Every finding on record at Carelife Hospice Inc

Based on observation, interview, and record review, the hospice agency failed to ensure the hospice agency operates in a location approved by the Centers for Medicare and Medicaid Services (CMS) prior to providing hospice care and services to the patients, when: 1. The hospice agency location address was not approved by the Centers for Medicare and Medicaid services; 2. The patient admission packet and pamphlets/brochure contained the name and address of the unapproved location; 3. The unapproved location was being utilized for staff to drop off and pick up patient documents and supplies; 4. The unapproved location utilized permanent staff to perform office duties; and 5. The location was not approved by the hospice agencys Governing Body. The cumulative effect of this systemic practice resulted in the potential for patients to receive care and supplies from an unapproved location and without the oversight of the parent organization. Findings: On February 10, 2025, at 10:30 a.m., an unannounced visit was conducted to investigate a complaint regarding the use of an unapproved hospice agency location. On February 10, 2025, at 11:06 a.m., a review of the hospice agencys census indicated 93 patients being serviced by the hospice agency. The list of current patients indicated most of the patients reside in Apple Valley and only three patients reside in Riverside. On February 10, 2025, the hospice agency documents were reviewed. A review of the hospice agencys pamphlet/brochure and patient admission packet indicated two location addresses (Riverside and Apple Valley). A review of the hospice agencys Governing Body meeting minutes for the following dates did not indicate approval of a ";drop off location," located at Apple Valley: - January 13, 2023; - April 21, 2023; - July 21, 2023; - November 3, 2023; - January 31, 2024; - April 18, 2024; - July 26, 2024; and - November 29, 2024. On February 10, 2025, at 2:12 p.m., the Director of Patient Care Services (DPCS) was interviewed. The DPCS stated the Apple Valley location was not considered an office but ";just a drop location." The DPCS stated the ";drop off location" have a staff member working there to hand out supplies when nurses come in, and for the Marketing staff to pick up paperwork and scan patients documents to be sent to the Riverside office. On February 11, 2025, at 8:30 a.m., an unannounced visit was conducted at the Apple Valley location and was greeted by the receptionist and the Administrator (ADM). On February 11, 2025, at 8:40 a.m., during an interview with the ADM, he stated he traveled back and forth between the two agency locations (Riverside and Apple Valley). The ADM stated he would come to the Apple Valley location to conduct meetings with medical members and when marketing for patients. On February 11, 2025, at 8:46 a.m., during an interview with the receptionist, she stated she worked full time at the Apple Valley location. On February 11, 2025, at 8:53 a.m., an observation was conducted of the Apple Valley location. The following were observed: - Two computer screens and an iPad were observed to the right of the reception area; - A meter reader for mail was observed next to the reception desk; - Three desks with a computer and chair for each desk; - A refrigerator/freezer containing food and drinks; - A table with chairs and cabinet with coffee pot and condiments; - A copier and fax machine were observed in the center of the room; - An enclosed office where the ADM conducted business; - An enclosed area with multiple boxes and cabinets containing medical supplies; - One five-shelf cabinet containing binders for new patients and a shelving unit with small slots to hold paper needed for admission packets. On February 11, 2025, at 9 a.m., the ADM was observed to conduct a conference call with a medical group. On February 11, 2025, at 9:30 a.m., during an interview with the receptionist (RC), a chair was observed to have bags of supplies. In a concurrent interview with the RC, she stated those bags of supplies were supplies requested by the nurses to pick up. On February 11, 2025, at 9:35 a.m., the receptionist desk was observed to have a computer screen showing schedule of patient visits. On February 11, 2025, at 10 a.m., the ADM stated there is no business license for the Apple Valley location as it is being used a ";drop off location." The ADM stated he would usually spend three to four days in a week at the Apple Valley location. On February 11, 2025, at 10:44 a.m., a follow up interview was conducted with the RC. The RC stated she conducted the following administrative duties: - Ordering and fixing patient supplies, preparing the patient supplies for the nurses pick up; - Assist in ordering DME (durable medical equipment – medical equipment and supplies ordered by the healthcare provider for a patients routing or long-term use such as bed, wheelchair, walker, etc.); -Answer phone calls from patients, staff, and providers; - Assist in scheduling patient visits; and - Providing copies of the patients medication list or plan of care to the nurses. On February 19, 2025, at 2:05 p.m., a review of the hospice agency admission packet and hospice agency pamphlet was conducted with the ADM and the Director of Patient Care Services Designee (DPCSD). The ADM and the DPCSD were shown the hospice agency admission packet and the hospice agency pamphlet. The ADM and the DPCSD stated the hospice agency admission packet and the hospice agency pamphlet each had information which consisted of two different phone numbers for two different office locations. Neither the hospice agency admission packet nor the hospice agency pamphlet had identified themselves as a location only used as a drop site. On February 19, 2025, at 2:08 p.m., a follow up interview was conducted with the ADM. The ADM acknowledged there should be a meeting of the governing body addressing the drop site location. On February 19, 2025, at 2:12 p.m. an interview was conducted with the DPCSD. The DPCSD stated the RC at the drop site location assisted with the scheduling. The DPCSD stated usually there are two other staff members that do most of the DME ordering. A review of the undated hospice agencys policy and procedure titled, ";Governing Body," indicated, ";...the Governing Body will assume full legal authority, responsibility, and accountability of the overall management and operations, the provision of services, fiscal operations, review of the organizations budget and its operational plans, and its quality assessment and performance improvement (QAPI) program. The Governing Body will serve as the governing authority for the care program, which will function according to the companys bylaws...the Governing Body will assist with development and approve strategic, marketing, and operational plans...that clear expectations for patient safety are established, implemented, and maintained...that any findings of fraud or waste are appropriately addressed..." A review of the undated hospice agencys policy and procedure titled, ";Organizational Planning," indicated, ";...clearly defining long-range, strategic, and operational plans...resources needed provide and support care and services...organizational leadership will communicate leadership regarding operational and clinical issues on a routine basis...development of long-range, strategic and operational plans which include all care and services to be provided, based on the organizations mission and philosophy...management of information...The Governing Body and senior management will communicate the organizations plan to personnel on a regular basis. All hospice personnel will have an opportunity to communicate with senior management regarding operational and clinical issues on a routine, scheduled basis..." A review of the undated hospice agencys policy and procedure titled, ";Staffing and Scheduling," indicated, ";...Continuity of care is fostered by assigning consistent personnel to the patient whenever possible...the Clinical Supervisor/Nursing Supervisor will review the patient census and staffing levels on a daily basis and will make patient assignments which consider...geographical area...patient load...clinicians will contact the office daily to confirm their schedule for the day...receive any necessary reports on patient to be visited...if an emergency arises or if any organization personnel are ill and it is impossible to fulfill their obligations, it is mandatory that the organization personnel contact the organization as soon as possible to report the absence..." A review of the undated hospice agencys policy and procedure titled, ";Durable Medical Equipment and Supplies," indicated, ";...the durable medical equipment needed for an individuals support to stay at home will be obtained from a hospice-approved company if the patient is on Medicare, Medicaid, or private insurance hospice benefit...those supplies required for optimal comfort, care, and management of the hospice patient will be obtained from the hospice stock supplies or approved company if the patient is on Medicare, Medical, or private insurance hospice benefit..." A review of the undated hospice agencys policy and procedure titled, ";Administrator," indicated, ";...operational planning and budgeting...ensuring organizational compliance with legal, regulatory, and accreditation requirements...establishing and maintaining effective channels of communication, including integrations of technology, as applicable...ensuring appropriate staff supervision during all service hours...monitoring service utilization to ensure delivery of comprehensive care...monitoring operational progress toward accomplishing operational and strategic goals...insuring appropriate data collection and regular, complete reports are received by the Governing Body...ensuring availability of adequate space, equipment, and supplies..." A review of the undated hospice agencys policy and procedure titled, ";Job Description-Hospice Administrator," indicated, ";...the hospice Administrator organizes and directs the functions with overall responsibility for day-to-day operations, comply with applicable rules and regulations and reporting to the Governing Body. They implement the organizations purposes in a manner consistent with the goals, objectives, and policies established by the Governing Body...reports to governing body and acts on recommendations of authorized planning, regulatory and inspecting agencies, and contracted managed care organization...ensures accuracy of public information materials and activities..."

Observed in Individual Tracer. In 5 of 5 patient records reviewed, the Hospice did not evaluate and document need for volunteer services. There was no documentation in RR#1-RR#5 of the need for and or acceptance of volunteer services. This observation was discussed with the director.

Observed in Individual Tracer. In 1 of 5 patient records reviewed, the goals detailed on the plan of care were not individualized based on the assessment . The following patient issues were identified on RR#2's nursing assessment ; pain, GI upset, multiple hypoglycemic episodes, high fall risk, pain, aspiration issues, and was oxygen dependent. The target dates for all of the goals that addressed each issue were the same. This observation was discussed with the director.

Observed in Record Review. In 2 of 2 patient records reviewed, the discharge summary was not sent to the receiving Medicare facility. Both RR#1 and RR#5 were sent to the hospital and were discharged. The summaries were not sent to the receiving hospital. This observation was discussed with the director.

Observed in Record Review. In 1 of 14 patient records reviewed, it was noted that there was no documentation of a bereavement risk assessment for this patient admitted on 8/2/23. This was confirmed by the DPCS.

Observed in Record Review. In 14 of 14 patient records reviewed, it was noted that the goals on the plan of care were not measurable, individualized or timed. For example, in review of record for home visit #1 the following examples were noted; pt will maintain optimal bowel elimination and comfort, Pt/pcg will verbalize understanding of medication and side effects, pt will verbalize Reduced pain to below SIT level within 48 hrs of admission for comfort, Family/PCG will verbalize understanding of non-verbal signs of pain, pt will remain in comfortable level during care. Example in record review for home visit #3, pt will remain safe and free from injury, Pt/pcg will express understanding of medication and side effects. Example in record review for home visit #2, pt will have adequate intake as tolerated, pt/ pcg will verbalize understanding of medication and side effects. This was discussed with leadership.

Observed in Record Review. In 4 of 14 patient records reviewed, it was noted that the plan of care was not revised to include new problems or issues to manage patient symptoms. For example, in review of record for home visit #1 it was noted that on 6/25/23 the patient had developed a tooth infection and was prescribed antibiotic, prescribed mouthwash and antifungal however the plan of care was not revised. Additionally, on 3/8/23 the patient was treated with Macrobid for a UTI and on 3/10/23 was treated with Cipro eye drops for conjunctivitis and these were also not added to the plan of care. In another example, in RRNHV#3 it was noted that the plan of care did not contain any issues or problems related to nutrition for the patient who was NPO and on tube feedings. Additionally, the pt was treated for URI on 6/19/23 and 8/14/23 and a UTI on 6/26/23 however the plan of care was not updated for these infections. Lastly, on 8/8/23 the skilled nurse documentation stated that the patient was having increased anxiety and hallucinations however these issues were not on the plan of care. In addition there were no orders to discontinue the foley catheter for this patient however there was documentation that the foley was discontinued by the skilled nurse and there were no orders to discontinue social work visits as indicated on the IDG summary. In RRNHV#5 it was noted that the plan of care did not address the new diagnosis of pneumonia. In RRNHV#7 it was noted that the plan of care did not contain any interventions or problems related to three wounds that were present on admission, and there was no frequency for the wound care. Additionally, the patient developed conjunctivitis and this also was not noted on the plan of care. This was discussed with leadership.

Observed in Record Review. In 2 of 2 patient records reviewed, who were discharged due to extended prognosis it was noted that there was no order for discharge in the record. This was confirmed by leadership.

Observed in Record Review. In 8 of 14 patient records reviewed, it was noted that care was not provided at the ordered frequency. For example in review of record for home visit #1, aide visits were to be made 2 times per week however there were two weeks in July that only had one visit per week with no documentation of missed visits. Additionally the SW was to visit monthly but there was no visit in June 2023. In another example, in review of record for home visit #2 the spiritual care was to be provided monthly however there were no visits, Dec, Jan, Feb, March, April, May, June. In another example, in review of record for home visit #3 the spiritual care was to be provided monthly however there was a missed visit documented in June but no attempt was made to reschedule in the remainder of the month. Also in this record the social worker was to visit monthly but in May, June and August there were only phone calls made with no in home visits. In another example, RRNHV#4 it was noted that the orders for oxygen were for 2L/Nc however skilled nursing note documentation stated that the patient was using 3L of oxygen. In addition the initial Social Worker assessment and two subsequent recertification assessments were not made to the patient in the home but were telephonic. In RRNHV#7 it was noted that no home visit for initial assessment was made by the spiritual counselor but was done telephonically. In RRNHV#1 it was noted that the SC and SW initial assessments were not made in person but were done telephonically. In RRNHV#2 and RRNHV#3 it was noted that the social worker initial assessment was not done in person but was done telephonically. This was discussed with leadership.

Observed in Patient Home. In 1 of 3 home visits conducted, it was noted in home visit #3 that the hospice aide placed his supply backpack on the floor in the patient home without the use of a barrier. Review of agency policy indicated that a barrier be used. This was observed by the leadership present on the visit.

Observed in Record Review. In 2 of 14 patient records reviewed, it was noted that supervisory visits for the hospice aide were not documented every 14 days in RRNHV#6 and RRNHV#7 during the month of August 2023. This was confirmed by the DPCS.

Observed in Tracer Activities. There was no evidence that the governing body and leadership had established requirements to support patient care treatment and services as evidenced by a condition level finding at 418.56, 418.104 and 418.100 as significant issues were found with care planning, physician orders, not following physician orders and documentation issues which were not followed as per policy. This was discussed with leadership.

Observed in Record Review. In 5 of 14 patient records reviewed, it was noted that documentation in the records was not complete and accurate. For example, in RRNHV#4 there were 28 skilled nursing notes from April to July 2023 that were incomplete or had been returned for correction but had not been corrected. In RRNHV#7 it was noted that the SN note from 8/15/23 was incomplete and only stated vital signs. In this same record it was noted that the orders for two metatarsal wounds were documented on the plan of care as cleanse with NS, apply Medi honey and for another wound cleanse with NS, apply Medi honey and calcium alginate however in the SN portion of the IDG note of 8/10/23 the wound care for two of the wounds was cleanse with NS, apply betadine and dry dressing for the two wounds on the metatarsals and no documentation of the wound care for the heel. Lastly, on SN visit note for 8/4/23 the documentation simply stated wound care as ordered. There was no documentation on the wound care flow sheet to indicate what care was provided. In RRHV#1 it was noted that there was documentation in the IDG meeting for 6/27/23 that the patient had a foley however the foley was discontinued in February 2023. Additionally, the same IDG note indicated that pain relief was being provided with the use of Norco however the order for Norco was discontinued in January 2023. In RRNHV#6 it was noted that the SN visit for 8/14/23 was incomplete and only contained vital signs. In RRNHV#3 the SN portion of the IDG meeting documentation was blank and the three prior IDG SN notes were copied and pasted from the initial assessment. Additionally on the SN visit note of 7/27/23 the following documentation was noted; Patient has no my blood pressure and strong pulses in the upper lower extremities and denies any chest pain or discomfort. Patient abdomen is firm and tender to touch and should be manage with opiate intervention and is currently NPO with PEG tube infusing diabetic sores at 80 cc an hour. Patient does have intermittent trenches episodes of gas in the stool. This was discussed with and verified by the DPCS.

Observed in Record Review. In 2 of 2 patient records reviewed, for patient's who were discharged due to extended prognosis it was noted that there was no documentation of a discharge summary and no documentation informing the attending physician of the availability of a discharge summary. This was confirmed by leadership.

Observed in Record Review. In 1 of 14 patient records reviewed, it was noted in review of record for home visit #2 that for this patient who resides in a SNF the plan of care was not integrated and did not identify the care and services that are needed and specifically identify which provider is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care. This was discussed with leadership.

Observed in Record Review. In 1 of 2 patient records reviewed, the update of the comprehensive assessment did not include specific information regarding the patient's progress toward outcomes. Upon review of IDG update documentation for HV#1, spiritual counselor documentation was the same on multiple notes and progress towards spiritual goals was not addressed. This was reviewed and validated with the Administrator/Director of Patient Care Services.

Observed in Record Review. In 2 of 2 patient records reviewed, the plan of care did not include all outcomes based on the patient's needs. Upon review of HV#1, it was noted the spiritual assessment indicated spiritual support was to be provided with a visit frequency of 1x/month; however, on review of the plan of care, there were no goals established to assist the spiritual counselor in determining if the spiritual needs of the patients were being met. The psychosocial assessment indicated psychosocial support and assistance with obtaining In Home Support Services (IHSS) services was to be provided with a visit frequency of 1x/month; however, on review of the plan of care, there were no goals established to assist the social worker in determining if the psychosocial needs of the patients were being met. The patient was identified as a fall risk on the comprehensive assessment; however, on review of the plan of care, there were no goals established related to safety. Upon review of RR#2, it was noted the psychosocial assessment indicated psychosocial support was to be provided with a visit frequency of 1x/month; however, on review of the plan of care, there were no goals established to assist the social worker in determining if the psychosocial needs of the patients were being met. The patient was identified as a fall risk on the comprehensive assessment; however, on review of the plan of care, there were no goals established related to safety. This was reviewed and validated with the Administrator/Director of Patient Care Services.

Observed in Record Review. In 2 of 2 patient records reviewed, the plan of care did not include all interventions based on the patient’s needs. Upon review of HV#1, it was noted the patient was receiving spiritual support; however, on review of the plan of care, there were no interventions established related to the patient's spiritual needs. The patient was receiving psychosocial support; however, on review of the plan of care, there were no interventions established related to the patient's psychosocial needs. The patient was identified as a fall risk on the comprehensive assessment; however, on review of the plan of care, there were no interventions established related to safety. Upon review of RR#2, it was noted the patient was receiving psychosocial support; however, on review of the plan of care, there were no interventions established related to the patient's psychosocial needs. The patient was identified as a fall risk on the comprehensive assessment; however, on review of the plan of care, there were no interventions established related to safety.This was reviewed and validated with the Administrator/Director of Patient Care Services.

Observed in Record Review. In 1 of 2 patient records reviewed, medication orders were incomplete. Upon review of RR#2, it was noted the patient had Norco ordered for pain; however, the order did not include a frequency and was written as follows: Norco 5mg/325mg 1 tab orally for moderate pain, 2 tabs for severe pain. This was reviewed and validated with the Administrator/Director of Patient Care Services.

Observed in Record Review. In 1 of 2 patient records reviewed, the visit frequency was not followed as ordered on the plan of care. Upon review of HV#1 and the plan of care, it was noted the spiritual counselor visit frequency was 1x/month; however, the patient had been on hospice services for 5 months with only 2 visits documented as completed and there was no documentation to validate the patient/family refused any visits. This was reviewed and validated with the Administrator/Director of Patient Care Services.

Observed in Patient Home. In 1 of 1 home visits conducted in which reusable equipment was utilized, standard precautions were not used to reduce the risk of infection related to disinfection of equipment. During HV#1, the clinician was observed cleaning their vital sign equipment with a Clorox disinfecting wipe and placing the equipment immediately back into their bag without observing the manufacturer's guidelines of a 4-minute wet time. This was discussed with the clinician and Administrator/Director of Patient Care Services following the visit.

Observed in Record Review. In 1 of 2 patient records reviewed, the record contained inaccurate information. Upon review of RR#2, it was noted the spiritual counselor assessment indicated declined chaplain services; however, on review of the plan of care, the spiritual counselor visit frequency was documented as 1x/month. Aide services were discontinued midway through the certification period; however, on review of RN documentation following the discontinuation of aide services, aide supervisory visits were documented as completed. This was reviewed and validated with the Administrator/Director of Patient Care Services.