Every finding on record at Capstone Hospice, LLC

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) This standard was not met as evidenced by a review of clinical records and interviews. 1 of 8 (13%) of records revealed that the agency did not ensure that the initial nursing assessment was completed within 48 hours of election of benefits. Clinical Record # 1 was reviewed and identified the patient elected hospice care on 4/29/2022 with an effective date of electing coverage on 4/29/2022. The nursing assessment was completed on 5/3/2022, day 4. In an Interview, the Director of Nursing stated this was the first patient and staff did not understand the importance of dates. 1 of 8 (13%) of records revealed that the agency did not ensure that the initial nursing assessment was completed within 48 hours of election of benefits.

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 a review of clinical records and interview. 1 of 8 (13%) of records revealed that the agency did not ensure that the spiritual counselor and the hospice social worker did not complete a comprehensive assessment within 5 calendar days after the patient elected the hospice benefit. Clinical Record #1 was reviewed and identified the patient elected hospice care on 4/29/2022.The Chaplain completed the comprehensive assessment on 5/9/2022 ( 9 days late) and social work assessment was completed on 5/11/2022 (11 days late). The record lacked evidence as the reason the assessment was not completed within the required 5 days. There was no documented explanation for the reason for the delay. In an interview, the Director of Nursing stated that "this was our first patient and the person who had the election of benefit signed did not understand the importance of the dates." 1 of 8 (13%) of records revealed that the agency did not ensure that the initial comprehensive assessment was completed within five days of election of benefits.

It is required that for those individuals eligible to be fully vaccinated for COVID-19, organization policy and procedure define the process for tracking and documenting each individual’s receipt, at a minimum, of a single dose COVID-19 vaccine, or the first dose of a COVID-19 primary vaccination series of a multi-dose vaccine prior to providing any care, treatment or other services for the hospice and/or its patients. The process for tracking and documenting an individual’s completion of a COVID-19 primary vaccination series; the process for tracking and documenting an individual’s receipt of COVID-19 booster doses, per CDC guidelines; what vaccination documentation is accepted; who receives the vaccination documentation, reviews it, and accepts or rejects it; and how each individual’s vaccination information is securely maintained. This standard was not met as evidenced by a review of documents and interview. The review of the policies revealed that the agency did not ensure that the required elements were included in policies and procedure related COVID-19. Policy and Procedures Agency Policy HR.29 titled Staff Vaccination Requirements for Covid-19 states in part, the hospice must maintain records of employee vaccinations in personnel health file and track the COVID-19 vaccination status. The policy does not include the process to track the vaccination status. This policy also states in part, Medical and religious exemption forms may be accessed at the following link, the policy does not describe the procedure defining who is to receive vaccination documentation, requests for exemption or who will accept or reject the exemption. In an interview, the Director of Nursing stated the agency does not have a tracking log of employee COVID-19 vaccinations. Further, director of nursing stated that the form referenced via an internet link is not utilized at this time and is only accessible for individuals signed into the secure site. Director of nursing agreed that policy is not specific and there is not a clearly defined process to accept, reject, approve or deny requests for an exemption. 1 of 1 (100%) policy related requirements to COVID -19 vaccination the agency did not ensure that the required elements were included in policies and procedure related COVID-19.