Every finding on record at Breeze Hospice, LLC

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 if any of them so desire, and the primary caregiver in accordance with the patient’s needs if any of them so desire. This standard was not met as evidenced by clinical record review and interview. In 4 of 19 (21%) clinical records reviewed, the agency did not ensure hospice care and services were provided as ordered on the individualized plan of care. CLINICAL RECORD 1: The patient elected the hospice benefit on 07/19/2024. The Interdisciplinary Group Meeting notes and updates to the plan of care dated 04/08/2025 and 04/22/2025 documented "Medical Social Worker; 1 m 3 m 2 PRN Psychosocial needs, [once a month for three months and two as needed], Start Date: 3/16/2025 - End Date: 5/14/2025." There was no documented evidence of a Medical Social Worker visit for April 2025 and no documentation of a missed visit for April. CLINICAL RECORD 12: The patient elected the hospice benefit on 01/15/2025. The Interdisciplinary Group Meeting notes and updates to the plan of care dated 03/11/2025 and 03/25/2025 included documentation "Chaplain; 1 m 3 m 4 PRN [once a month for three months and four as needed] visits for pt [patient] /family for spiritual distress, Start Date: 2/11/2025 - End Date: 4/14/2025." There was no documented evidence of a Chaplain visit for March 2025 and no documentation of a missed visit for March. CLINICAL RECORD 16: The patient elected the hospice benefit on 02/01/2024. The Interdisciplinary Group Meeting notes and the updates to the plan of care dated 04/09/2024 and 04/23/2024 documented "Medical Social Worker; 1 m 3 m [once a month for three months], Start Date: 3/11/2024 - End Date: 5/31/2024." There was no documented evidence of a Medical Social Worker visit for April 2025 and no documentation of a missed visit for April. CLINICAL RECORD 18: The patient elected the hospice benefit on 02/01/2024. The Interdisciplinary Group Meeting notes and updates to the plan of care dated 06/04/2024 and 06/18/2024 included documentation "Chaplain; 1 m 3 m 3 PRN [once a month for three months and three as needed], Start Date: 5/21/2024 - End Date: 7/29/2024." There was no documented evidence of a Chaplain visit for June 2025 and no documentation of a missed visit for June. During a joint record review and interviews on 05/08/2025, the Vice President of Operations and the Senior Administrator/Registered Nurse confirmed there was no documentation in the clinical records to show the Chaplain, and the Social Worker had provided services as ordered on the plan of care.

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, safe handling of equipment in the patient’s care environment if it is likely to have been contaminated with body fluids, safe handling of soiled items in the patient’s care environment, and other requirements of applicable state and federal law and regulation. This standard was not met as evidenced by document review, observation, and interview. In 2 of 4 (50%) home visit observations, the agency did not ensure staff performed hand hygiene as required by agency policy. Agency policy No. 7-009 Hand Hygiene, undated, required in part, "Hand decontamination using an alcohol-based hand rub should be performed: after removing gloves... Hand Washing with Soap and Water... Rinse with warm water and dry the hands with a disposable towel from the fingers toward the forearm. Use a dry disposable towel to turn off faucet." HOME VISIT 1: During the home visit observation on 05/06/2025 with the Certified Nurse Aide (CNA) (Personnel Record 8), the CNA was observed to wash hands with soap and water, rinse the hands, turn off the water with the bare wet hands, and dry the hands with paper towels three separate times. The CNA did not use a disposable towel to turn off the faucet. HOME VISIT 2: During the home visit observation on 05/06/2025 with the Registered Nurse (RN) (Personnel Record 9), the RN was observed to provide wound care. During wound care, the RN applied gloves, removed the dressing to the left hip, removed the gloves, picked up the iPad to take a picture, placed the iPad on the barrier, and used alcohol rub to decontaminate the hands. The RN did not wash hands after glove removal. The nurse then applied a new pair of gloves, cleaned the wound, dried the wound area, retrieved a pen from the uniform pocket, wrote the date on the dressing, returned the pen to the pocket, applied the dressing to the wound, and removed the gloves. The RN did not remove gloves and wash hands before obtaining the pen for the uniform pocket. During a joint review and interviews on 05/06/2025, the Vice President of Operations and the Senior Administrator/Registered Nurse agreed that the staff did not follow the hand hygiene policy.

It is required that a hospice aide provide services ordered by the Interdisciplinary Group, included in the plan of care, permitted to be performed under state law and regulation and consistent with the hospice aide training. This standard was not met as evidenced by clinical record review and interview. In 1 of 18 (6%) clinical records reviewed with hospice aide services provided, the agency did not ensure the Hospice Aide provided services as ordered in the plan of care. CLINICAL RECORD 2: The hospice aide plan of care dated 04/10/2025, and updated 04/22/2025, assigned the aide the following tasks, "assist patient with dressing every visit, skin care every visit, oral care every visit, shampoo every visit, shave every visit as needed, change patient linen weekly, incontinent care every visit, shower chair every visit, catheter care every visit, and assist with transfer every visit." On the hospice aide visit note dated 04/24/2025, the Hospice Aide (HA) did not document that oral care and catheter care were provided. On the aide visit note dated 04/30/2025, the HA did not document that oral care was provided. On the HA visit note dated 05/07/2025, the HA did not document that oral care, dressing, and catheter care were provided. During a joint clinical record review and interview on 05/08/2025, the Vice President of Operations and the Senior Administrator/Registered Nurse agreed the record lacked evidence that the hospice aide provided services as ordered on the plan of care.

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. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. This standard was not met as evidenced by clinical record review and interview. In 1 of 18 (6%) clinical records reviewed with hospice aide services provided, the agency did not ensure the Hospice Aide notified the Registered Nurse of the changes in the patient’s nursing needs. CLINICAL RECORD 11: The hospice aide plan of care dated 05/03/2025 included an order for the aide to provide visits at a frequency of twice a week. The Hospice Aide documented on the aide visit note dated 05/06/2025 "patient refused" all assigned tasks and documented in the narrative, "Called patient multiple times. No answer." The HA did not include documentation that the Registered Nurse was notified of the missed visit and change to the plan of care. During a joint clinical record review and interviews on 05/08/2025, the Vice President of Operations and the Senior Administrator/Registered Nurse confirmed that the hospice aide documentation lacked notification to the Registered Nurse of the missed visit.

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 4 (50%) records reviewed it was revealed that the agency did not ensure the initial assessments were completed no later than five (5) calendar days after the patient’s election of hospice care. Record 1: The date of the election of benefits was 4/13/2023. The initial psychosocial assessment was completed by the social worker on 4/24/2023, day 11. There was no documented reason for the delay. There was no documented evidence that an initial psychosocial assessment was completed no later than five days after the election of hospice care. Record 2: The date of the election of benefits was 5/17/2023. There was no documented evidence that an initial spiritual assessment was completed no later than five days after the election of hospice care. Chaplain services were documented as accepted during the nursing admission visit on 5/17/2023. There was no documented evidence spiritual care visits were completed or declined between 5/17/2023-6/14/2023. The Administrator was interviewed on 6/14/2023 and agreed, there was no documented evidence the initial assessments were completed no later than five days after the election of hospice care as required. Record 1: The patient’s date of election was 4/13/2023. The initial psychosocial assessment was completed by the social worker on 4/24/2023, day 11. There was no documented reason for the delay. There was no documented evidence that an initial psychosocial assessment was completed no later than five days after the election of hospice care. Record 2: The patient’s date of election was 5/17/2023. There was no documented evidence an initial spiritual assessment was completed no later than five days after the election of hospice care. Chaplain services were documented as accepted during the nursing admission visit on 5/17/2023. There was no documented evidence spiritual care visits were completed or declined between 5/17/2023-6/14/2023. The Administrator was interviewed on 6/14/2023 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 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 4 (25%) records reviewed it was revealed that the agency did not ensure that the drug profile was updated. Record 1: The date of the election of benefits was 4/13/2023. The primary hospice diagnosis was liver cell carcinoma. The registered nurse assessment completed on 5/12/2023 and 6/3/2023 documented "Advil effective for pain management". The licensed practical nurse documentation on 6/8/2023 stated "Tylenol effective for pain management". The drug profile was reviewed for the benefit period 4/13/2023-6/14/2023. There were no updates that included the use of Advil or Tylenol for pain management. The Administrator was interviewed on 6/14/2023 and agreed, there was no documented evidence that drug profile was updated to include the medications Advil and Tylenol. Record 1: The patient’s date of election was 4/13/2023. The primary hospice diagnosis was liver cell carcinoma. The registered nurse assessment on 5/12/2023 and 6/3/2023 revealed Advil affective for pain management. The licensed practical nurse documentation on 6/8/2023 revealed Tylenol effective for pain management. The drug profile was reviewed between 4/13/2023-6/14/2023. There was no documented evidence that the drug profile was updated to include the Advil and Tylenol. The Administrator was interviewed on 6/14/2023 and agreed, there was no documented evidence that drug profile was updated to include the Advil and Tylenol.

It is required that each patient’s individualized written plan of care reflects patient and family goals, 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: medical supplies and appliances necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. In 2 of 4 (50%) records reviewed it was revealed that the hospice did not ensure that the plan of care included the medical supplies and appliances necessary to meet the needs of the patient. Record 1: The date of the election of benefits was 4/13/2023. The primary hospice diagnosis was liver cell carcinoma. The registered nurse assessment on 4/13/2023 documented the durable medical equipment (DME) to be provided by the hospice was a shower bench, over the bed table, and oxygen concentrator. The plan of care reviewed for the benefit period 4/13/2023-6/14/2023 did not include the shower bench, over the bed table, oxygen concentrator under the DME section. Record 2: The date of the election of benefits was 5/17/2023. The primary hospice diagnosis was secondary malignant neoplasm of the retroperitoneum and the peritoneum. The registered nurse assessment on 5/17/2023 documented that the patient had durable medical equipment (DME) of a hospital bed, wheelchair, and wheelchair cushion. The plan of care reviewed for the benefit period 5/17/2023-6/14/2023 did not include the hospital bed, wheelchair and wheelchair cushion under the DME section. The Administrator was interviewed on 6/14/2023 and agreed, there was no documented evidence of the DME listed on the plan of care. Record 1: The patient’s date of election was 4/13/2023. The primary hospice diagnosis was liver cell carcinoma. The registered nurse assessment on 4/13/2023 revealed durable medical equipment (DME) to be provided by the hospice: shower bench, over the bed table, and oxygen concentrator. The plan of care reviewed between 4/13/2023-6/14/2023 did not include the shower bench, over the bed table, oxygen concentrator under the DME section. Record 2: The patient’s date of election was 5/17/2023. The primary hospice diagnosis was secondary malignant neoplasm of retroperitoneum and peritoneum. The registered nurse assessment on 5/17/2023 revealed patient has durable medical equipment (DME): hospital bed, wheelchair, and wheelchair cushion. The plan of care reviewed between 5/17/2023-6/14/2023 did not include the hospital bed, wheelchair and wheelchair cushion under the DME section. The Administrator was interviewed on 6/14/2023 and agreed, there was no documented evidence the DME was listed on the plan of care.

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. (L628) THIS IS A CONTINUING PRIOR REQUIRED ACTION. This standard was not met as evidenced by clinical record review and interview. In 1 of 4 (25%) records reviewed with a hospice aide ordered, it was revealed that the agency did not ensure that the hospice aide reported changes in the patient's medical, nursing, and social needs as the changes related to the plan of care, to a registered nurse. Record 1: The patient’s date of election was 4/13/2023. The hospice aide visit documentation on 6/1/2023 revealed, “Pt did express pain in his left hand, where an old IV was placed.” There was no documented evidence that the registered nurse was notified. The Administrator was interviewed on 6/14/2023 and agreed, there was no documented evidence that the hospice aide notified the registered nurse with the change. Record 1: The patient’s date of election was 4/13/2023. The hospice aide visit documentation on 6/1/2023 revealed, “pt did express pain in his left hand, where an old IV was placed.” There was no documented evidence that the registered nurse was notified. The Administrator was interviewed on 6/14/2023 and agreed, there was no documented evidence that the hospice aide notified the registered nurse with the change.

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 IS A CONTINUING PRIOR REQUIRED ACTION. This standard was not met as evidenced by clinical record review and interview. In 1 of 4 (25%) records reviewed revealed the agency did not ensure the election statement addendum included non-covered medications and non-covered diagnosis. Record 2: The patient’s date of election of benefits was 5/17/2023. The primary hospice diagnosis was secondary malignant neoplasm of retroperitoneum and peritoneum. The election statement addendum was requested on admission. The addendum provided to the patient/caregiver did not list any non-covered medications or non-covered diagnoses. The medication profile was reviewed and revealed medications effective 5/17/2023 not covered by hospice were Glipizide 5mg daily for Diabetes Mellitus, and Folic Acid 1mg daily. The Administrator was interviewed on 6/14/2023 and agreed, there was no documented evidence the hospice's election statement addendum included the non-covered medications or non-covered diagnosis. Record 2: The patient’s date of election was 5/17/2023. The primary hospice diagnosis was secondary malignant neoplasm of retroperitoneum and peritoneum. The hospice election statement addendum was requested on admit. The addendum provided to the patient/caregiver did not list any non-covered medications or non-covered diagnosis. The medication profile was reviewed and revealed medications effective 5/17/2023 not covered by hospice: Glipizide 5mg daily for Diabetes Mellitus, Folic Acid 1mg daily. The Administrator was interviewed on 6/14/2023 and agreed, there was no documented evidence the hospice's election statement addendum included non-covered medications or non-covered diagnosis.

Based on agency policy, clinical record review, and interview, the agency failed to ensure an appropriate discharge for cause and/or revocation was completed as required in one of three discharged patient's reviewed (Record/Patient #1). This deficient practice has the potential to affect the revocation and discharge process for all of the agency's patients. Findings Included: --- Review of the provider's policy titled, "Discharge From Hospice Program," dated 12/2018, showed that if the hospice determines the patient should be discharged for the cause of disruptive, abuse, or uncooperative behavior, the following steps would be taken: - Advise the patient and/or caregiver that a discharge for cause is being considered; - Make serious effort to resolve the problem(s) caused by the behavior or situation of the patient or other persons in the patients home and document the problem(s) and efforts made to resolve it in the clinical record; - Prior to discharging a patient for cause, the hospice interdisciplinary group (IDG) must obtain a written discharge order from the hospice medical director. If the patient has an attending physician involved in the care, this physician should be consulted before discharge and his/her review and decision should be included in the discharge note; - The hospice should also consider referrals to other appropriate and/or relevant state/community agencies or health care facilities prior to discharge; and - The hospice notified it Medicare Administrative Contractor and the state licensure agency of the circumstances surrounding the impending discharge for cause. Review of the providers policy titled, ";Revocation of Hospice Benefit," dated 12/2018 showed that: - The patient will choose to revoke his/her election of hospice benefit chooses to withdraw from the program with or without cause; - The care manager will facilitate the patients revocation and assist with a smooth transition to another setting or independent care; - The case manager will notify the attending physician and interdisciplinary group about the revocation and reason; and - A revocation of election of hospice care statement will be signed by the patient and will document the date, time, and reason for revocation. A copy will be sent to billing and will be retained in the clinical record. The organization will submit the notice of transfer to the Medicare contractor within five days. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice services with a terminal diagnosis of chronic obstructive pulmonary disease (a term referring to chronic bronchitis and emphysema, characterized by obstruction of airflow that interferes with normal breathing). The patient resided in his/her own home with the assistance of family members. Review of the providers document titled, ";Patient Rights and Responsibilities," signed by the patient 04/28/2023, showed that the patient had the right to: - Refuse services and treatment within the confines of the law and to be informed of the consequences of refusing care; - Voice grievances regarding treatment or care or lack thereof; lack of respect of property or person by anyone who is furnishing services on behalf of the hospice company, and the patient/family shall not be subjected to discrimination or reprisal for doing so; and - Be referred to another provider if [the provider] is unable to meet the patients needs or if the patient is not satisfied with care received. Review of the providers document titled, ";Prior Authorization Statement," signed by the patient 04/28/2023, showed that the patient: - May stop hospice at any time, to do so, [the patient] must sign a written revocation statement in advance; and - May be discharged from the providers service for a limited number of reasons including, ";for cause" as established in the providers discharge policy. Review of the clinical documentation showed that: - The patient was admitted to the providers service on 04/28/2023; - On Saturday, 04/29/2023: * At 08:30 AM the patient called the agency requesting a refill on his/her cough medication. The patient wanted the medication to be delivered. The cough medication was ordered through a pharmacy that delivers and the patient was told it would not be delivered until Monday; * At 04:40 PM the patient called the agency to ask where the ";stuff" was that was supposed to be delivered to his/her home. The clinician notified the patient that ";being the weekend, unsure when they would be delivered" and it might be Monday; * At 04:43 PM the patient called the agency to ask about when his/her medications would be delivered, and the nurse, ";explained nothing has changed since our earlier conversation, the soonest would be Monday since [he/she] did not want to go pick it up from [the pharmacy]; - On Sunday, 04/30/2023: * The patient called the providers staff reporting bleeding hemorrhoids, requesting ";Dilaudid" (an opioid pain medication) for pain management. The patient had Percocet (an opioid pain medication), zanaflex (a short-acting muscle relaxer), and gabapentin (a medication used to treat nerve-type pain) in the home; the physician was notified of the patients request. The physician offered morphine (an opioid pain medication) which the patient refused. The patient was instructed to go to the emergency room if his/her pain was ";that" bad; * No nursing visit was provided; and - On Monday, 05/01/2023: * The patient called the office and stated he/she wanted to discharge hospice services. The documentation failed to identify the reason the patient was requesting discharge from services; * At 11:00, a nurse arrived at the patients home to have the patient sign the revocation form, and the patient refused to sign the form; and * A live discharge order titled, ";Discharge for Cause," dated 05/01/2023 showed that the patient requested a discharge ";because [he/she] was no longer satisfied with" services. The patient refused to sign the revocation papers stating, ";they lied to me on Friday about my medicine. They lied to me on Saturday again about my medicine. They lied to me on Sunday about my medicine and other stuff, and now its Monday and yall are here lying again" Review of the clinical record showed the record failed to contain documentation for: - Revocation of services, including * A signed revocation of hospice election form; * A smooth transition to another provider or independent care; - Discharge for cause, including documentation: and * Advising the patient and/or caregiver that a discharge for cause was being considered; * Of the effort to resolve the problem(s) caused by the behavior or situation of the patient or other persons in the patients home and document the problem(s) and efforts made to resolve it in the clinical record; * A written discharge order from the hospice medical director, prior to the discharge; . If the patient has an attending physician involved in the care * Referrals to other appropriate and/or relevant state/community agencies or health care facilities prior to discharge; and - Notification of the Medicare Administrative Contractor and the state licensure agency of the circumstances surrounding the impending discharge for cause. During an interview: - On 05/03/2023at 11:50 AM the complainant stated that: * He/she had called the agency for assistance and the staff members did not offer or make any visits; * Requested a refill on his/her cough syrup, was told it would be there on Monday, and he/she was running out of the medication; - On 05/09/2023 at 03:05 PM the complainant stated that he/she: * Never said he/she was firing the agency; * Did not have any nursing visits other than the admission visit; * Was surprised that the nurse showed up with revocation papers; * Never signed a revocation paper; and * He/she is trying to get another hospice provider since this provider stopped providing service. During an interview on 05/03/2023 at 11:30 AM, the administrator stated that: - The patient had called requesting a discharge from the agency and he/she arranged for a nurse to visit and get the revocation form signed; - The patient refused to sign the revocation form; - Confirmed that the patients discharge was documented as discharged for cause; and - The steps for discharge for cause and/or revocation were not completed per agency policy.

Based on agency policy, clinical record review, and interview, the agency failed to ensure that the patient rights were protected and promoted when the agency failed to: - §418.52(c)(1) Ensure the patient received effective pain management and symptom control from the hospice for conditions related to the terminal illness (L0512). --- The severity of this deficient practice resulted in the agency's inability to ensure the patient's rights were protected and promoted.

Based on agency policy, clinical record review, and interview, the agency failed to ensure that the patient received effective pain management and symptom control from the hospice for conditions related to the terminal illness in one of three clinical records reviewed (Record/Patient #2). This deficient practice has the potential to affect the pain management and symptom control of all the agency's patients. Findings included: --- Review of the providers policy titled, ";Bill of Rights," dated 12/2018 showed the patient had the right to:- Receive effective pain management and symptom control from the hospice for conditions related to the terminal illness; and- Be involved in developing his or her hospice plan of care. Review of the providers undated document titled, ";Patient Rights & Responsibilities," showed that the patient has the right to:- Have questions regarding pain management answered and to have [your] plan thoroughly assessed and promptly managed; and- The provider would assure that all medically related hospice care is provided in accordance with physicians orders and that a plan of care, which is developed by the patients physician and the hospice interdisciplinary group in conjunction with the patient, specifies the services to be provided and their frequency and duration. RECORD/PATIENT #2: Review of the clinical record showed that the patient was admitted to hospice services on 01/03/2023 with a terminal diagnosis of cerebral infarction (stroke) due to thrombosis (a clot). The patient resided in their own home with the assistance of their family. Review of the providers document titled, ";Patient Rights & Responsibilities," signed and dated by the patients legal representative on 01/03/2023 showed that the patient had the right to:- Have questions regarding pain management answered and to have [your] plan thoroughly assessed and promptly managed; and- The provider would assure that all medically related hospice care is provided in accordance with physicians orders and that a plan of care, which is developed by the patients physician and the hospice interdisciplinary group in conjunction with the patient, specifies the services to be provided and their frequency and duration. Review of the providers document titled, ";Patient Medication Record," dated 01/03/2023 – 01/12/2023 showed that the patient was to take:- Lorazepam concentrate every four hours as needed for anxiety effective 01/03/2023; - Morphine oral solution (a opioid pain medication) every four hours as needed for pain effective 01/03/2023; and- The document failed to contain orders for lorazepam tablets. Review of the registered nurse visit dated 01/05/2023 showed that:- The patient complained of pain in their back and the family was administering Tylenol (a non-narcotic analgesic) for pain management;- The registered nurse instructed the family that they could also administer morphine for pain management; - The patient was having increased shortness of breath; and- The registered nurse instructed the family on the use of lorazepam (an antianxiety medication) to decrease the work of their breathing. Review of the registered nurse visit dated 01/10/2023 showed that the patient:- Had not slept for ";3-4 days" and was agitated; - The lorazepam tablets were not working to manage the patients symptoms; - The registered nurse instructed the family member to: * give the lorazepam liquid ";as soon as [the family member] got it from the pharmacy"; and * ";To give [the patient] some morphine". Review of the interdisciplinary group meeting notes from 01/11/2023 showed that:- The plan of care contained interventions for pain management, including instruction to use morphine to control pain; and- The patients care plans, medications, and assessments were reviewed and approved by the medical director, the primary physician and the IDG; and- The IDG notes failed to contain documentation that the patient/family did not have liquid morphine and lorazepam in the home, or measures taken to get the medications in the home. During an interview on 03/16/2023 at 12:55 PM, the family member stated that: - The patient did well with symptom management until around 01/10/2023;- The patients symptoms increased and they did not have liquid morphine or lorazepam in the home to give the patient; - They had called the pharmacy, the physician, and the prescriptions for the medications were never authorized or approved and they (the family) could not pick the medications up from the pharmacy; - They called the providers office and spoke with the administrator who told them the orders for the medications had been sent to the pharmacy; and- The nurse knew the patient did not have the liquid lorazepam and morphine in the home because they had talked about it. During an interview on 04/05/2023 at 2:00 PM, registered nurse 1 (RN1) stated that:- There were orders for the liquid morphine and lorazepam ordered at the start of care, but the family never picked up the medication from the pharmacy; - The provider was not responsible for picking up the medications and they did not take measures to get the medications in the home if the family did not pick them up; and- The patient had lorazepam tablets in the home, and the medication profile failed to contain orders for lorazepam tablets. During an interview on 04/06/2023 the acting hospice administrator stated that there was no additional documentation to provide supporting the providers efforts to get the liquid morphine or lorazepam in the patients home for symptom management.

It is required that the hospice registered nurse completes an initial assessment within 48 hours of the patient’s election of hospice care, in accordance with CMS §418.24 (the elements of the hospice care election statement). 1. The physician, patient, or representative may request that the initial hospice assessment be completed in less than 48 hours. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 11 (9%) records revealed revealed that the agency failed to complete an initial assessment within 48 hours of patient's election of hospice care. Clinical Record 1 Election of benefit dated 6/10/2022. Date for care to begin on Election of Benefit form is left blank. Initial nursing assessment completed 6/13/2022. Plan of care dated 6/13/2022. Interview with administrator revealed that benefit election and consents were signed by a liaison while the patient was continuing to receive skilled care. Administrator confirmed that date for service to begin was left blank and nursing assessment exceeded 48 from the date of election of benefit. 1 of 11 (9%) of records revealed that the agency failed to complete an initial assessment within 48 hours of patient's election of hospice care.

It is required that a hospice aide provides services ordered by the Interdisciplinary Group included in the plan of care. This standard was not met as evidenced by a review ofclinical records and interviews. 1 of 10 (10%) of applicable records reviewed in which an aide was ordered, the agency failed to ensure that the hospice aide provided services as ordered in the plan of care. Clinical Record 1 Aide care plan dated 6/13/2022 includes in part, "take vital signs every visit, complete shower every visit, shampoo hair every visit. Aide documentation on 6/14/22, 6/17/22, 6/21/22, 6/24/22, and 7/1/2022 does not include vital signs. Aide documentation on on 6/21/2022 6/24/2022 and 7/1/2022, aide documented gave patient a bed bath. Staff #1 Interview with administrator confirmed that the clinical record demonstrated that the aide did not follow the plan of care. 1 of 10 (10%) of applicable records in which an aide was ordered, the agency failed to ensure that the hospice aide provided services as ordered in the plan of care.

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. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 10 (10%) of clinical records revealed that the agency did not ensure that the aide reported change in condition to the nurse. Clinical Record 1 Aide documented on 6/24/2022 that a bed bath was given instead of a shower because patient was not feeling well. No documentation of notification to nurse. Care plan did not allow for a bed bath bath and specified only a shower. Staff #1 Interview with administrator confirmed that documentation does not indicate that the nurse was notified of change in condition. 1 of 10 (10%) of clinical records revealed that the agency did not ensure that the aide reported change in condition to the nurse.

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 and interviews. 10 of 11 (90%) clinical records reviewed revealed that the records did not contain completed list of non-covered items when the patient elected to receive notice of non-covered items on the Election of Benefits. Clinical Record 2 Hospice Benefit Election indicates "I elect to receive the patient notification of non-covered items, services, and drugs." The chart does not contain evidence that a completed notification of non-covered items was prepared and given to patient. Clinical Record 1 Hospice Benefit Election indicates "I elect to receive the patient notification of non-covered items, services, and drugs." The chart does not contain evidence that a completed notification of non-covered items was prepared and given to patient. Clinical Record 8 Hospice Benefit Election indicates "I elect to receive the patient notification of non-covered items, services, and drugs." The chart does not contain evidence that a completed notification of non-covered items was prepared and given to patient. Clinical Record 3 Hospice Benefit Election indicates "I elect to receive the patient notification of non-covered items, services, and drugs." The chart does not contain evidence that a completed notification of non-covered items was prepared and given to patient. Clinical Record 5 Hospice Benefit Election indicates "I elect to receive the patient notification of non-covered items, services, and drugs." The chart does not contain evidence that a completed notification of non-covered items was prepared and given to patient. Clinical Record 10 Hospice Benefit Election indicates "I elect to receive the patient notification of non-covered items, services, and drugs." The chart does not contain evidence that a completed notification of non-covered items was prepared and given to patient. Clinical Record 4 Hospice Benefit Election indicates "I elect to receive the patient notification of non-covered items, services, and drugs." The chart does not contain evidence that a completed notification of non-covered items was prepared and given to patient. Clinical Record 7 Hospice Benefit Election indicates "I elect to receive the patient notification of non-covered items, services, and drugs." The chart does not contain evidence that a completed notification of non-covered items was prepared and given to patient. Clinical Record 0 Hospice Benefit Election indicates "I elect to receive the patient notification of non-covered items, services, and drugs." The chart does not contain evidence that a completed notification of non-covered items was prepared and given to patient. Clinical Record 9 Hospice Benefit Election indicates "I elect to receive the patient notification of non-covered items, services, and drugs." The chart does not contain evidence that a completed notification of non-covered items was prepared and given to patient. Interview with administrator confirmed that completed notification of non-covered items are not in the chart and she believes staff require further education, 10 of 11 (90%) of the clinical revealed that the records did not contain completed list of non-covered items when the patient elected to receive notice of non-covered items on the Election of Benefits.

It is required that the hospice discharge summary provided or to the patient’s community attending physician upon hospice discharge. This standard was not met as evidenced by a review of clinical records and interviews. 2 of 2 (100%) of applicable discharged records reviewed revealed that the agency did not ensure that a discharge summary was sent to the attending physician upon discharge. Clinical Record 6 Reveals date of discharge 6/05/2022. The record has no evidence of a discharge summary being sent to physician, Clinical Record 4 Reveals date of discharge 7/19/2022. The record has no evidence of a discharge summary being sent to physician, Interview with administrator on 7/27/2022 revealed that she was unaware that a discharge summary was required for hospice and the agency has not been sending discharge summaries. 2 of 2 (100%) of applicable discharged records revealed that the agency did not ensure that a discharge summary was sent to the attending physician upon discharge.

It is required that the Interdisciplinary Group determines the ability of the patient and/or family to safely self-administer drugs and biologicals to the patient in their home. The plan of care identifies the IDG’s finding regarding safe self-administration and/or family administration of drugs and biologicals. 1. If the patient and/or family cannot administer drugs or biologicals, it is noted in the plan of care, as well as how it is addressed by the IDG. This standard was not met as evidenced by a review of clinical records and observations. 2 of 2 (100%) of the clinical records in which patients live at home, the facility did not ensure that the ability of the patient and family to safely administer drugs and biologicals were assessed or addressed. Clinical Record 0 Revealed that patient lives alone with a mental illness and does not like other people to be around. The ability to safely manage his medications in not addressed in the assessment or care plan. Staff #1 Interview with the administrator revealed that the software system does not prompt them to address the ability of the patient and caregiver to safely administer drugs and biologicals, therefore the staff are not documenting it. Clinical Record 7 Revealed that patient lives in home with daughter and son in law but the assessment and care plan does not address the ability for patient or family to safety administer drugs to the patient. 2 of 2 (100%) of the clinical records in which patients live at home, the facility did not ensure that the ability of the patient and family to safely administer drugs and biologicals were assessed or addressed.