Every finding on record at Bristol Hospice - Bend, L.L.C.

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 19 (11%) clinical records reviewed, the agency did not ensure the patient's plan of care (POC) reflected patient and family goals and interventions based on problems identified in the initial and updated comprehensive assessments. Clinical Record 5: The patient elected hospice care on 07/23/2024 with a diagnosis of Alzheimer's disease, unspecified. The recertification comprehensive assessment completed by the skilled nurse (SN) dated 09/17/2024 documented "New dysphagia over the last two weeks" per the face-to-face encounter completed by the Associate Medical Director. The interdisciplinary group (IDG) POC dated 09/17/2024 did not include documentation of a goal and intervention(s) for the patient's identified problem with dysphagia. Clinical Record 6: The patient elected hospice care on 11/08/2024 with a diagnosis of senile degeneration of the brain, not elsewhere classified. The initial SN comprehensive assessment dated 11/08/2024 documented, "They utilize oxygen; the Power of Attorney (POA) says they use the oxygen daily." The patient's medication profile documented, "Oxygen 2 liters/per minute (L/Min) via nasal cannula continuous for shortness of breath (SOB)." The IDG POC dated 11/08/2024 did not include documentation of a goal and intervention(s) for the patient's identified respiratory problem, including using oxygen. In an interview on 03/06/2025, the Executive Director and Regional Director of Clinical Operations confirmed the findings. They stated the POCs did not reflect the goals and interventions based on problems identified in the comprehensive assessments.

It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. This standard was not met as evidenced by clinical record review and interview. In 3 of 12 (25%) clinical records reviewed of patients who received Hospice Aide (HA) services and had changes related to the HA care plan that required reporting to the Registered Nurse (RN), the agency did not ensure that the HA reported the changes to the RN. Clinical Record 6: The patient elected hospice care services on 11/08/2024 with a diagnosis of senile degeneration of the brain, not elsewhere classified. The patient died on 11/30/2024. The plan of care ordered HA services two (2) times per week. The HA care plan dated 11/08/2024 assigned the HA the relevant tasks every visit: assist with ambulation using a walker, assist with bedpan or urinal, assist with bedside commode, empty bedside commode, mouth care every visit, record bowel movements, seated shower and voids in bathroom with assist. The HA visit note dated 11/25/2024 documented that the assigned tasks were "Not Performed." A clinical record review revealed no evidence that the HA reported the change in the patient's care plan and needs to the Registered Nurse (RN). Clinical Record 9: The patient elected hospice care services on 08/12/2024 with a diagnosis of malignant neoplasm of the larynx, unspecified. The patient resided in a skilled nursing facility (SNF). For the certification period dated 12/10/2024 through 01/15/2025, the plan of care ordered HA services two (2) times per week. The HA care plan dated 12/05/2024 assigned the HA the relevant task: seated shower every visit. The HA visit note dated 01/10/2025 documented that the patient refused the assigned task, a seated shower. A clinical record review revealed no evidence that the HA reported the change in the patient's care plan and needs to the RN. Clinical Record 10: The patient elected hospice care services on 07/10/2024 with a diagnosis of pulmonary fibrosis, unspecified. For the certification period dated 01/06/2025 - 03/06/2025, the plan of care ordered HA services two (2) times per week. The HA care plan dated 01/02/2025 assigned the HA the relevant tasks: ... gentle, comforting approach: soft music, Thera-Bear, weighted blanket, change bed linens, fingernail care: file and clean nails no trimming, foot care: file and clean nails no trimming, and shampoo hair. The HA visit note dated 02/28/2025 documented that the assigned tasks were "Not Performed." A clinical record review revealed no evidence that the HA reported the change in the patient's care plan and needs to the RN. During an interview on 03/06/2025, the Executive Director and Regional Director of Clinical Operations confirmed the finding. They stated that the aide had not reported changes in the patient's care needs to the RN as the changes related to the assigned tasks in the care plan.

It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This standard was not met as evidenced by document review and interview. The agency did not ensure that hospice volunteers provided day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. The "Volunteer Coordinator Monthly Reports" review revealed that the volunteer percentage of hours worked from 01/01/2024 through 12/31/2024 was 2.11%. During an interview on 03/07/2024, the Executive Director and Volunteer Coordinator confirmed the finding. They stated that volunteers had not provided 5% volunteer day-to-day administrative or direct patient care services. The review of the "Volunteer Coordinator Monthly Reports" revealed the agency did not ensure that volunteers provided day-to-day administrative or direct patient care services in an amount that, at a minimum, equaled five percent (5%) of the total patient care hours of all paid hospice employees and contract staff.

It is required that the hospice medical director or physician-designee provides written and signed recertification of the terminal illness to meet the hospice care benefit requirement. Recertification is completed no later than two (2) calendar days after the first day of each benefit period, and no more than fifteen (15) days before the next benefit period begins. This standard was not met as evidenced by clinical record review, document review, and interview. In 4 of 10 (40%) clinical records reviewed of patients who required recertification with a face-to-face visit, the agency did not ensure the face-to-face was completed by a physician-designee, a Nurse Practitioner (NP) as required in 418.22. Agency Contract List: A review of the agency's current local "Contract List" revealed the Nurse Practitioner (NP) listed as a contracted employee. The "Nurse Practitioner Agreement" was signed and dated 11/19/2024. The "Nurse Practitioner Agreement" read in part, "Article 3: Nurse Practitioner's Obligations...3.3.2 Nurse Practitioner shall receive (payment information) for each Face-to-Face visit conducted by Nurse Practitioner in compliance with all CMS requirements and applicable laws, rules, and regulations including but not limited to [42 CFR 418.22]." Clinical Record 2: The patient elected hospice on 08/15/2024 with a diagnosis of senile degeneration of the brain, not elsewhere classified. For the patient's third (3rd) benefit period, dated 02/11/2025 through 04/11/2025, the contracted Nurse Practitioner (NP) completed the face-to-face on 02/07/2025. A clinical record review revealed no evidence that the face-to-face was completed by a directly employed (W2) Nurse Practitioner (NP) as per the regulation. Clinical Record 12: The patient elected hospice on 10/15/2024 with a diagnosis of Alzheimer's disease unspecified. For the patient's eleventh (11th) benefit period, dated 02/12/2025 through 04/12/2025, the contracted NP completed the face-to-face on 02/07/2025. A clinical record review revealed no evidence that the face-to-face was completed by a directly employed (W2) Nurse Practitioner (NP) as per the regulation. Clinical Record 15: The patient elected hospice on 07/30/2024 with the diagnoses of hypertensive heart and chronic kidney disease (CKD) with heart failure and stage 1-4/unspecified CKD. For the patient's sixth (6th) benefit period, dated 01/26/2025 through 03/26/2025, the contracted NP completed the face-to-face on 01/23/2025. A clinical record review revealed no evidence that the face-to-face was completed by a directly employed (W2) Nurse Practitioner (NP) as per the regulation. Clinical Record 17: The patient elected hospice on 07/30/2024 with a diagnosis of Alzheimer's disease unspecified. For the patient's sixth (6th) benefit period, dated 01/26/2025 through 03/26/2025, the contracted NP completed the face-to-face on 01/14/2025. A clinical record review revealed no evidence that the face-to-face was completed by a directly employed (W2) Nurse Practitioner (NP) as per the regulation. During an interview on 03/06/2025, the Executive Director and Regional Director of Clinical Operations (RDCO) confirmed that the physician designee's review of the patient's clinical information (face-to-face) was completed by a contracted hospice NP and not a W-2 employee as per regulation. On 03/05/2025, the NP was converted from a contract employee to an agency employee (W-2 employee). The ED stated that the NP finished onboarding and orientation on 01/08/2025 and started completing the F2F visits on 01/09/2025. Also, per the RDCO, the agency identified all face-to-face visits completed by the NP since 01/09/2025 and was doing due diligence as per regulation.

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. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical record review of a patient who revoked the hospice benefit, the agency did not ensure a copy of the discharge summary was forwarded to the patient's attending physician. Clinical Record 8: The patient elected the hospice benefit on 08/12/2024 and revoked the hospice benefit on 10/01/2024 to seek aggressive treatment. A clinical record review revealed no evidence that the discharge summary was forwarded to the patient's attending physician. The Executive Director and Regional Director of Clinical Operations confirmed in an interview on 03/06/2025 that a copy of the discharge summary was not forwarded to the patient's attending physician.

It is required that the hospice designates a registered nurse member of the IDG to provide coordination of care, ensure continuous assessment of each patient’s and family’s needs and ensure the implementation of the interdisciplinary plan of care. 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. This standard was not met as evidenced by clinical record review and interview. 1 of 8 (12%) records reviewed revealed the hospice did not ensure the skilled nurse followed the plan of care as ordered. Record #72431: There was an order for skilled nursing visits 2 x week for the week of Jan 30 and February 6, 2022. During the week of 1/30/2022-2/5/2022, there was one visit on 2/3/2022. During the week of 2/6/2022-2/12/2022, there was one visit on 2/11/2022. There were no documented reasons for the missed visits. The Executive Director was interviewed on 5/19/2022 and confirmed the nurse did not follow the plan of care as ordered.

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. This standard was not met as evidenced by observation on home visits, interview, and document review. 1 of 3 (33%) visits revealed the hospice did not ensure the adherence to agency infection prevention and control policies and procedures for hand hygiene. Agency policy, “Hand Hygiene, Policy No. 77-009”, revised May 2020, states in part, “Hand decontamination using an alcohol-based hand rub should be performed: after contact with inanimate objects (including medical equipment) in the immediate vicinity of the paint and after removing gloves.” Record #72431: During the observed visit on 5/18/2022 at 10:15am, the RN (employee record #10467) removed supplies from the nursing bag and completed the vital signs. The nurse was observed cleaning the blood pressure cuff, pulse oximeter, and stethoscope. Next, the nurse was observed removing her gloves, using hand sanitizer, then proceeded to type the vitals and other information into the tablet before picking up the clean blood pressure cuff, pulse oximeter, and stethoscope and returned them to the nursing bag without performing hand hygiene. The Executive Director was interviewed on 5/19/2022 and she agreed with the finding that the nurse did not follow agency policy for handwashing.

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 clinical record review and interview. 3 of 8 (37%) records reviewed revealed the hospice did not ensure the notification of hospice non-covered items were provided to the patient within five days of the request upon admission." Cross-reference CFR 418.24(d) which states in the relevant part, "(d) Timeframes for the hospice election statement addendum. (1) If the addendum is requested within the first five days of a hospice election (that is, in the first five days of the hospice election date), the hospice must provide this information, in writing, to the individual (or representative), non-hospice provider, or Medicare contractor within five days from the date of the request. Record #72431: The patient's start of care (SOC) was 11/30/2021. The hospice election statement was reviewed and documented the patient/caregiver requested the hospice election addendum on 11/30/2021. The notification of hospice non-covered items was completed and signed on 12/6/2021 (6 days from the request). Record #58115: The patient's SOC was 4/13/2022. The hospice election statement was reviewed and documented the patient/caregiver requested the addendum on 4/13/2022. The notification of hospice non-covered items was completed and signed on 4/28/2022 (15 days from the request). Record #25045: The patient's SOC was 2/17/2022. The hospice election statement was reviewed and identified the patient/caregiver requested the addendum on 2/17/2022. The notification of hospice non-covered items was completed and signed on 4/4/2022 (46 days from the request). The Executive Director was interviewed on 5/19/2022 and stated, “these were done late, we are aware and have provided training to staff.”