Every finding on record at Careplus Hospice Services, Inc.

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. This standard was not met as evidenced by clinical record review and interview. I of 13 (8%) clinical records reviewed revealed the agency did not ensure that the comprehensive assessment was completed no later than the five days after the election of hospice care. Clinical Record 5: The patient elected hospice care on 2/16/2023. The Spiritual Care assessment was completed on 3/1/2023. In an interview during joint record review on 3/2/2023, the Director of Patient Care Services confirmed that the Spiritual Care assessment was not completed within five days of the patient's election of hospice care and that the record did not include documentation of the reason why the Spiritual Care assessment was delayed.

It is required that the comprehensive assessment includes an initial bereavement assessment of the needs of the patient's family and other individuals, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and considered in the bereavement plan of care. This standard was not met as evidenced by clinical record review and interview. 2 of 13 (15%) clinical records reviewed revealed the agency did not ensure that the comprehensive assessment included an initial bereavement assessment. Clinical Record 2: The patient elected hospice care on 3/4/2021. The 3/4/2021 plan of care (POC) did not include an initial bereavement assessment. Clinical Record 4: The patient elected hospice care on 9/17/2022. The 9/17/2022 POC did not include an initial bereavement assessment. In an interview on 3/2/2023 during joint record reviews, the Director of Patient Care Services confirmed that initial bereavement assessments had not been completed.

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician: a copy of the hospice discharge summary and a copy of the patient's clinical record, if requested. This standard was not met as evidenced by clinical record review and interview. 2 of 2 (100%) clinical records reviewed for patients discharged from services, revealed the agency did not ensure that a copy of the discharge summary was sent to the patient's attending physician. Clinical Record 10: The patient elected hospice care on 10/26/2022 and revoked hospice care on 12/15/2022. The clinical record lacked evidence that a copy of the discharge summary was forwarded to the patient's attending physician. Clinical Record 13: The patient elected hospice care on 9/28/2022 and was discharged from hospice care on 12/26/2022. The clinical record lacked evidence that a copy of the discharge summary was forwarded to the patient's attending physician. In an interview during joint record reviews on 3/2/2023, the Director of Patient Care Services confirmed that the agency did not have documentation of discharge summaries being forwarded to the patient's attending physician.

It is required that organization policy and procedure state the requirements for a medical or a spiritual exemption to being fully vaccinated for COVID-19 per state and federal law and regulation. A medical exemption from being fully vaccinated for COVID-19 includes: Documentation of information specifying which of the authorized COVID-19 vaccines is clinically contraindicated for the individual to receive, and the recognized clinical reasons for the contraindications; and a documented statement by the authenticating practitioner recommending that the individual be exempted from the hospice requirement to be fully vaccinated for COVID-19 based on the recognized clinical contraindications; and a statement signed and dated by a licensed practitioner, who is not the individual requesting the exemption, and who is acting within their respective scope of practice as defined by, and in accordance with, all applicable state and local law and regulation. A spiritual exemption from being fully vaccinated for COVID-19 includes documentation of the Organization’s defined criteria of an individual’s sincerely held religious belief, practice, or observance per federal law and regulation. This standard was not met as evidenced by document review and interview. Review of the agency's policy titled "COVID-19 Workplace Policy" stated that "all employees will be vaccinated unless they requested exemption." The policy did not define the requirements or criteria that need to be documented for medical or spiritual exemptions to being fully vaccinated for COVID-19. In an interview the Director of Patient Care Services and the Administrator confirmed that the agency's COVID-19 policy did not have all of the required elements for a medical or a spiritual exemption to being fully vaccinated for COVID-19. Review of the agency's policy titled "COVID-19 Workplace Policy" stated that "all employees will be vaccinated unless they requested exemption," The agency did not ensure the policy stated the requirements that are needed to be documented for medical exemptions. The agency also did ensure that the policy included the agency's defined criteria for a spiritual exemption.