinical record review revealed no documentation of what became of this volunteer request. As of this review on 05/20/2025, the patient has not had a volunteer. No volunteer was provided during the first benefit period dated 03/04/2024 through 06/01/2024. During an interview and a joint record review on 05/21/2025, the Vice President of Quality called the Volunteer Coordinator, who stated that the patient's needs were more related to spiritual care needs, and that spiritual care visits were increased to meet the need. A late entry into the record to explain this was then completed. They agreed that the Chaplain had increased frequency, but the explanation had not related to the Volunteer not being needed.

It is required that a patient's 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. In 1 of 14 (7%) clinical records reviewed, the agency did not ensure that the patient's clinical record included physician orders for all care and services. Clinical Record 12: The patient elected the hospice benefit on 03/04/2024. On 03/22/2024, the physician ordered a Foley catheter, with directions for the catheter to be changed as needed. The skilled nurse (SN) visited and inserted the catheter. The updated SN assessments dated 05/28/2024 and 04/30/2025 documented that the Foley catheter was flushed - it was not documented what it was flushed with or how much solution. The plan of care did not document interventions for flushing the catheter, and there was no documented physician order to flush the catheter. There were no documented procedures presented that documented that catheter care would include a process to flush. During the interview and a joint record review on 05/21/2025, the Vice President of Quality stated that there was no physician order to flush the catheter and that an order should have been documented.

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 a review of clinical records, document review and interviews. The Policy, "Interdisciplinary Group (IDG) Plan of Care (POC)", states in part, "Policy: The IDG plan of care reflects patient/family goals and interventions based on the findings of the initial and updated comprehensive assessments." 3 of 5 (60%) clinical records reviewed revealed the individualized written plans of care lacked patient and family goals and interventions based on problems identified in the initial and updated comprehensive assessments. Clinical Record 5: The patient was admitted on 12/8/22 with a diagnosis of Parkinson's Disease. The Certificate of Terminal Illness (CTI) dated 12/8/22 for the benefit period 12/8/22 through 3/7/23 stated the patient had oropharyngeal dysphasia. The IDG POC dated 12/8/22 lacked a goal and interventions for dysphasia. Clinical Record 2: The patient was admitted on 1/26/23 with a diagnosis of Hypertensive Heart Disease without Heart Failure. The CTI dated 1/26/23 for the benefit period 1/26/23 through 4/25/24) stated the patient had urinary incontinence. The IDG POC lacked a goal and interventions for urinary incontinence. Clinical Record 1: The patient was admitted on 1/11/23 with a diagnosis of CHF (congestive heart failure). Physical Therapy (PT) was ordered on 1/11/23 to evaluate and treat for patient safety and oxygen use. There is supportive documentation that the patient had declined PT initially and asked to start on 2/8/23. The PT evaluated the patient on 2/8/23. The interdisciplinary group (IDG) plan of care (POC) dated 2/9/23 lacked goals and interventions for the PT. Upon interview on 2/22/23, the Director of Healthcare Services and the Director of Hospice reviewed the records and agreed with the findings.

It is required that the hospice discharge summary provided to a facility receiving a hospice patient for care—or to the patient’s community attending physician upon hospice discharge—includes a summary of the patient’s hospice stay, including treatments, symptoms, and pain management. This standard was not met as evidenced by a review of clinical records, document review and interviews. The policy, "Transfer, Benefit Revocation and Discharge", states in part, "Procedure: 7. The hospice discharge summary documented by a designated Interdisciplinary Group (IDG) member includes at least the following: a) A summary of the patient's stay, including treatments, symptoms and pain management...." 1 of 2 (50%) clinical records reviewed of patients/family who either revoked the hospice benefit or transferred to another hospice lacked a discharge/transfer summary in accordance with the agency's discharge policy. Clinical Record 4: The patient was admitted on 10/25/22 with a diagnosis of Senile Degeneration of the Brain. The family revoked the hospice benefit on 12/28/22. The record lacked evidence of a completed discharge summary. The record included a completed discharge visit note that failed to include the required summary elements of the patient's hospice stay, including treatments, symptoms, and pain management. Upon interview on 2/22/23, the Director of Healthcare Services and the Director of Hospice Services reviewed the record and agreed with the finding. The Director of Healthcare Services stated the electronic medical record company was in the process of developing a discharge/transfer summary form. NOTE: An interim form was created by the agency and implemented in 1/2023. THIS FORMER REQUIRED ACTION CONTINUES at a lower rate of non-compliance than previously cited (100%)

It is required that the hospice implements emergency preparedness (EP) policies and procedures, based on the emergency plan, the risk assessment, and the communication plan. The policies and procedures address: development and inclusion of a plan for each hospice patient during a natural or man-made disaster as part of a patient/family comprehensive assessment and the documented discussion of the plan provided to the patient/family, and maintained by the hospice. Policies and procedures are reviewed and updated at least every two (2) years. This standard was not met as evidenced by a review of clinical records, document reviews, interviews, and observations. In 2 of 8 (16%) clinical records reviewed did not ensure agency policy for the Emergency/Disaster Risk Classification category was followed. Additionally, no written plan was provided to the patients upon admission to service to follow in case of emergency in 8 of 8 (100%) clinical records. Clinical Record 7: Election of Hospice Benefit dated 04/24/2022. No documentation of emergency risk level in the clinical record as of review date 08/09/2022. Additionally, no evidence of a patient-specific emergency plan is provided for the patient regarding what to do during a disaster. Clinical Record 2: Election of Hospice Benefit dated 07/01/2022. There is no documentation of a patient-specific emergency risk level in the clinical record as of 08/09/2022. Additionally, during the observed visit on 08/10/2022, no evidence of an emergency plan was provided for the patient regarding what to do during a disaster. The interview with the Administrator stated that the home health program has a one-page form provided to patients. I think we will use that. Clinical Record 0: Election of Hospice Benefit dated 06/09/2022 and observed visit 08/10/2022, no documented emergency plan provided on admission or as of visit date for the patient. Clinical Record 5: Election of Hospice Benefit dated 05/18/2022 and observed visit 08/09/2022 no documented emergency plan provided on admission or as of visit date for the patient. Clinical Record 4: Election of Hospice Benefit dated 01/18/2022, no documented patient-specific emergency plan provided on admission or as of review date 08/10/2022. Clinical Record 3: Election of Hospice Benefit dated 02/25/2022, no documented patient-specific emergency plan provided on admission or as of review date 08/10/2022. Clinical Record 1: Election of Hospice Benefit dated 05/31/2022, no documented patient-specific emergency plan provided on admission for the patient. Clinical Record 6: Election of Hospice Benefit dated 01/03/2022, no documented patient-specific emergency plan provided on admission for the patient. Agency Policy Emergency Preparedness [date 11/29/2019] stated in part, "upon admission, and as needed according to changes in the patient's status, the assessing employee/contractor assigns an Emergency/Disaster Risk Classification category to each patient." Agency Policy Emergency Preparedness [date 11/29/2019] stated in part, "upon admission, and as needed according to changes in the patient's status, the assessing employee/contractor assigns an Emergency/Disaster Risk Classification category to each patient."

It is required that the hospice informs and distributes to the patient written information about its policies on advance directives, including a description of applicable state law. It is the patient’s right to formulate an advance directive should she or he wishes to do so. This standard was not met as evidenced by a review of clinical records, document reviews, and interviews. In 8 of 8 (100%) clinical records reviewed, the agency did not ensure their policy to provide advanced directive policy to patients was followed. Clinical Record 5: Election of Hospice Benefit was signed on 05/18/2022. The agency policy on advanced directives was not provided to the patient/family. Clinical Record 7: Election of Hospice Benefit was signed on 04/24/2022. The agency policy on advanced directives was not provided to the patient/family. Clinical Record 2: Election of Hospice Benefit was signed on 07/01/2022. The agency policy on advanced directives was not provided to the patient/family. Clinical Record 0: Election of Hospice Benefit was signed Hospice Benefit on 06/09/2022. The agency policy on advanced directives was not provided to the patient/family. Clinical Record 1: Election of Hospice Benefit was signed Hospice Benefit on 05/31/2022. The agency policy on advanced directives was not provided to the patient/family. Clinical Record 4: Election of Hospice Benefit was signed on 01/018/2022. The agency policy on advanced directives was not provided to the patient/family. Clinical Record 3: Election of Hospice Benefit was signed on 02/25/2022. The agency policy on advanced directives was not provided to the patient/family. Clinical Record 6: Election of Hospice Benefit was signed on 01/03/2022. The agency policy on advanced directives was not provided to the patient/family. Agency Policy, Admission to Hospice Care [08/03/2018] stated in part, "The individual is provided the appropriate admission documentation, as well as a verbal description of the documentation, which includes, but is not limited to: The [agency name] policies regarding Advance Directives, as well as applicable state law and regulation." The interview with the Administrator stated we ask for their Power of Attorney, Living Will, and Do Not Resuscitate, but I did not know we had to provide more than that. Agency Policy, Admission to Hospice Care [08/03/2018] stated in part, "The individual is provided the appropriate admission documentation, as well as a verbal description of the documentation, which includes, but is not limited to: The [agency name] policies regarding Advance Directives, as well as applicable state law and regulation."

It is required that the written Patient Bill of Rights includes the right to: choose his or her attending physician. This standard was not met as evidenced by a review of clinical records, document review, and interviews. In 1 of 8 (08%) clinical records reviewed did not ensure the agency followed their policy for choice of attending physician. Clinical Record 5: Election of Hospice Benefit on 05/18/2022. The consent is signed by the patient's power of attorney but is blank for the attending physician's choice. The interview with the Case Manager stated that the choice of Physician was for the Hospice Medical Director to care for the patient but agreed that the consent was blank and the physician choice was not documented as of review 08/09/2022. Admission Consent Form number 10. Right to Choose Attending Physician stated in part, "I understand that I have the right to designate my attending physician." Then there are two boxes to identify the desire to not choose an attending physician or acknowledge the choice of attending physician with the date specified. Interview with Administrator stated we verified all information, but it was not documented. Admission Consent Form number 10. Right to Choose Attending Physician stated in part, "I understand that I have the right to designate may attending physician." Then there are two boxes to identify the desire to not choose an attending physician or acknowledge choice of attending physician with date specified.

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, supplements, herbal remedies, and other alternative treatments that could affect drug therapy. 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. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and, as appropriate, preventive measurements are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when a new medication is added, or changes are made to existing medication. This standard was not met as evidenced by a review of clinical records, document review, and interviews. In 1 of 8 (08%) clinical records reviewed, the agency did not ensure all medications were documented on the medication profile and reviewed for all interactions. Clinical Record 5: Comfort Kit containing Oxycodone [pain medication], Levsin [comfort medication], and Lorazepam [medication for anxiety] was prescribed for the patient upon admission on 6/29/2022, the comfort kit medications were not documented on the initial drug profile or updated medication profile. Agency policy Drugs and Biologicals - Administration, Use and Disposal dated 06/08/2021 stated in part, "Each patient's drugs, biologicals, over-the-counter drugs, herbal remedies, and alternative treatments (e.g., alternative medications/supplements) are identified on the medication profile as part of the interdisciplinary Group (IDG) plan of care." Interview with the Case Manager stated that I did not realize the system did not update the medication profile. Agency policy Drugs and Biologicals - Administration, Use and Disposal dated 06/08/2021 stated in part, "Each patient's drugs, biologicals, over-the-counter drugs, herbal remdies and alternative treatments (e.g., alternative medications/supplements) are identified on the medication profile as part of the interdisciplinary Group (IDG) plan of care."

It is required that each patient’s individualized written plan of care: a detailed statement of the scope and frequency of services necessary to meet specific patient and family needs. This standard was not met as evidenced by a review of clinical records, document review, and interviews. In 2 of 8 (16%) clinical records did not ensure agency policy was followed to include the complete scope and frequency of services provided on the plan of care. Clinical Record 5: Election of Hospice Benefit 05/18/2022. The Plan of Care (POC) dated 5/20/2022 documented the volunteer visit frequency was "three," effective 6/18/2022, ending 8/15/2022 prn. There was no description as to for what reason a prn visit would be done. The social work visit frequency is beginning 05/20/2022 documented a frequency of two times a month starting 6/29/2022, ending 8/30/2022, 1wk12, PRN start 6/29/2022, ending 9/16/2022. There was no description as to for what reason a prn visit would be done. Interview with the Administrator and Case Manager stated that the Social worker and Chaplain were struggling to learn how to document frequencies and that more time would be spent with them. Clinical Record 3: The Plan of Care was 4/22/2022. The visit frequency for spiritual care was the number three and 03/28/2022 - 06/22/2022 PRN. Then 1 every other week 6 and then dates 03/25/2022 - 06/10/2022. This is unclear for what the 3 was and the ow was not a clear frequency. The frequency for Skilled Nurse 1w14 03/25/2022 - 06/22/2022 PRN was unclear for how many prn visits were to be provided. The interview with the Administrator stated that nursing would fix all unclear frequencies for nursing and more work to train social workers and chaplains. Agency Policy Interdisciplinary Group Plan of Care [6/21/2013] stated in part, "The plan of care includes, but is not limited to a detailed statement of the scope and frequency of services necessary to meet identified patient/family needs." Agency Policy Interdisciplinary Group Plan of Care [6/21/2013] stated in part, "The plan of care includes, but is not limited to a detailed statement of the scope and frequency of services necessary to meet identified patient/family needs."

It is required that each patient’s individualized written plan of care: drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by a review of clinical records, document review, and interviews. In 1 of 8 (13%) clinical records reviewed did not include all medications the patient was taking on the plan of care. Clinical Record 5: Admitted on 05/18/2022 with a comfort kit ordered on this date that included Oxycodone [pain medication], Levsin [comfort], and Lorazepam [anxiety]. These medications were all initiated on 05/18/2022. A review of the initial plan of care and updated plans of care as of 08/11/2022 did not document any evidence of these medications on the plan of care. Agency Policy, Interdisciplinary group plan of care, [06/21/2013] stated in part, "The plan of care includes, but is not limited to the following: drugs and treatment, medical supplies and medical appliances necessary to meet the needs of the patient." Interview with the Case Manager on 08/11/2022 stated that the comfort kit was started on admission and is still in use. The medications should have been on the care plan but agreed they were not. Agency Policy, Interdisciplinary group plan of care, [06/21/2013] stated in part, "The plan of care includes, but is not limited to the following: drugs and treatment, medical supplies and medical appliances necessary to meet the needs of the patient."

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: a revised plan of care includes: information from the patient’s updated comprehensive assessment and 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 a review of clinical records, document review, and interviews. In 1 of 8 (8%) clinical records reviewed, the plan of care did not reflect patient progress and goals. Clinical Record 7: The patient was admitted on 04/24/2022 but admit discussion was on an interdisciplinary note dated 04/18/2022. (The IDT meeting was held six days prior to admission but documented the admission). On 05/02/2022 the next IDT meeting was held, and no update was documented on the progress of the patient who had plans to be transferred on 05/13/2022. Agency Policy Interdisciplinary Group Plan of care [12/02/2008] stated in part, "The Interdisciplinary Group (IDT) plan of care reflects patient/family goals and interventions based on the findings of the initial and updated comprehensive assessments." Interview with the Administrator who scribed for all IDT meetings and stated that the dates made no sense and were not sure how the meeting on 05/02/2022 was not updated as the patient was discussed. The software company was notified, and the technology dated the note incorrectly related to the date that the note was closed. Agency Policy Interdisciplinary Group Plan of care [12/02/2008] stated in part, "The Interdisciplinary Group (IDT) plan of care reflects patient/family goals and interventions based on the findings of the initial and updated comprehensive assessments."

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: signed copies of the notice of patient rights and the hospice election statement. This standard was not met as evidenced by a review of clinical records, document review, and interviews. In 1 of 8 (13%) clinical records reviewed, the agency did not ensure a signed election statement was complete per agency policy. Clinical Record 5: The patient was admitted on 5/18/2022 with a documented signed consent on that date. The hospice benefit of election date was blank on this form as of 08/09/2022. Agency Policy Admission to Hospice Care [08/03/2018] stated in part, "The individual is provided the appropriate admission documentation, as well as a verbal description of the documentation, which includes but is not limited to a signed consent and election of hospice care statement." Interview with the Case Manager and Administrator, who stated that the information was discussed with a power of attorney (POA) on admission, and the form was sent to the POA for signature. The form was signed, but the hospice benefit of election date was blank. Policy Admission to Hospice Care [08/03/2018] stated in part, "The individual is provided the appropriate admission documentation, as well as a verbal description of the documentation, which includes but is not limited to a signed consent and election of hospice care statement."

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 certification and recertification of terminal illness as required. This standard was not met as evidenced by a review of clinical records and interviews. In 4 of 8 (50%) clinical records reviewed, the agency did not ensure that the required physician certification for the first benefit period was completed. Clinical Record 6: First benefit period admission date of 1/31/2022 certification of terminal illness completed by Medical Director, the agency failed to obtain Attending Physician certification. as of review 8/11/2022. Clinical Record 2: First benefit period admission date of 7/01/2022, certification of terminal illness completed by Medical Director, the agency failed to obtain Attending Physician certification as of 8/11/2022. Clinical Record 7: First benefit period admission date of 4/24/2022, certification of terminal illness completed by Medical Director, the agency failed to obtain Attending Physician certification as of 8/11/2022. Clinical Record 4: First benefit period admission date of 1/18/2022, certification of terminal illness completed by the Medical Director, the agency failed to obtain Attending Physician certification. as of review 8/11/2022. The interview with the Administrator stated that we did not understand our software and needed the second signature during the first benefit period.

It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid/MediCal-certified facility, the hospice forwards to the receiving facility a copy of: the hospice discharge summary described in HCDT 40. I; and the patient’s record, if requested. This standard was not met as evidenced by a review of clinical records, document reviews, and interviews. In 1 of 1 (100%) clinical record review of a live discharge to a Medicare provider did not ensure a discharge summary was sent to the provider. Clinical Record 7: Election of the Hospice Benefit was signed on 04/24/2022, and the patient was transferred on 05/13/2022 to another hospice as the patient was moving out of the area. The discharge visit on 05/13/2022 stated that the hospice did not need anything. There was no discharge summary documented in the record. There was no evidence as of review on 08/10/2022 that any documentation was sent to the hospice. Agency Policy, Transfer, Benefit Revocation or Discharge [06/21/2022] stated in part, "When the patient/family is transferring to another hospice provider, the designated Registered Nurse ensures that the following information is provided to the receiving provider: the hospice discharge summary and if requested, a copy of the patient/family record." The interview with the Case Manager stated that a call was made to the hospice, but no information was sent and that the hospice was to call if they wanted information. Agency Policy, Transfer, Benefit Revocation or Discharge [06/21/2022] stated in part, "When the patient/family is transferring to another hospice provider, the designated registered nurse ensures that the following information is provided to the receiving provider: the hospice discharge summary and if requested , a copy of the patient/family record."

It is required that the hospice discharge summary provided to a facility receiving a hospice patient for care—or to the patient’s community attending physician upon hospice discharge—includes at least the following: A summary of the patient’s hospice stay, including treatments, symptoms, and pain management, the patient’s current plan of care, the patient’s latest physician orders, and any other documentation that will assist in the post-discharge continuity of care or that is requested by the receiving facility or the attending physician. This standard was not met as evidenced by a review of clinical records, document review, and interview. In 3 of 3 (100%) clinical records reviewed of patients that had a live discharge, the agency did not ensure a complete discharge summary was provided to the receiving provider. Clinical Record 4: Live discharge on 04/15/2022. There was no discharge summary documented as of review date 08/10/2022. Clinical Record 3: Live discharge on 06/28/2022. There was no discharge summary documented as of review date 08/10/2022. Clinical Record 7: Live discharge on 05/13/2022. There was no discharge summary documented as of review date 08/10/2022. Agency Policy, Transfer, Benefit Revocation or Discharge [06/21/2013] stated in part, "The hospice discharge summary documented by a designated interdisciplinary group member includes at least the following: a summary of the patient stay, including treatments, symptoms and pain management; the current interdisciplinary plan of care, the latest physician orders relating to the care of the patient and any other documentation that supports post discharge continuity of care or is requested by the attending physician or physician designee or the receiving provider." The interview with the Case Manager stated that written instructions were provided to the patient on the last visit, but no discharge summary was documented in the record. Agency Policy, Transfer, Benefit Revocation or Discharge [06/21/2013], stated in part, "The hospice discharge summary documented by a designated interdisciplinary group member includes at least the following: A summary of the patients stay, including treatments, symptoms and pain management; the current interdisciplinary plan of care, the latest physician orders relating to the care of the patient and any other documentation that supports post discharge continuity of care or is requested by the attending physician or physician designee or the receiving provider."

It is required that when controlled medications are first ordered, a copy of the hospice’s written policies and procedures for the management and disposal of controlled medications is provided to the patient or family or patient’s legal representative(s). The Interdisciplinary Group: documents in the patient record that the policies and procedures for managing and disposing of controlled medications is provided and discussed. This standard was not met as evidenced by a review of clinical records, document reviews, and interviews. In 8 of 8 (100%) clinical records reviewed, the agency did not ensure the patient or caregiver were provided or reviewed the drug disposal policy on admission or when the narcotic was started. Clinical Record 6: Oxycodone [pain medications] 10mg every four hours for pain ordered on 3/03/2022. No drug disposal policy was provided to the patient on admission on 1/31/2022 or reviewed when the narcotic started on 03/03/2022. Clinical Record 1: Dilaudid [for severe pain], 2mg every four hours for pain ordered on 7/21/2022. No drug disposal policy was provided on admission or review when ordered on 07/21/2022. Clinical Record 5: Comfort pack [a group of pain and anxiety medications] started on 5/18/2022. No drug disposal policy was provided on admission or when the narcotics were started on 5/18/2022. Clinical Record 2: Admitted on 07/01/2022, there was no policy of drug disposal provided. Clinical Record 7: Admitted 04/24/2022, there was no policy of drug disposal provided. Clinical Record 4: Admitted 01/18/2022, there was no policy of drug disposal provided. Clinical Record 0: Admitted 07/09/2022, there was no policy of drug disposal provided. Clinical Record 3: Oxycodone [pain medication] 5mg every six hours as needed for pain ordered on 3/25/2022. No drug disposal policy was provided to the patient on admission on 2/25/2022 or reviewed when the narcotic started on 03/25/2022. Interview with the Administrator stated that she did not realize a policy should be given to the patients. Admission Folder: There was a form titled, Information Regarding Managing you Medication and Disposing of unused Medications Policy," but no agency policy was provided in the admission folder. The patient signed that they had received information, but Policy Drugs and Biologicals -Administration, Use and Disposal, a 5-page policy dated 6/8/2021, was not provided to the patients. The interview with the Administrator stated we provided some direction for drug disposal, but we did not include our policy in the admission folder. Agency Policy, Admission to Hospice Care [08/03/2018] stated in part, "The individual is provided the appropriate admission documentation, as well as a verbal description of the documentation, which includes, but is not limited to: The [agency name] policy on managing and disposing of medication." Agency Policy, Admission to Hospice Care [08/03/2018] stated in part, "The individual is provided the appropriate admission documentation, as well as a verbal description of the documentation, which includes, but is not limited to: The [agency name] policy on managing and disposing medication."