Every finding on record at Bva Hospice Care Inc

It is required that the update of the comprehensive assessment is completed by the hospice Interdisciplinary Group, who, in collaboration with the individual’s attending physician, if any, consider the changes that have taken place since the initial assessment. The update of the comprehensive assessment includes information on the patient’s progress toward desired outcomes and reassessment of the patient’s response to care. The assessment update is completed as frequently as the condition of the patient requires and no less frequently than every 15 days. CONTINUING PRIOR REQUIRED ACTION This standard was not met as evidenced by the review of clinical records and interview. 1 of 3 (33%) applicable clinical records reviewed of patients with wounds revealed the hospice did not ensure that the assessment includes information on the patient’s progress toward desired outcomes and reassessment of the patient’s response to care. Record #96063: For the recertification period dated 5/24/2022 through 8/21/2022. The wound care order documented, "Wound treatment to right anterior lower skin tear, cleanse right anterior lower skin tear with normal saline apply TAO, covered with bordered gauze." The IDT/IDG reviews dated 5/31/2022 and 6/13/2022 revealed the comprehensive assessment sections did not include an updated wound assessment of the skin tear on the anterior of the right knee. Wound measurements were not documented by the the SN in the visit notes completed on 5/29/2022, 6/2/2022, 6/5/2022 and 6/12/2022. The IDG/IDT on 5/31/2022 documented that the wound care was provided by the "wound specialist” but did not provide documentation of the Right Anterior Lower Leg treatment. During interview 6/21/22, the administrator confirmed the finding.

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). CONTINUING PRIOR REQUIRED ACTION This standard was not met as evidenced by the review of clinical records and interview. 2 of 5 (40%) clinical records reviewed revealed that the hospice did not ensure nursing visits were provided to patients as ordered and/or included in the plan of care. Record #96063: The nursing visit schedule as ordered read “LVN visit frequency two times each week.” The clinical record revealed missing LVN visit notes for the week of 6/05/2022 and 6/12/2022. Record #97879: The nursing visit frequency as ordered read "LVN visit frequency is two times each week." The clinical record revealed a missing LVN visit note for the week of 6/05/2022. During an interview on 6/21/2022, the Administrator confirmed that the LVN visit notes were missing from the patients' records.

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 the initial plan of care, updated plans of care, initial assessment, comprehensive assessment, updated comprehensive assessments, and clinical notes including the care and services provided. This standard was not met as evidenced by the review of clinical records and interview.. 1 of 5 (20%) records reviewed revealed the home health agency did not ensure that the patient record contained clinical notes including the care and services provided. Record # 96063 was reviewed and identified the patient elected hospice care on 3/23/2022. For the recertification dated 5/24/2022 through 8/21/2022, the patient’s hospice diagnosis included Alzheimer's, Hyperlipidemia, Anxiety, and Mobility with fall risk. The wound care order documented, "Wound treatment to right anterior lower skin tear, cleanse right anterior lower skin tear with normal saline apply TAO, covered with bordered gauze." The skilled nurse visit completed on 5/22/2022 did not include documentation of the skin tear. The skilled nursing visits completed 5/29/2022, 6/2/2022, 6/52022, and 6/12/2022 did not include documentation of wound measurements for the skin tear. In an interview with the administrator, during the exit conference, on 6/21/2022, it was stated that the RN is required to provide documentation and/or communication to ensure care and services have been undertaken to meet the needs of the patients.

It is required that the update of the comprehensive assessment is completed by the hospice Interdisciplinary Group, who, in collaboration with the individual’s attending physician, if any, consider the changes that have taken place since the initial assessment. The update of the comprehensive assessment includes information on the patient’s progress toward desired outcomes and reassessment of the patient’s response to care. The assessment update is completed as frequently as the condition of the patient requires and no less frequently than every 15 days. This standard was not met as evidenced by review of clinical records and interview. 3 of 4 (75%) applicable clinical records of patients with wounds who received hospice care greater than 21 days revealed the hospice did not ensure the hospice Interdisciplinary Group (IDG) updated the comprehensive assessment no less frequently than every 21 days. During the public health emergency (PHE), the timeframe for updating the comprehensive assessment is extended from 15 days to 21 days. Record #88286: the "IDG POC Review" forms in the "comprehensive reassessment" sections dated 2/22/22, 3/8/22 and 3/22/22 included, "ongoing wound treatment" and did not include an updated wound assessment of the buttock pressure ulcer, progress toward desired outcomes and reassessment of the patient's response to care. Nursing visits 2/19/22 and 3/16/22 included, "buttock pressure ulcer stage II, redness and drainage". Nursing visits 2/22/22 and 3/22/22 did not include an updated wound assessment of the buttock pressure ulcer. Wound care orders were obtained 2/19/22, "wound treatment buttock pressure ulcer, cleanse wound with NSS, pat dry, apply Calmoseptine and leave open to air." Record #93518: nursing Visit dated 4/1/22 read, "Right lower leg stage II resolved and left buttocks resolved". Nursing visit note 4/5/22 included wounds located on right leg and right buttock with no documented reassessments of the wounds. The "IDG POC Review" dated 4/5/22 included, "ongoing wound treatment to right leg and coccyx" with no documented wound assessment updates, progress toward desired outcomes and reassessment of the patient's response to care. Nursing visit 4/18/22 included, "right lower leg stage II, buttock excoriation". The "IDG POC Review" dated 4/19/22 included, "ongoing wound treatment to right leg, wound to sacrum appears bad" with no documented wound assessment updates, progress toward desired outcomes and reassessment of the patient's response to care. The "IDG POC Review" dated 5/3/22 included, "start new wound treatment" with no documented wound assessment updates for leg and sacrum wounds, progress toward desired outcomes and reassessment of the patient's response to care. Wound care orders were obtained 3/23/22 for right lower leg, 3/29/22 for sacrum, changed wound care orders 4/25/22 for sacrum, and additional wound care orders on 5/2/22 for sacrum. Record #34644 was reviewed and revealed the patient transferred to another hospice 1/18/22. During the dates of review 12/14/21 through 1/18/22, two nursing visit notes 12/16/21 and 12/22/21 were documented in the clinical record. Nursing visit 12/16/21 included, "wound buttocks healed, ongoing treatment wound left heel" with no documented nursing assessment of the left heel wound. Nursing visit 12/22/21 included the documented location of four wounds on the "right and left buttock, right knee, and left heel" with "wound to right buttock healed, wound left heel still visible" and no nursing assessment of the left heel, right knee and left buttock wounds. The "IDG POC Review" 12/14/21 and 12/21/21 included, "wound to buttocks healed, ongoing treatment left heel pressure ulcer" and did not include a reassessment of the heel pressure ulcer and knee wounds with progress toward desired outcomes and reassessment of the patient's response to care. The "IDG POC Review" forms dated 1/11/22 included no wound reassessment with progress to outcomes and patient’s response to care. Review of the clinical record revealed documented contracted wound specialist physician visit notes 12/18/21, 1/1/22, 1/8/22 and 1/15/22 which all included, "wound one stage 3 closed right buttock and wound two stage 4 open left heel". Documentation reviewed revealed a "communication note" 12/28/21 with the wound specialist physician which included, "wound buttock healed, pressure injury right heel visible, continue wound treatment ordered today". Physician order 12/28/21 included, "wound right buttock pressure injury stage 3, cleanse with NS, apply xeroform to wound, change every 2-3 days and as needed". Review of the clinical record revealed no documented nursing and/or IDG reassessment of all wounds. During interview 5/12/22, the administrator and office LVN confirmed the missing updates of the comprehensive wound assessments to include information on the patient’s progress toward desired outcomes and reassessment of the patient’s response to care.

It is required that the hospice designates an Interdisciplinary Group (IDG) composed of individuals who work together to meet the physical, medical, psychosocial, emotional, and spiritual needs of the patient/family facing terminal illness and bereavement. IDG members provide the care and services offered by the organization. The IDG, in its entirety, supervises the care and services provided to the patient and family. This CONDITION was not met as evidenced by clinical record review and interview. The hospice failed to develop plans of care specific to the hospice care and services necessary to meet the patient and family needs identified in the comprehensive assessment, following the election of the hospice benefit [HCPC.18.I/L538]; when plans were developed, the hospice failed to follow the individualized written plans of care established by the hospice interdisciplinary group (IDG) and patient /caregiver [HCPC.19.I/L543] and the hospice did not include information from the patient's updated comprehensive assessments to document the patient’s progress toward outcomes and goals specified in the plan of care [HCPC.22.I/L553]. The cumulative effect of these systemic problems resulted in the inability of the hospice to ensure safe, quality patient care. This is a CMS CONDITION level finding.

It is required that the hospice designates an Interdisciplinary Group or groups who, in consultation with the patient's attending physician, prepare a written plan of care (POC) for each patient. The plan of care specifies the hospice care and services necessary to meet the specific needs of the patient and family identified in the comprehensive assessment, relative to the terminal illness and associated conditions. This standard was not met as evidenced by clinical record review and interview. 6 of 9 (67%) applicable clinical records of patients on service after the comprehensive assessment revealed the hospice did not ensure the Interdisciplinary Group (IDG), in consultation with the attending physician, prepared an initial written plan of care with patient and family identified problems, goals and planned interventions for each patient to meet the specific needs of the patient and family identified in the comprehensive assessment. Record #88286 was reviewed and revealed the patient elected hospice care on 2/12/22. The clinical record documentation revealed the initial plan of care problems, goals and interventions were not established by the IDG until the first IDG meeting on the "Update IDG POC Review" form dated 2/22/22. There was no documentation in the clinical records following the election of hospice benefit that the IDG had discussed and agreed upon the initial plan of care once each discipline's services had been accepted by the patient. Record #93518 was reviewed and revealed the patient elected hospice care on 10/20/21. The clinical record documentation revealed the initial plan of care problems, goals and interventions were not established by the IDG until the first IDG meeting on the "Update IDG POC Review" form dated 11/2/21. There was no documentation in the clinical records following the election of hospice benefit that the IDG had discussed and agreed upon the initial plan of care once each discipline's services had been accepted by the patient. Record #87935 was reviewed and revealed the patient elected hospice care on 2/23/22. The clinical record documentation revealed the initial plan of care problems, goals and interventions were not established by the IDG until the first IDG meeting on the "Update IDG POC Review" form dated 3/8/22. There was no documentation in the clinical records following the election of hospice benefit that the IDG had discussed and agreed upon the initial plan of care once each discipline's services had been accepted by the patient. Record #34644 was reviewed and revealed the patient elected hospice care on 3/4/20. The clinical record documentation revealed the initial plan of care problems, goals and interventions were not established by the IDG until the first IDG meeting on the "Update IDG POC Review" form dated 3/10/21. There was no documentation in the clinical records following the election of hospice benefit that the IDG had discussed and agreed upon the initial plan of care once each discipline's services had been accepted by the patient. Record #75898 was reviewed and revealed the patient elected hospice care on 1/6/22. The clinical record documentation revealed the initial plan of care problems, goals and interventions were not established by the IDG until the first IDG meeting on the "Update IDG POC Review" form dated 1/11/22. There was no documentation in the clinical records following the election of hospice benefit that the IDG had discussed and agreed with the initial plan of care. Record #79248 was reviewed and revealed the patient elected hospice care on 8/12/21. The clinical record documentation revealed the initial plan of care problems, goals and interventions were not established by the IDG until the first IDG meeting on the "Update IDG POC Review" form dated 8/24/21. There was no documentation in the clinical records following the election of hospice benefit that the IDG had discussed and agreed with the initial plan of care. During an interview 5/11/22, the Director of Patient Care confirmed the care plan problems, goals and interventions were not established by the IDG until the first IDG meeting.

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). This standard was not met as evidenced by review of clinical records and interview. 5 of 11 (45%) clinical records reviewed revealed the hospice did not ensure nursing visits were provided to patients as ordered and/or included in the plan of care. Record #34644 was reviewed and revealed the patient had one open wound stage IV on left heel with dressing change orders and was visited by the contracted wound care specialist physician weekly. The nursing visit frequency read "RN per two weeks." During interview 5/12/22, the administrator and LVN office nurse stated "per two weeks means once every two weeks". The clinical record revealed one missing RN visit the week 1/2/22. Review of the clinical record revealed the patient transferred to another hospice on 1/18/22. Record #88286 was reviewed and revealed the LVN visit frequency was one time a week. The clinical record revealed a missing LVN visit note the week of 2/20/22. Record #41173 was reviewed and revealed the LVN visit frequency of one time a week. The clinical record revealed an extra LVN visit note the week of 3/23/22. Record #79248 was reviewed and revealed the RN visit frequency was ordered "one as needed, recertification and supervisory visit" and LVN ordered visit frequency "as needed and recertification". Review of the clinical record revealed an extra RN visit note 9/5/21 that was not a recertification or supervisory visit. Record #20926 was reviewed and revealed the patient tested positive for COVID infection on 1/8/22. The assisted living facility contacted the hospice by phone 1/8/22 to notify that the patient tested positive for COVID 1/8/22. The LVN visit frequency was two times a week and the clinical record was missing one LVN visit the weeks of 12/27/21 and 1/2/22, and missing two LVN visits and/or telehealth contacts the weeks of 1/9/22 and 1/16/22. The RN visit frequency was "as needed and recertification" with no scheduled nursing visits. The clinical record contained one extra RN visit for supervision on 12/29/21. 1 of 11 (9%) clinical records reviewed revealed the hospice did not ensure social worker visits were ordered and/or included in the plan of care. Record #34644 was reviewed and revealed no order for the social worker visit on 12/24/21. During interview 5/11/22, the Director of Patient Care stated the missing LVN visit notes could not be located in the clinical record and/or a physician's order/plan of care update for the missing LVN visit note. Additionally during interview 5/12/22, the Administrator and Office LVN confirmed the visit frequencies, the missing RN and LVN visits and the extra RN, LVN and social worker visits.

It is required that the Interdisciplinary Group, in collaboration with the individual's attending physician (if any), reviews, revises, and documents the individualized care plan as frequently as the patient's condition requires but no less frequently than every 15 calendar days. A revised plan of care includes information from the patient’s updated comprehensive assessment and record of the patient’s progress toward the outcomes and goals specified in the plan of care. This standard was not met as evidenced by review of clinical records and interview. 3 of 11 (27%) clinical records reviewed revealed the hospice did not ensure the Interdisciplinary Group (IDG), in collaboration with the individual's attending physician (if any), reviewed, revised, and documented the individualized care plan as frequently as the patient's condition requires but no less frequently than every 15 calendar days. Record #75898 was reviewed and revealed the IDG, in collaboration with the individual's attending physician (if any), did not review, revise and document the individualized care plan as frequently as the patient's condition requires but no less frequently than every 15 calendar days. Review of the clinical record revealed an "IDG POC" dated 3/22/22 and the next "IDG POC" was documented on 4/15/22. During interview 5/12/22, the Administrator and Office LVN confirmed the missing "IDG POC" for 4/5/22. Record #87935 was reviewed and revealed the the IDG, in collaboration with the individual's attending physician (if any), did not revise the care plan as frequently as the patient's condition requires but no less frequently than every 15 calendar days. Review of the clinical record revealed the nursing assessment note 2/23/22 included "shortness of breath and high fall risk". The problems, goals and interventions in the "IDG POC" dated 3/8/22 and 3/22/22 did not include an revision to the plan of care for the shortness of breath and high risk for falls. Record #20926 was reviewed and revealed the IDG, in collaboration with the individual's attending physician (if any), did not revise the care plan as frequently as the patient's condition requires but no less frequently than every 15 calendar days. Review of the clinical record revealed the assisted living facility made a phone call to the hospice 1/8/22 to report the patient tested positive for COVID. The "IDG POC" dated 1/11/22 and 1/25/22 did not include information regarding the COVID infection and the plan of care problems, goals and interventions were not revised. During interview 5/12/22, the administrator and LVN office nurse confirmed the missing updates to the plan of care and the missing IDG meeting to review the plan of care.

It is required that the hospice provides infection control education to patients, family members, and other caregivers that is individualized to the needs of each patient. This standard was not met as evidenced by review of clinical records and interview. 1 of 1 (100%) applicable clinical records of patients with COVID infection revealed the hospice did not ensure that infection control education was provided to the caregiver until four days after the patient's positive COVID infection date. Record #20926 was reviewed and revealed the assisted living facility made a phone call to the hospice 1/8/22 and reported the patient tested positive for COVID. The phone call from the facility on 1/8/22 was documented by the hospice RN and did not include infection control education to the caregiver. Review of the clinical record documentation revealed the hospice RN made a phone call to the caregiver 1/12/22 and included infection control education. During interview 5/12/22, the Administrator and Office LVN confirmed the patient tested COVID positive 1/8/22 and the infection control education was not documented until 1/12/22.

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. 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 and the frequency of service delivery. This standard was not met as evidenced by review of documents, clinical records and interview. 2 of 3 (66%) applicable clinical records of expired patients revealed the hospice did not ensure after death bereavement services were provided, as required in agency policy. Record #79938 was reviewed and revealed the patient expired on 11/18/21. The initial bereavement assessment was completed 10/22/21. There was no documented after death bereavement assessment and bereavement plan of care, as required in agency policy. The clinical record included a volunteer contact note 11/18/22 which read "offered condolences" and a typed, unsigned bereavement letter dated 3/30/22. Record #20926 was reviewed and revealed the patient expired on 1/27/22. The initial bereavement assessment was completed 6/15/21. There was no documented after death bereavement assessment and bereavement plan of care, as required in agency policy. The clinical record included typed, unsigned bereavement letters dated 3/30/22 and 4/22/22. During interview on 5/12/22, the administrator and office LVN confirmed the missing after death bereavement assessments, bereavement care plans, and signed bereavement letters in the clinical records. During interview 5/12/22, the consultant stated "unsigned bereavement letters in the clinical record mean the letters were not sent to the bereaved." Additionally during phone interview 5/12/22 with the administrator present, the Bereavement Counselor stated, "Bereavement letters are being sent to bereaved family members of patients who expired during the past year but none of the bereaved family members are receiving bereavement services." "Yes, when the bereaved receive bereavement letters, they are receiving bereavement services" and "I am the one who does the after death bereavement assessment and I don't know why the after death bereavement assessments and care plans are missing." "Bereavement Services" policy, not dated, read, "after a death has occurred, the bereavement assessment will be updated" and "bereavement interventions will reflect the family/caregiver's choices to participate in the bereavement program", "Within two weeks after the death of a patient, a sympathy card will be sent to the bereaved", "After three weeks, a bereavement letter will be sent to the bereaved, offering support and outlining the hospice bereavement services", "Within three to five weeks after the patient's death, a bereavement assessment will be completed by the bereavement counselor." "This assessment will identify grief issues", "The bereavement counselor will render a professional judgement as to whether the bereaved is experiencing normal grief, moderate grief, or a severe grief reaction", "A bereavement file will be maintained on each family/caregiver unit of care, each file will contain the following information: copy of the initial bereavement assessment, bereavement service report, all bereavement assessments made and a bereavement plan of care", and "All bereavement clinical notes that have been written and/or sent to the bereaved".

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. This CONDITION was not met as evidenced by clinical record review and interview. The hospice failed to ensure that the hospice aide had successfully completed a competency evaluation prior to performing wound care [HSRM. 9.I/L615]; that the Registered Nurse prepared written instructions for hospice aides to carry out assigned duties and tasks [HCDT.15.I/L625] and that the hospice aide performed tasks ordered by the interdisciplinary group and included in the plan of care [HCDT.22.I.I/L626]. The cumulative effect of these systemic issues resulted in the potential for compromised quality health care and patient safety. This is a CMS CONDITION level finding.

It is required that 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 a pseudo patient: Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff; reading and recording temperature, pulse, and respiration; and appropriate and safe techniques in performing personal hygiene and grooming tasks, including items on the following basic checklist: bed bath; sponge, tub, and shower bath; hair shampoo (sink, tub, and bed); nail and skin care; oral hygiene; toileting and elimination; safe transfer techniques and ambulation; normal range of motion and positioning, and any remaining task(s) that the hospice chooses to have an aide perform. This standard was not met as evidenced by interview and personnel record review. 1 of 1 (100%) applicable personnel records of hospice aides revealed the hospice did not ensure the initial competency evaluation was completed for the task of changing wound care dressings that the Hospice Aide was performing. Record #74258 was reviewed and revealed the Hospice Aide date of hire was 11/4/21. The "Initial Competency Assessment Skills Checklist Hospice Aide" dated 11/1/21 included "NA" in the evaluation column of the task "dressing changes". The additional "Competency Skills Checklist Hospice Aide" dated 11/20/21 did not include the task of "dressing changes". During interview 5/11/22, the Director of Patient Care Services stated "the hospice aide should not be changing the wound care dressings". During a phone interview 5/12/22 with the Administrator present, the hospice aide stated, "I do change the wound dressing on the buttock and add new gauze when it gets wet during the bath but I do not get the dressing on the leg wet and do not change the dressing on the leg", "It was not assigned on the Hospice Aide care plan and I did not get instructions from the RN to change the wound dressing", and "The hospice RN has not trained or observed me doing a dressing change with a patient or a pseudo patient."

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 review of clinical records and interview. 1 of 10 (10%) applicable clinical records of patients with ordered hospice aide visit frequencies revealed the hospice did not ensure the registered nurse completed written patient care instructions for ordered hospice aide services. Record #79248 was reviewed and revealed the hospice aide visit frequency was ordered "two times a week" on admission 8/12/21 and on the "IDG POC" 8/24/21 and 9/1/21. Review of the clinical record revealed a missing hospice aide plan of care. During interview 5/12/22, the administrator and office LVN confirmed the hospice aide was ordered to visit the patient two times a week and the hospice aide plan of care was not completed by the RN and documented in the clinical record.

It is required that a hospice aide provides services ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by review of clinical records and interview. 4 of 10 (40%) applicable clinical records of patients with hospice aide visit frequencies revealed the hospice did not ensure that the hospice aide was compliant with tasks as assigned in the hospice aide plan of care. Record #93518 was reviewed and revealed the patient had a stage 2 right lower leg wound and a right buttock wound with ordered dressing changes to be performed by the hospice nurse and/or caregiver. The Hospice Aide plan of care included, in part, "shower chair bath" and "brush teeth", and did not include for the hospice aide to change the wound dressings. The hospice aide visit note 4/18/22 which included documentation "provided bed bath" and "changed wound dressings." Additionally, the hospice aide visit note dated 5/5/22 included "changed wound dressings", "provided bed bath" and "turned and repositioned." These tasks were not assigned on the aide care plan. There was no documented communication between the hospice aide and the RN as to why the hospice aide plan of care was not followed and no documented communication from the RN to the hospice aide to perform tasks that were not assigned on the hospice aide plan of care. During phone interview on 5/12/22 with the Administrator present, the Hospice Aide stated "yes, I documented I changed the wound dressings but I only changed the buttock dressing since it is the only one that gets wet during the bath", "No, the hospice RN has not instructed me to performed wound dressings", "The hospice RN has not observed me changing wound dressings on a patient or a pseudo patient", and "I do call the office and speak to the office LVN when I cannot perform a task that is assigned on the hospice aide plan of care". During interview 5/11/22, the Director of Patient Care stated "the hospice aide should not be performing wound dressing changes" and confirmed she could not locate documentation in the clinical record as to why the hospice aide tasks were not performed. Record #41173 was reviewed and revealed the Hospice Aide plan of care assigned to "visualize condition of skin and report to RN" and "peri care every visit". The clinical record revealed documentation on a Hospice Aide note 3/21/22 that the assigned tasks to "visualize condition of skin and report to RN" and "peri care every visit" were not completed by the Hospice Aide. There was no documented communication between the Hospice Aide and the RN as to why the assigned tasks on the hospice aide plan of care were not completed. Record #87935 was reviewed and revealed the Hospice Aide plan of care assigned to "visualize condition of skin and report to RN". The clinical record revealed documentation on a Hospice Aide note 3/21/22 that the assigned tasks to "visualize condition of skin was not completed by the hospice aide. There was no documented communication between the Hospice Aide and the RN as to why the assigned task on the hospice aide plan of care were not completed. Record #79938 was reviewed and revealed the Hospice Aide plan of care assigned to "shower" patient each visit. The narrative section on hospice aide note 11/5/21 included documentation that the Hospice Aide "gave bed bath". There was no documented communication between the Hospice aide and the RN as to why a bed bath was completed and not the assigned shower. During interview 5/12/22, the administrator and office LVN confirmed the hospice Aide was not following the tasks as assigned on the plan of care and that the clinical record did not include documented communication between the Hospice Aide and RN. Additionally, 1 of 10 (10%) applicable clinical records of patients with Hospice Aide visit frequencies revealed the hospice did not ensure the Hospice Aide was compliant with the visit frequency as ordered and/or included in the plan of care. Record #79248 was reviewed and revealed the hospice aide visit frequency of two times a week on physician's orders 8/12/21 and "IDG POC" 8/24/21 and 9/7/21. The clinical record documentation was missing two Hospice Aide visits the weeks of 8/15/21, 8/22/21, 8/29/21 and 9/5/21. There was no RN documentation and/or IDG documentation as to why the Hospice Aide visits were not completed. During interview 5/12/22, the Administrator and office LVN confirmed the missing Hospice Aide visits.

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 for the hospice care benefit is informed by the medical director or physician designee’s review of the patient’s clinical information. This standard was not met as evidenced by review of clinical records and interview. 2 of 4 (50%) applicable clinical records of patients requiring recertification revealed the hospice did not ensure the required hospice Medical Director narratives were completed. Record #20926 was reviewed and revealed the patient was recertified for 2nd benefit period 9/13/21-12/11/21. The "Physician Certification for Hospice Benefit" form for the recertification benefit period starting 9/13/21 included a section for "physician narrative" which included "see attached medical director evaluation note". The attached typed document dated 9/13/21 titled "Office Visit" did not contain the signature of the individual who completed the "Office visit" note. There was no documented evidence the attached typed "Office Visit" note was completed by the Medical Director. Record #34644 was reviewed and revealed the patient was recertified 5/3/20 in the 7th benefit period, 7/2/20 in the 8th benefit period, 8/31/20 in the 9th benefit period, 10/30/20 in the 10th benefit period, 4/28/21 in the 13th benefit period, 6/27/21 in the 14th benefit period, 8/26/21 in the 15th benefit period, 10/25/21 in the 16th benefit period, and 12/24/21 in the 17th benefit period. The "Physician Certification for Hospice Benefit" forms included a section for "physician narrative" which included "see attached Medical Director evaluation note". Review of the clinical record revealed missing Medical Director narratives for the recertification benefit periods 5/3/20, 7/2/20, 8/31/20, 10/30/20, 4/28/21, 6/27/21, 8/26/21, 10/25/21, and 12/24/21. During interview 5/12/22, the Administrator confirmed the missing hospice Medical Director required physician narratives. Additionally, 2 of 3 (66%) applicable clinical records of patients that were recertified in the 3rd or subsequent benefit periods revealed the hospice did not ensure the required face-to-face visits were completed by the Hospice Medical Director. Record #20926 was reviewed and revealed a missing face-to-face Hospice Medical Director visit note for the third benefit period 12/12/21-2/9/22. Record #34644 was reviewed and revealed the patient was admitted in the 6th benefit period 3/4/20 and transferred to another hospice 1/18/22. Review of the clinical record revealed the patient was recertified 5/3/20 in the 7th benefit period, 7/2/20 in the 8th benefit period, 8/31/20 in the 9th benefit period, 10/30/20 in the 10th benefit period, 4/28/21 in the 13th benefit period, 6/27/21 in the 14th benefit period, 8/26/21 in the 15th benefit period, 10/25/21 in the 16th benefit period, and 12/24/21 in the 17th benefit period. Review of the clinical record revealed missing face-to-face Hospice Medical Director visit notes for the recertification benefit periods starting 5/3/20, 7/2/20, 8/31/20, 10/30/20, 4/28/21, 6/27/21, 8/26/21, 10/25/21, and 12/24/21. During interview 5/12/22, the Administrator confirmed the missing face-to-face visit notes from the hospice Medical Director. Section 418.22 includes: "Certification will be based on the physician's or medical director's clinical judgment regarding the normal course of the individual's illness. The certification must conform to the following requirements: the physician must include a brief narrative explanation of the clinical findings that supports a life expectancy of 6 months or less as part of the certification and recertification forms, or as an addendum to the certification and recertification forms. If the narrative is part of the certification or recertification form, then the narrative must be located immediately prior to the physician's signature. If the narrative exists as an addendum to the certification or recertification form, in addition to the physician's signature on the certification or recertification form, the physician must also sign immediately following the narrative in the addendum". 418.22 (4) Face-to-face encounter: As of January 1, 2011, a hospice physician or hospice nurse practitioner must have a face-to-face encounter with each hospice patient whose total stay across all hospices is anticipated to reach the 3rd benefit period. The face-to-face encounter must occur prior to, but no more than 30 calendar days prior to, the 3rd benefit period recertification, and every benefit period recertification thereafter, to gather clinical findings to determine continued eligibility for hospice care.

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 and 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 review of clinical records and interview. 5 of 11 (45%) clinical records reviewed revealed the hospice did not ensure the initial certification Hospice Medical Director narrative requirements were completed. Record #88286 was reviewed and revealed the patient elected hospice care on 2/12/22. The "Physician Certification for Hospice Benefit" form for the benefit period of 2/12/22 to 5/12/22 included a section for "physician narrative" which included "see attached Medical Director evaluation note". The attached typed document dated 2/12/22 titled "Office Visit" did not contain the signature or name of the individual who completed the "Office visit" note. During interview on 5/11/12, the administrator stated the Medical Director dictates his note and that it was not signed and did not include the name of the individual who completed the "Office Visit" note. There was no documented evidence the attached typed "Office Visit" note was completed by the hospice Medical Director. Record #79248 was reviewed and revealed the patient elected hospice care on 8/12/21. The "Physician Certification for Hospice Benefit" form for the benefit period of 8/12/21 to 11/9/21 included a section for "physician narrative" which included "see attached Medical Director evaluation note". The attached typed document dated 8/12/21 titled "Office Visit" did not contain the signature of the individual who completed the "Office visit" note. There was no documented evidence the attached typed "Office Visit" note was completed by the hospice Medical Director. Record #79938 was reviewed and revealed the patient elected hospice care on 10/22/21. The "Physician Certification for Hospice Benefit" form for the first benefit period 10/22/21 to 1/19/22 included a section for "physician narrative" which included "see attached Medical Director evaluation note". Review of the clinical record revealed a missing hospice Medical Directive narrative. Record #75898 was reviewed and revealed the patient elected hospice care on 1/6/22. The "Physician Certification for Hospice Benefit" form for benefit period starting 1/6/22 included a section for "physician narrative" which read "see attached Medical Director evaluation note". Review of the clinical record revealed a missing hospice Medical Director narrative. Record #34644 was reviewed and revealed the patient elected hospice care on 3/4/20 in the 6th benefit period. The "Physician Certification for Hospice Benefit" form included a section for "physician narrative" which included "see attached Medical Director evaluation note". The hospice Medical Director narrative was missing for the admission benefit period 3/4/20. During interview 5/12/22, the administrator confirmed the missing hospice Medical Director required physician narratives and/or not signed typed "Office Visit" notes. During interview 5/12/22, the Administrator stated the Medical Director likes to dictate his narratives which are typed on "Office Visit" notes forms. Additionally, 3 of 11 (27%) clinical records reviewed revealed the hospice did not ensure initial certifications where obtained from the attending physician. Record #79938 was reviewed and revealed the patient elected hospice care on 10/22/21 and the patient designated the name of their attending physician on the signed "Hospice Election" form. The clinical record was missing an initial certification from the patient's attending physician. Record #75898 was reviewed and revealed the patient elected hospice care on 1/6/22 and the patient designated the name of their attending physician on the signed "Hospice Election" form. The clinical record was missing an initial certification from the patient's attending physician. Record #68815 was reviewed and revealed the patient elected hospice care on 5/6/22 upon transfer from another hospice and the patient designated the name of their Attending Physician on the signed "Hospice Election" form, which was not the current hospice physician or the prior hospice physician. As of 5/11/22, review of the clinical record revealed there was no documented verbal or written initial certification from the patient's attending physician within two days of election of hospice care. During interview 5/11/22, the Director of Patient Care Services confirmed the initial verbal certification was not obtained from the patient's attending physician. Additionally during interview 5/11/22, the administrator confirmed that the hospice had obtained only the previous certification from the prior hospice Medical Director at the time of patient transfer. During interview 5/12/22, the administrator and office LVN confirmed the name of the attending Physician that was designated by the patient at the time of admission and the missing initial certifications from the Attending Physicians. Additionally, 1 of 1 (100%) applicable clinical records of patients who were admitted in the 3rd or subsequent benefit periods revealed the hospice did not ensure face to face visits where completed by the hospice Medical Director. Record #34644 was reviewed and revealed the patient elected hospice care on 3/4/20 in the 6th benefit period. The clinical record revealed a missing hospice Medical Director face-to-face visit for the admission benefit period 3/4/20. During interview 5/12/22, the Administrator confirmed the missing initial face-to-face visit note from the Hospice Medical Director. Section 418.22 includes: "Certification will be based on the physician's or medical director's clinical judgment regarding the normal course of the individual's illness. The certification must conform to the following requirements: the physician must include a brief narrative explanation of the clinical findings that supports a life expectancy of 6 months or less as part of the certification and recertification forms, or as an addendum to the certification and recertification forms. If the narrative is part of the certification or recertification form, then the narrative must be located immediately prior to the physician's signature. If the narrative exists as an addendum to the certification or recertification form, in addition to the physician's signature on the certification or recertification form, the physician must also sign immediately following the narrative in the addendum". Section 418.22(a)(3)(i) includes: "If the hospice cannot obtain the written certification within 2 calendar days after a period begins, it must obtain an oral certification within 2 calendar days". 418.22 (4) Face-to-face encounter: As of January 1, 2011, a hospice physician or hospice nurse practitioner must have a face-to-face encounter with each hospice patient whose total stay across all hospices is anticipated to reach the 3rd benefit period. The face-to-face encounter must occur prior to, but no more than 30 calendar days prior to, the 3rd benefit period recertification, and every benefit period recertification thereafter, to gather clinical findings to determine continued eligibility for hospice care.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum physician orders. This standard was not met as evidenced by review of clinical records and interview. 1 of 5 (20%) applicable clinical records of patients receiving wound care treatments revealed the hospice did not ensure complete physician's orders. Record #34644 was reviewed and revealed patient lived in an assisted living facility with a stage 4 pressure ulcer requiring dressing changes. The physician's order dated 1/17/22 stated, "wound treatment left heel pressure ulcer, stage 4, cleanse with wound cleanser, apply xeroform to wound bed, cover gauze, wrap with Kerlix and secure with tape, change dressings every 3 days and as needed for soiling". Review of the clinical record revealed the physician's order did not include who was ordered to change the dressing, either the hospice nurse, wound care specialist physician and/or facility staff. During interview 5/12/22, the Administrator and office LVN confirmed the physician's orders did not identify who was assigned to change the stage 4 wound care dressing to the left heel.