Every finding on record at Bright Hospice Care Inc

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 and interview. In 2 of 5 (40%) clinical records reviewed revealed the agency did not ensure the plan of care (POC) reflected patient and family goals and interventions based on problems identified in the initial and updated comprehensive assessments. THIS IS A CONTINUING REQUIRED ACTION Clinical Record 2: The initial nursing assessment dated 08/05/2024 stated in the narrative that per the family, "The patient has become confused with episodes of anxiety, combativeness and sundowning." The interdisciplinary group (IDG) POC dated 08/05/2024 lacked evidence of goal(s) and intervention(s) for anxiety, combativeness and sundowning. Clinical Record 3: The initial nursing assessment dated 04/24/2024 stated in the narrative, "Patient was combative, hitting out at nurses and holding onto our hands." The IDG POC dated 04/24/2024 lacked evidence of goal(s) and intervention(s) for the patients' combativeness. The Chief Executive Officer, Executive Director/Administrator, and Operations Manager stated in an interview on 09/17/2024 that the agency did not ensure the POC reflected patient and family goals and interventions based on problems identified in the initial and updated comprehensive assessments. CONTINUATION OF REQUIRED ACTION

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. Hospice aide documentation complies with hospice policies and procedures. This standard was not met as evidenced by clinical record review and interview. In 2 of 5 (40%) records reviewed in which the patient elected hospice aide services revealed the agency did not ensure the hospice aide reported changes in the patient's medical needs to the registered nurse (RN) as the changes related to the aide care plan. Clinical Record 2: The aide care plan dated 08/05/2024 ordered the tasks: "Bed Bath, Shampoo, and Hair Care." The aide visit note dated 08/08/2024 documented for the "Bed Bath", "Shampoo", and "Hair Care" tasks: Completed: "N." Note: "Task already completed." The record lacked evidence that the aide reported changes in the patient's medical needs to the RN as the changes related to the aide care plan. Clinical Record 4: The aide care plan dated 07/30/2024 ordered the task: "Nail Care." The aide visit note dated 08/01/2024 documented for the "Nail care" task: Completed "N." Note: "Task already completed." The record lacked evidence that the aide reported changes in the patient's medical needs to the RN as the changes related to the aide care plan. The Chief Executive Officer, Executive Director/Administrator, and Operations Manager stated in an interview on 09/17/2024 that the agency did not ensure the hospice aide reported changes in the patient's medical needs to the RN as the changes related to the aide care plan.

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 document review, clinical record review, and interview. In 3 of 14 (21%) clinical records reviewed, the hospice did not ensure an initial bereavement assessment was completed no later than five (5) calendar days after the patient’s election of hospice care. Agency policy Initial Assessment/Comprehensive Assessment stated in part, “An initial bereavement risk 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 must be incorporated into the plan of care and considered in the bereavement plan of care. The Hospice IDG [interdisciplinary group], in consultation with the patient’s attending physician (if any), must complete the comprehensive assessment no later than 5 calendar days after patient’s election of Hospice care.” Clinical Record 1: The patient elected the hospice benefit on 07/26/2023. Clinical record review revealed no documented evidence an initial bereavement assessment was completed for the patient, as of the date of record review on 10/19/2023. Clinical Record 6: The patient elected the hospice benefit on 08/04/2023. Clinical record review revealed no documented evidence an initial bereavement assessment was completed for the patient, as of the date of record review on 10/19/2023. Clinical Record 8: The patient elected the hospice benefit on 06/01/2023. Clinical record review revealed no documented evidence an initial bereavement assessment was completed for the patient, as of the date of record review on 10/19/2023. During a joint review of the record and an interview on 10/19/2023, the Director of Patient Care Services agreed there was no documented evidence that an initial bereavement assessment was completed. The Director of Patient Care Services stated, “we just started a performance improvement project on this, the chaplain, social worker or nurse should be doing them in the first five days.”

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. This standard was not met as evidenced by clinical record review and interview. In 3 of 14 (21%) clinical records reviewed, the hospice did not ensure the patient’s individualized plan of care identified planned interventions and goals based on problems identified in the initial and updated comprehensive assessments. Clinical Record 4: The patient elected the hospice benefit on 06/28/2023, with a terminal diagnosis of Parkinsonism. The Registered Nurse (RN) documented on the comprehensive assessment dated 06/28/2023 the patient was at risk for falls and the patient’s pain rating was 4/10 with pain being an active problem for the patient. The RN visit note dated 07/10/2023 documented the patient’s pain at 3/10. The plan of care dated 06/28/2023 through 10/19/2023 did not include problems, goals, or interventions related to the patient’s pain and fall risk. Clinical Record 8: The patient elected the hospice benefit on 06/01/2023, with terminal diagnosis of chronic obstructive pulmonary disease. The RN documented on the comprehensive assessment dated 06/01/2023 the patient was at risk for falls and the patient was dyspneic [short of breath] at rest on 4 liters per minute of continuous oxygen. The plan of care dated 06/01/2023 through 10/19/2023 did not include problems, goals, or interventions related to the patient’s dyspnea, oxygen use, and fall risk. Clinical Record 14: The patient elected the hospice benefit on 06/14/2023, with terminal diagnosis of senile degeneration of the brain. The RN documented on the comprehensive assessment dated 06/14/2023 the patient had 1+ edema to the left and right ankles. The RN visit note dated 07/31/2023 documented 2+ edema in lower right and lower left extremities. The plan of care dated 06/14/2023 through 10/06/2023 did not include problems, goals, or interventions related to the patient’s edema. During record review and interview on 10/19/2023, the Director of Patient Care Services agreed there was no documented evidence that the plans of care included problems, goals, or interventions for the problems identified in the assessments.

It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including 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 5 of 14 (36%) clinical records reviewed, the hospice did not ensure the individualized plan of care included medical supplies and appliances necessary to meet the needs of the patients. Clinical Record 1: The patient elected the hospice benefit on 07/26/2023, with terminal diagnosis of malignant neoplasm, unspecified. The Registered Nurse (RN) documented on the comprehensive assessment dated 07/26/2023 the patient was on oxygen at 2 liters per minute, and equipment ordered by hospice included bedrails, hospital bed, over bed table, oxygen concentrator, oxygen cylinder, and wheelchair. The DME [durable medical equipment] and Supplies section the plan of care dated 07/26/2023 stated “none.” There was no documented evidence the plan of care included the medical supplies, including the DME necessary to meet the needs of the patient. Clinical Record 2: The patient elected the hospice benefit on 05/20/2023, with terminal diagnosis of senile degeneration of the brain. The RN documented on the comprehensive assessment dated 05/20/2023 the patient was on oxygen at 2 liters per minute as needed for shortness of breath/wheezing. The DME and Supplies section of the plan of care dated 05/20/2023 stated “none.” There was no documented evidence the plan of care included the medical supplies, including DME necessary to meet the needs of the patient. Clinical Record 3: The patient elected the hospice benefit on 10/14/2023, with terminal diagnosis of chronic obstructive pulmonary disease. The medication profile dated 10/14/2023 included an order for oxygen at 2 liters per minute continuously. The DME and Supplies section of the plan of care stated “none.” There was no documented evidence that the plan of care included the medical supplies or DME related to the patient’s prescribed oxygen therapy. Clinical Record 4: The patient elected the hospice benefit on 06/28/2023, with terminal diagnosis of Parkinsonism. The RN documented on the comprehensive assessment dated 06/28/2023 the patient had a coccyx wound with treatment to clean with wound cleanser, pat dry, apply Medihoney, cover with dressing, change three times a week and prn [as needed]. The DME and Supplies section of the plan of care dated 06/28/2023 stated “none.” There was no documented evidence the plan of care included the medical supplies related to the patient’s prescribed wound care. Clinical Record 8: The patient elected the hospice benefit on 06/01/2023, with terminal diagnosis of chronic obstructive pulmonary disease. The RN documented on the comprehensive assessment dated 06/01/2023 equipment ordered by hospice included over bed table, oxygen concentrator, wheelchair, shower chair, briefs, gloves, wipes, Chux pads, basin, perineal spray, shampoo/body wash, barrier cream, mouth swab. The DME [durable medical equipment] and Supplies section the plan of care dated 06/01/2023 stated “none.” There was no documented evidence the plan of care included the medical supplies, including the DME necessary to meet the needs of the patient. During a joint record review and interview on 10/19/2023, the Director of Patient Care Services agreed the plans of care did not include the medical supplies and DME necessary to meet the needs of the patients.

It is required that all hospice aide services must be provided by an individual who has successfully completed one (1) of the four (4) training and competency evaluations programs described below, and the individual furnishes hospice aide services on behalf of a hospice only after successfully completing a competency evaluation program also described below, and the hospice maintains documentation that each hospice aide has met the requirements. Documentation of training includes a description of the training and competency evaluation program; the qualifications of the instructor; a statement that distinguishes skills taught in a laboratory using a real person (not a mannequin); indicators of which skills the aide was judged to be competent in; and how additional skills, if any, are taught and tested if the hospice’s admission policies and case-mix of hospice patients requires aides to perform more complex procedures. Hospice Aide Training and Competency Evaluation, A qualified hospice aide has successfully completed a competency evaluation program that evaluates the aide’s competency in the following subject areas by observation of the aide’s performance with a patient or pseudo-patient: a) Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff; b) Reading and recording temperature, pulse, and respiration; c) Appropriate and safe techniques in performing personal hygiene and grooming tasks, including items on the following basic checklist: i. Bed bath; ii. Sponge, tub, and shower bath; iii. Hair shampoo (sink, tub, and bed); iv. Nail and skin care; v. Oral hygiene; vi. Toileting and elimination; d) Safe transfer techniques and ambulation; e) Normal range of motion and positioning. Evaluates the aide’s competency in the following subject areas by written exam, oral examination, or after observation of a hospice aide with a patient or a pseudo-patient during a simulation: a) Observation, reporting, and documentation of patient status and the care or service provided; b) Basic infection control procedures; c) Basic elements of body functioning and changes in body function that must be reported to an aide’s supervisor; d) Maintenance of a clean, safe, and healthy environment; e) Recognizing emergencies and the knowledge of emergency procedures and their application; f) The physical, emotional, and developmental needs of—and ways to work with—the populations served by the hospice, including the need for respect for the patient, his or her privacy, and his or her property; g) Adequate nutrition and fluid intake; h) Any remaining task(s) that the hospice chooses to have an aide perform. AND The competency evaluation is performed by a registered nurse in consultation with other skilled professionals, as appropriate. AND A hospice aide is not considered competent in any task for which he or she is evaluated as “unsatisfactory.” A hospice aide may not perform that task without direct supervision by a registered nurse until after he/she has received training in the task for which he/she was evaluated as “unsatisfactory.” and has successfully completed a subsequent evaluation. A hospice aide is not considered to have successfully completed a competency evaluation if the aide has an “unsatisfactory” rating in more than one (1) of the required areas. AND The hospice maintains documentation that demonstrates the requirements of competency evaluation are met. This standard was not met as evidenced by document review, personnel record review, and interview. In 1 of 2 (50%) personnel records reviewed of hospice aides, the hospice did not ensure the skills and competencies of hospice aides where assessed. Agency policy Staff Competency Program stated in part, “Hospice will provide for initial and ongoing competency assessments for all patient care staff by qualified individuals. Patient care staff will be competency assessed at defined intervals: for each new employee (including contract employees) during orientation. Hospice has established competency criteria for each job category. Qualified individuals will observe the employee during competency evaluation. The competency evaluation checklist will be completed and retained in the employee’s record. Competency evaluations are performed at the time of hire and annually.” Agency policy Hospice Aide Services and Training Program stated in part, “All hospice aides employed by Hospice will satisfactorily complete a hospice aide training program and/or competency evaluation program prior to performing patient care. Documentation is maintained to demonstrate that the training requirements are met and includes a description of the training/competency evaluation program, a record that distinguishes between skills taught at a patient’s bedside with supervision, and those taught in a laboratory using a real person (not a mannequin) and indicators of which skills each aide was judged to be competent. Documentation is maintained to demonstrate that the competency evaluation requirements are met.” Personnel Record 9: Hospice Aide date of hire 04/11/2023. The personnel record contained no documented evidence that an initial hospice aide competency assessment was completed. During personnel record review and interview on 10/19/2023, the Director of Patient Care Services agreed the personnel record did not include a competency assessment for the hospice aide and stated “the competency should have been done before the hospice aide was on their own. I am told it was done, but I do not have any documentation to show one was ever completed.”

It is required that 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, documented in the patient record, including the time spent. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical record reviewed with volunteer services, the hospice did not ensure volunteer services were documented in the clinical record. Clinical Record 12: The patient elected the hospice benefit on 02/22/2023, with terminal diagnosis of cerebral atherosclerosis. Clinical record review revealed a physician’s order dated 02/27/2023 for volunteer services to be provided once a month. The clinical record contained no documented evidence of volunteer visits provided to the patient from 02/27/2023 through 05/19/2023. During joint record review record and interview on 10/19/2023, the Director of Patient Care Services agreed there was no documented evidence of a volunteer visit. The Director of Patient Care Services stated, “we know we went because we have talked about it but do not have anything documented.”

It is required that orientation on the hospice philosophy is also provided to all employees and contracted staff who have patient and family contact. This standard was not met as evidenced by document review, personnel record review, and interview. In 1 of 10 (10%) personnel records reviewed, the hospice did not ensure hospice employees received initial orientation to hospice philosophy. Agency policy Employee Orientation stated in part, “Each employee and contracted staff who has patient and family contract will receive an orientation about the hospice philosophy. Orientation for all employees will be performed and documented by supervisory staff and preceptors. Orientation checklist will be used to document orientation for all staff, including contract staff.” Personnel Record 6: Social Worker date of hire 03/01/2023. The personnel record contained no documented evidence that an initial orientation to hospice philosophy was provided. During personnel record review and interview on 10/19/2023, the Director of Patient Care Services agreed there was no evidence that the social worker was provided with an initial orientation that included hospice philosophy.

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 document review, personnel record review, and interview. In 2 of 8 (25%) personnel records reviewed excluding hospice aide records, revealed the hospice did not ensure the skills and competencies of all individuals providing care were assessed. Agency policy Staff Competency Program stated in part, “Hospice will provide for initial and ongoing competency assessments for all patient care staff by qualified individuals. Patient care staff will be competency assessed at defined intervals: for each new employee (including contract employees) during orientation. Hospice has established competency criteria for each job category. Qualified individuals will observe the employee during competency evaluation. The competency evaluation checklist will be completed and retained in the employee’s record. Competency evaluations are performed at the time of hire and annually.” Personnel Record 7: Chaplain/Bereavement Coordinator date of hire 12/05/2022. The personnel record contained no documented evidence that chaplain or bereavement coordinator competency assessments were completed upon hire. Personnel Record 6: Social Worker date of hire 03/01/2023. The personnel record contained no documented evidence social worker competency assessment was completed upon hire. During joint personnel record review and interview on 10/19/2023, the Director of Patient Care Services agreed the personnel records did not include documentation of a completed competency assessment and stated “these should be done before they were on their own. I do not have any documentation to show they were ever completed.”

It is required that the hospice medical director or physician designee reviews the clinical information for each patient being evaluated for admission and provides written certification that it is anticipated that the patient's life expectancy is six months or less if the illness runs its normal course. The physician considers the following when making this determination the primary terminal condition, related diagnosis(es), if any, current subjective and objective medical findings, current medication and treatment orders, information about the medical management of any of the patient's conditions unrelated to the terminal illness. This standard was not met as evidenced by document review, clinical record review, and interview. In 2 of 14 (14%) clinical records reviewed, the hospice did not ensure the written certification included the required elements. Agency policy Certification/Recertification of Terminal Illness, Brief Narrative Statement and Face to Face Evaluations, stated in part, “Hospice will obtain the written certification of terminal illness. The Medical Director, or designee, reviews the clinical information and other documentation that supports the medical prognosis for each hospice patient. This Brief Narrative Statement must accompany the certification and be filed in the patient record. The written certification must specify that it is anticipated that the patient’s life expectancy is six months or less if the illness runs its normal course. The physician must consider the following when making this determination: the primary terminal condition, related diagnosis(es) if any, current subjective and objective medical findings, current medication and treatment orders, information about the medical management of any of the patient’s conditions unrelated to the terminal illness.” Clinical Record 4: The patient elected the hospice benefit on 06/28/2023, with a terminal diagnosis of Parkinsonism. The initial certification of terminal illness (CTI) signed by the hospice Medical Director documented a verbal order on 06/27/2023 for certification period 06/28/2023 to 09/25/2023. The CTI description stated, “I certify that the patient’s prognosis is six months or less if the disease runs it’s normal course.” There was no documented evidence of a written certification narrative explaining the clinical findings that supported the patient's life expectancy of six months or less. Clinical Record 7: The patient elected the hospice benefit on 03/29/2023, with a terminal diagnosis of degenerative disease of nervous system. The initial CTI signed by the hospice Medical Director documented a verbal order on 03/29/2023 for certification period 03/29/2023 to 06/26/2023. The physician narrative stated, “I have reviewed the patient’s clinical information and considered the terminal diagnosis, related diagnosis, current subjective and objective findings and find (the patient) hospice appropriate." There was no documented evidence of a written certification narrative explaining the clinical findings that supported the patient's life expectancy of six months or less. During joint record review and interview on 10/19/2023, the Director of Patient Care Services agreed the records did not contain documentation of a written certification narrative explaining the clinical findings that supported the patient's life expectancy of six months or less. The Director of Patient Care Services stated, “it looks like just the template information and the physician narrative information is missing.” During a review of the record and interview on 10/19/2023, the Hospice Medical Director agreed, the CTI was lacking the required documentation, and “I don’t have a good answer for why it wasn’t completed.”

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary, the patient's record, if requested. This standard was not met as evidenced by document review, clinical record review, and interview. In 1 of 3 (33%) clinical records reviewed of patients that were discharged, the hospice did not ensure the patient’s attending physician was sent a copy of the discharge summary. Agency policy Discharge Summary stated in part, "If a patient revokes the election of Hospice care or is discharged from Hospice, Hospice will forward to the patient’s attending physician, a copy of the Hospice discharge summary." Clinical Record 12: The patient elected the hospice benefit on 02/22/2023, with terminal diagnosis of cerebral atherosclerosis. The patient revoked hospice services on 05/19/2023 to seek aggressive treatment. Clinical record review revealed no documented evidence the discharge summary was sent to the patient’s attending physician. During joint record review and interview on 10/18/2023, the Director of Patient Care Services agreed there was no documented evidence that the discharge summary was sent to the patient's attending physician.

It is required that the hospice obtains a criminal background check on all hospice employees who have direct patient contact or access to patient records. Hospice contracts require that all contracted employees who have direct patient contact or access to patient records obtain criminal background checks. This standard was not met as evidenced by document review, personnel record review, and interview. In 2 of 10 (20%) personnel records reviewed, the hospice did not ensure criminal background checks were obtained for all hospice employees, including contracted staff, who have direct patient contact or access to patient records. Agency policy Personnel Records stated in part, “The personnel record for an employee will include, but not be limited to, criminal background checks on all employees who have direct patient contact or access to patient records.” Personnel Record 6: Social Worker date of hire 03/01/2023. The personnel record did not include documented evidence the hospice obtained a criminal background check. Personnel Record 4: Associate Medical Director date of hire 12/01/2021. The personnel record did not include documented evidence the hospice obtained a criminal background check. During personnel record review and interview on 10/19/2023, the Director of Patient Care Services agreed the personnel records did not include documentation that the criminal background checks were completed and both staff have access to patient records and should have had a background check completed.