Every finding on record at Breeze 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 supplements, herbal remedies, and other alternative treatments that could affect drug therapy. 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 document review, interview and observation. In 2 of 4 (50%) home visit observations conducted where medication reconciliations were completed, it was revealed that the agency did not ensure that agency medication profiles were updated to include all medications the patients were currently taking. Document 2: Policy# 2-004, titled Medication Profile (revised December 2018) sub-section one (1), stated in part, "Upon admission to hospice, the admitting nurse will initiate a medication profile to document the current regimen." Sub-section seven (7) stated in part, "A drug regimen review will be performed at the time of the initial and the comprehensive assessment, when updates to the comprehensive assessments are performed, when care is resumed after a patient has been placed on hold, and with the addition of a new medication." Sub-section eight (8)(A) stated in part, "During subsequent home visits, the medication profile will be used as a care planning and teaching guide to evaluate the use of drugs in the home setting." Home Visit 1: During the home visit on 8/1/2023 with an LPN (staff 4) the patient and caregiver provided medication bottles for all medicines taken. The hospice agency's medication profile listed Docusate Sodium one hundred (100) milligrams (mg). Take one (1) capsule orally (PO) two (2) times (x's) daily as needed (PRN) for constipation. The patient and caregiver reported that the patient no longer takes Docusate Sodium one hundred (100) milligrams (mg). Take one (1) capsule orally (PO) two (2) times (x's) daily as needed (PRN) for constipation. The patient and caregiver reported the patient had not taken the medication for "quite a while." The patient and caregiver said the patient takes Aspirin eighty-one (81) milligrams (mg) every day and has been taking the Aspirin eighty-one (81) milligrams (mg) every day before admission to hospice services. The hospice agency medication profile did not contain the medication Aspirin eighty-one (81) milligrams (mg) every day, Home Visit 4: A home visit was conducted on 8/1/2023 with an RN (staff 6) in the presence of the Director of Clinical Services (staff 1) for a patient with a hospice benefit election date of (record 4). A medication reconciliation compared the hospice agency medication profile to the Skilled Nursing Facility medication profile. The Skilled Nursing Facility medication profile listed Remeron (mirtazapine) fifteen (15) milligrams (mg). Administer half (1/2) tablet every bedtime (QHS). The hospice agency medication profile did not list the medication Remeron (mirtazapine), fifteen (15) milligrams (mg). Administer half (1/2) tablet every bedtime (QHS). A joint record review and interview with the Director of Clinical Services on 8/1/2023 confirmed the hospice agency did not have accurate medication profiles.

It is required that the hospice maintains, documents, and provides hospice volunteer orientation and training that is consistent with hospice industry standards; it includes guidance specific to individual responsibilities. This standard was not met as evidenced by interview and personnel record review. In 1 of 1 (100%) personnel record reviewed, of a volunteer, it was revealed that the hospice agency did not ensure there was documentation of orientation and training to the volunteer role responsibilities at hire. Personnel Record 10: The volunteer was hired 11/3/2021. The job description was blank on the signature line and the date line. The record contained an "Annual Volunteer Performance Evaluation/Core Competency Skill" signed and dated 7/21/2022 by the employee and the Director of Clinical Services. There was no documentation of orientation to specific role responsibilities. A joint record review and interview with the Director of Clinical Services confirmed that the hospice agency did not provide volunteer training. The Director of Clinical Services reported the hospice agency did not have a volunteer training program. The Director of Clinical Services reported the employee volunteered as a marketer.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. 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 clinical record review and interview. In 3 of 14 (21%) clinical records reviewed it was revealed that the agency did not ensure the hospice benefit election form was completed, signed, and dated with the effective date that the benefit was elected. Clinical Record 6: A patient with a hospice benefit election date of 7/28/2023 had a hospice benefit election form signed by the patient representative on 7/22/2023 and the hospice representative on 7/22/2023. the effective date of the election was left blank. The form stated in part, "I acknowledge and understand the above, and authorize hospice Medicare coverage to be provided by (Hospice agency name) to begin on (blank)." Clinical Record 9: A patient with a hospice benefit election date of 6/23/2023 had a hospice benefit election form signed by the patient representative on 6/21/2023 and the hospice representative on 6/21/2023. The effective date of the election was left blank. The form stated in part, "I acknowledge and understand the above, and authorize hospice Medicare coverage to be provided by (Hospice agency name) to begin on (blank)." Clinical Record 10: A patient with a hospice benefit election date of 7/11/2023 had a hospice benefit election form signed by the patient representative on 7/10/2023 and the hospice representative on 7/10/2023. The effective date of the election was left blank. The form stated in part, "I acknowledge and understand the above, and authorize hospice Medicare coverage to be provided by (Hospice agency name) to begin on (blank)." A joint record review and interview with the Director of Clinical Services on 8/2/2023 confirmed the hospice benefit election forms were incomplete because the hospice date of benefit election was blank.

It is required that medical supplies and appliances related to the palliation and management of the patient’s terminal illness and related conditions are checked for expiration dates. This standard was not met as evidenced by interview and observation. During a tour of the office and inspection of the supply room, it was revealed that the agency did not ensure that all supplies were checked for expiration dates. The supply room was inspected on 7/31/2023 in the presence of the Director of Clinical Services (staff 1). The following items were expired: a quantity of four (4) five hundred (500) milliliter (mL) bottles of normal saline with an expiration date of 6/28/2023, a quantity of two (2) System Biohazard spill cleanup kits with an expiration date of 5/19/2019, and a quantity of fifty (50) lubricating Jelly with an expiration date of 4/28/2023. The Director of Clinical Services (staff 1) confirmed the supplies were expired. The Director of Clinical Services (staff 1) checked the supply room for expired supplies. However, supply room inspections were not completed due to the large number of current responsibilities due to the recent departure of the Business Manager. The supply room was inspected on 7/31/2023 in the presence of the Director of Clinical Services (staff 1). The following items were expired: a quantity of four (4) five hundred (500) milliliter (mL) bottles of normal saline with an expiration date of 6/28/2023, a quantity of two (2) System Biohazard spill cleanup kits with an expiration date of 5/19/2019, and a quantity of fifty (50) lubricating Jelly with an expiration date of 4/28/2023. The Director of Clinical Services (staff 1) confirmed the supplies were expired. The Director of Clinical Services (staff 1) checks the supply room for expired supplies. However, supply room inspections were not completed due to the large number of current responsibilities due to the recent departure of the Business Manager.

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 3 of 6 (50%) records reviewed, it was revealed that the hospice did not ensure the initial spiritual assessments were completed no later than five (5) calendar days after the patient’s election of hospice care. Clinical Record 1: The patient elected hospice care on 3/30/23. The initial spiritual assessment was completed on 5/11/23. There was no evidence that an initial spiritual assessment was completed no later than five days after the election of hospice care. Clinical Record 2: The patient elected hospice care on 3/31/23. The initial spiritual assessment was completed by telephone on 4/10/23. There was no evidence that an initial spiritual assessment was completed no later than five days after the election of hospice care. Clinical Record 3: The patient elected hospice care on 4/13/23. The initial spiritual assessment was completed on 4/28/23. There was no evidence that an initial spiritual assessment was completed no later than five days after the election of hospice care. During an interview on 6/22/23, the Clinical Director confirmed the finding. Record 1: The patient elected hospice care on 3/30/2023. The initial spiritual assessment was completed on 5/11/2023. A telephone call was documented on 4/10/2023. There was no documented evidence that an initial spiritual assessment was completed no later than five days after the election of hospice care and no documented reason for the delay. Record 2: The patient elected hospice care on 3/31/2023. The initial spiritual assessment was completed by telephone on 4/10/2023. There was no documented evidence that an initial spiritual assessment was completed no later than five days after the election of hospice care and no documented reason for the delay. Record 3: The patient elected hospice care on 4/13/2023. The initial spiritual assessment was completed on 4/28/2023. There was no documented evidence that an initial spiritual assessment was completed no later than five days after the election of hospice care and no documented reason for the delay. The clinical director was interviewed on 6/22/2023 and agreed, there was no documented evidence the initial assessments were completed no later than five days after the election of hospice care.

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. Information gathered from the initial bereavement assessment is incorporated into the plan of care and considered in the bereavement plan of care. This standard was not met as evidenced by clinical record review and interview. In 3 of 6 (50%) records reviewed, it was revealed that the hospice did not ensure an initial bereavement assessment was completed. Clinical Record 1: The patient elected hospice care on 3/30/23. There was no evidence an initial bereavement assessment was completed. Clinical Record 2: The patient elected hospice care on 3/31/23. There was no evidence an initial bereavement assessment was completed. Record 3: The patient elected hospice care on 4/13/23. There was no evidence an initial bereavement assessment was completed. During an interview on 6/22/23, the Clinical Director confirmed the finding. Record 1: The patient elected hospice care on 3/30/2023. There was no documented evidence an initial bereavement assessment was completed no later than five (5) calendar days after the patient’s election of hospice care. Record 2: The patient elected hospice care on 3/31/2023. There was no documented evidence an initial bereavement assessment was completed no later than five (5) calendar days after the patient’s election of hospice care. Record 3: The patient elected hospice care on 4/13/2023. There was no documented evidence an initial bereavement assessment was completed no later than five (5) calendar days after the patient’s election of hospice care. The clinical director was interviewed on 6/22/2023 and agreed, the initial bereavement assessments were not completed no later than five days after the patient’s election of hospice care.

It is required that hospice care and services provided to patients and families follow the individualized plan of care established by the hospice IDG in collaboration with the attending physician (if any), the patient or patient representative, the primary caregiver in accordance with the patient’s needs. This standard was not met as evidenced by clinical record review and interview. In 1 of 4 (25%) records reviewed, it was revealed that the hospice did not ensure that hospice aide services were provided as ordered. Clinical Record 1: The patient elected hospice care on 3/30/23. The physician’s order stated hospice aide services twice weekly starting 4/2/23. During the week of 4/9/23 - 4/15/23, there was a hospice aide visit on 4/13/23. The missed visit on 4/11/23 did not include a reason for the missed visit. During the week of 5/7/23 - 5/13/23, there was a hospice aide visit on 5/11/23. The missed visit on 5/9/23 did not include a reason for the missed visit. During the week of 5/14/23 - 5/20/23, there was a hospice aide visit on 5/16/23. The missed visit on 5/18/23 did not include a reason for the missed visit. During the week of 5/21/23 - 5/27/23, there was a hospice aide visit on 5/25/23. The missed visit on 5/23/23 did not include a reason for the missed visit. During an interview on 6/22/23, the Clinical Director confirmed the finding and stated, “There isn’t a reason documented for the missed visits. That means the aide called off, and we didn’t have another aide available to cover those visits.” Record 1: The patient elected hospice care on 3/30/2023. The physician’s order effective 4/2/2023 ordered hospice aide services twice weekly starting 4/2/2023. During the week 4/9/2023-4/15/2023, there was a hospice aide visit on 4/13/2023. The missed visit on 4/11/2023 did not include a reason for the missed visit. During the week 5/7/2023-5/13/2023, there was a hospice aide visit on 5/11/2023. The missed visit on 5/9/2023 did not include a reason for the missed visit. During the week 5/14/2023-5/20/2023, there was a hospice aide visit on 5/16/2023. The missed visit on 5/18/2023 did not include a reason for the missed visit. During the week 5/21/2023-5/27/2023, there was a hospice aide visit on 5/25/2023. The missed visit on 5/23/2023 did not include a reason for the missed visit. There was no documented evidence of a second hospice aide visit for the weeks identified. The clinical director was interviewed on 6/22/2023 and agreed, hospice aide services were not provided as ordered on the plan of care by the attending physician. Additionally, during interview on 6/22/2023, the clinical director stated, “there isn’t a reason documented for the missed visits so that means the aide called out and we didn’t have another aide available to cover those visits.”

It is required that counseling services include an organized program for providing bereavement services delivered by or under the supervision of a qualified professional with experience or education in grief or loss counseling. Bereavement services are available to the family and other individuals up to one (1) year following the death of the patient. Bereavement counseling extends to residents of a SNF/NF (skilled nursing facility/nursing facility) or ICF/IDF (intermediate care facility/intellectual disability facility) when appropriate and identified in the bereavement plan of care. The bereavement services reflect the needs of the bereaved per a bereavement plan of care that includes: the types of bereavement services to be offered; the frequency of service delivery. This standard was not met as evidenced by clinical record review, document review, and interview. In 2 of 3 (67%) records reviewed, it was revealed that the hospice did not ensure that bereavement services reflected the needs of the bereaved per a bereavement plan of care, and in compliance with hospice policy and procedure. Agency policy, Bereavement Services, stated in part, “The program will provide bereavement services to the families/caregivers of hospice patients both before and after the patient’s death in accordance with the plan of care. After a death has occurred, the bereavement assessment will be updated and the family/caregiver needs will be discussed at the next interdisciplinary group meeting. Within two (2) weeks after the death of a patient, a sympathy card will be sent to the bereaved. A bereavement file will be maintained on each family/caregiver unit of care. Each file will contain the following information: a bereavement plan of care.” Clinical Record 4: The patient elected hospice care on 3/24/23. The patient died on 4/14/23. There was no evidence of the following: that a bereavement assessment was discussed during the interdisciplinary group meeting on 4/21/23; a bereavement plan of care; and that a sympathy card was sent to the bereaved. Clinical Record 5: The patient elected hospice care on 1/6/23. The patient died on 4/8/23. There was no evidence of the following: that a bereavement assessment was discussed during the interdisciplinary group meeting on 4/21/23; a bereavement plan of care; and that a sympathy card was sent to the bereaved. During an interview on 6/22/23, the Clinical Director confirmed the finding. Agency policy, “Bereavement Services,” stated in part, “The program will provide bereavement services to the families/caregivers of hospice patients both before and after the patient’s death in accordance with the plan of care. After a death has occurred, the bereavement assessment will be updated and the family/caregiver needs will be discussed at the next interdisciplinary group meeting. Within two (2) weeks after the death of a patient, a sympathy card will be sent to the bereaved. A bereavement file will be maintained on each family/caregiver unit of care. Each file will contain the following information: a bereavement plan of care.” Record 4: The patient elected hospice care on 3/24/2023. The bereavement record was reviewed and revealed the patient died on 4/14/2023. There was no documented evidence bereavement was discussed during the interdisciplinary group meeting on 4/21/2023. There was no documented evidence of a bereavement plan of care. There was no documented evidence a sympathy card was sent to the bereaved. Record 5: The patient elected hospice care on 1/6/2023. The bereavement record was reviewed and revealed the patient died on 4/8/2023. There was no documented evidence bereavement was discussed during the interdisciplinary group meeting on 4/21/2023. There was no documented evidence of a bereavement plan of care. There was no documented evidence a sympathy card was sent to the bereaved. The clinical director was interviewed on 6/22/2023 and stated, “we just identified this isn’t being done and we are working on it.” Additionally, during interview on 6/22/2023, the clinical director agreed, there was no documented evidence that bereavement was discussed at the IDG following the patients deaths, that a sympathy card was mailed or of a bereavement plan of care in the records identified. The clinical director confirmed, there was no documented evidence bereavement was declined.

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 4 (25%) records reviewed, it was revealed that the hospice did not ensure that hospice aides were provided written patient care instructions. Clinical Record 1: The patient elected hospice care on 3/30/23. The aide care plan dated 3/30/23 assigned the following tasks to be completed every visit: "bed bath, shower chair.” The care plan did not provide specific instruction to the aide, to determine whether to provide either a bed bath, or shower. During an interview on 6/22/23, the Clinical Director confirmed the finding. Record 1: The patient elected hospice care on 3/30/2023. The aide care plan dated 3/30/2023 assigned tasks to be completed every visit, “bed bath, shower chair.” The care plan did not provide specific instruction to the aide on whether to provide a bed bath or shower. The clinical director was interviewed on 6/22/2023 and agreed, the care plan did not provide specific instructions to the aide on whether to provide a bed bath or shower.

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. The hospice has written policies and procedures describing the method(s) of assessing competency and maintains a written description of the in-service training provided during the previous 12 months. This standard was not met as evidenced by personnel record review, document review, and interview. In 1 of 2 (50%) records reviewed, it was revealed that the hospice did not have a written policy describing the method of assessing competency, and did not ensure the skills and competencies were assessed before providing care. The hospice did not have evidence of written policies and procedures describing the method(s) of assessing competency. Personnel Record 1: The Chaplain's date of hire was 4/3/23. The initial competency was signed by the Clinical Director on 4/3/23. However, the competency did not include the Chaplain's signature. There was no evidence that the competency evaluation was completed and reviewed with the chaplain. During an interview on 6/22/23, the Clinical Director confirmed the findings. Record 1 (Chaplain): hire date 4/3/2023. The initial chaplain competency signed by the clinical director on 4/3/2023 did not include a signature by the chaplain. There was no documented evidence a competency evaluation was completed and reviewed with the chaplain. The policy on competency assessments was requested on day one. The clinical director was interviewed on 6/22/2023 and stated, “we do not have a specific competency policy.” During an interview on 6/22/2023, the clinical director agreed, there was no documented evidence an initial competency was completed with the chaplain. There was no further documentation provided by the agency prior to the survey exit on 6/22/2023.