Every finding on record at Charter Healthcare of San Antonio, LLC

It is required that the hospice maintains an emergency preparedness communication plan that complies with federal, state, and local laws. The communication plan includes primary and alternate means for communicating with hospice staff and federal, state, tribal, regional, and local emergency management agencies. This standard was not met as evidenced by document review and interview. A review of the agency's Emergency Plan (EP) (effective 2022 - 2023) revealed that the agency did not ensure that its plan included any alternate staff contact phone numbers or an alternate person to reach out to if the hospice is unable to reach the employee at the primary number listed. In addition, while the plan included a small list of contact information for local emergency management entities, Federal Emergency Management Agency (FEMA) as well as the Center for Disease Control (CDC), there were no primary contact information numbers for regional, tribal, or state government or healthcare-related emergency contacts. There were no alternate means of contact for entities included in the plan. During an interview with the Administrator on 3/15/2023, it was confirmed that there was contact information missing for some of the local, regional, tribal, state, and federal emergency management and preparedness officials, other healthcare facilities, or emergency healthcare coalitions and no alternate numbers, emails, etc. contacts for the staff or emergency officials included. A review of the agency's emergency plan (effective 2022 - 2023) revealed that the agency did not ensure that its plan included any alternate staff contact number or person to reach out to in the event that the hospice is unable to reach the employee at the primary number listed. In addition, while the plan included a small list of contact information for local emergency management entities, FEMA as well as the CDC, there was no primary contact information for regional, tribal, or state government or healthcare-related emergency contacts. There were no alternate means of contact for those entities that were included in the plan. An interview with the Administrator on 3/15/2023 confirmed that there was contact information missing for some of the local, regional, tribal, state, and federal emergency management/preparedness officials, other healthcare facilities, or emergency healthcare coalitions and no alternate numbers, emails, etc. contacts for the staff or emergency officials included. No additional documentation was presented prior to the conclusion of the site visit.

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, document review, and interview. 2 of 11 (18%) clinical records reviewed revealed that the agency did not ensure that the patient's Plan of Care (POC) addressed the specific communication needs, interventions, or goals of the patient. Record 1: The patient elected the hospice benefit on 6/28/2022. In the Skilled Nurse Visit note dated 2/8/2023, the Registered Nurse (RN) first identified a sacral wound. The record contained no documented evidence of updated care interventions on the plan of care or interim physician orders for wound care. Upon recertification the Skilled Nurse documented the continued presence of the sacral wound, however, the recertification plan of care for episode 2/23/2023, there was no documented update to the POC to reflect wound care interventions or goals. Record 2: The patient elected the hospice benefit on 4/5/2022. Documentation in the initial comprehensive assessment completed on 4/5/2022 stated the patient was hard of hearing. During the home visit observation (Home Visit 2) Staff 6 on 03/16/2023, it was noted that the nurse utilized a whiteboard to facilitate communication with the patient due to the severity of the patient's hearing loss. The POC effective from 1/30/2023 to the present was reviewed, and no documentation described interventions and goals to address the patient’s communication needs. During an interview and record review with the Director of Patient Care Services (DPCS) on 3/16/2023, it was confirmed that the patient's POC did not include any problems, interventions, or goals related to the patient's difficulty with communication due to the patient's hearing loss. No additional documentation was presented before the conclusion of the site visit.

It is required that each patient’s individualized written plan of care: includes all services necessary for the palliation and management of the terminal illness, including the following: drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. 1 of 11 (9%) clinical records reviewed revealed that the agency did not ensure that the patient's Plan of Care (POC) was updated with orders to address a patient's wound. Record 1: The patient elected the hospice benefit on 6/28/2022. In the Skilled Nurse Visit note dated 2/8/2023, the Registered Nurse (RN) first identified a sacral wound. The record contained no documented evidence of updated care interventions on the plan of care or interim physician orders for wound care. Upon recertification the Skilled Nurse documented the continued presence of the sacral wound, however, the recertification plan of care for episode 2/23/2023, there was no documented update to the POC to reflect wound care interventions or orders. During a clinical record review and interview on 3/16/2023 with the Director of Patient Care Services, it was confirmed that the clinical record did not contain any updates to the patient's POC to address the sacral wound documented in the chart. No additional documentation was presented before the conclusion of the site visit.

It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services, and, as necessary, provides in-service training and education programs where required. The hospice has written policies and procedures describing the method(s) of assessing competency and maintains a written description of the in-service training provided during the previous 12 months. This standard was not met as evidenced by personnel record review and interview. 2 of 8 (25%) personnel records reviewed of direct care staff revealed the agency did not ensure that competencies were completed for field staff upon hire. Personnel Record 3: The Chaplain assumed the additional role of Bereavement Coordinator at the beginning of December 2022. An updated job description was signed with orientation to the new duties, but no Bereavement Coordinator, or clinical competency assessment, was in the personnel file. Personnel Record 4: The Social Worker had a hire date of hire was 9/20/2022. There was no Social Worker clinical competency assessment found in the personnel file. Personnel records were presented via TEAMS during an interview and record review on 3/17/2023 with the corporate Human Resource Manager. The Director of Patient Care Services (DPCS) was present on site as a witness, where the corporate Human Resource Manager confirmed that the requested clinical competency assessments were not in their personnel file.

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. 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 11 (27%) clinical records reviewed revealed that the hospice did not ensure that the patients signed hospice election forms and admission consents and informed the patient/responsible party of the correct organizational name, address, and contact information at the time of admission. Record 2: The patient elected the hospice benefit on 4/5/2022. The patient/responsible party signed consents with the previous hospice name and address before the change of ownership occurred on 8/6/2021. The election of the hospice benefit was signed eight months after the name of the hospice changed. Record 5: The patient elected the hospice benefit on 3/5/2022. The patient/responsible party signed consents with the previous hospice name and address before the change of ownership occurred on 8/6/2021. The election of the hospice benefit was signed seven months after the name of the hospice changed. Record 8: The patient elected the hospice benefit on 4/18/2022. The patient/responsible party signed consents with the previous hospice name and address before the change of ownership occurred on 8/6/2021. The consent forms were signed by the patient and had the previous hospice name before the change of ownership occurred on 8/6/2021. During an interview with the Director of Patient Care Services (DPS) beginning on 3/16/2023 and continued on 3/17/2023, it was confirmed that the agency was using outdated forms for the patient consent and election of hospice benefits.