Every finding on record at Circle of Friends Hospice, LLC

Based on staff interview, review of personnel files, and the review of undated policy titled ";Emergency Operations Plan" 2.1.1", it was determined that the Condition of Emergency Preparedness (EP) for Hospice Agencies was not in compliance as a result of the agency's failure to comply with all applicable Federal, State and local EP requirements by not establishing and maintaining a comprehensive EP plan based on and including a documented facility-based and community-based risk assessment, utilizing an all-hazards approach by not establishing and maintaining a comprehensive EP plan to address patient/client population, the type of services the agency has the ability to provide in an emergency, and continuity of operations including delegations of authority and succession plans by not developing and maintaining an emergency preparedness training and testing program that is based on the emergency plan, risk assessment, and the communication plan and testing requirements. --- Findings include: Review of the undated policy titled ";Emergency Operations Plan" 2.1.1" revealed the following: POLICY The Administrator, Director and staff implement emergency operations plan, as appropriate. Upon request, the agency failed to provide an emergency preparedness program to the surveyors during the survey. Review of the personnel file for staff #1, #2, #3, #4, and #5 revealed that the staff failed to be given training on EP policies and procedures and failed to be provided training on Emergency preparedness. During an interview on 7/12/2023 at 3:00 p.m., the Clinical Director acknowledged that no documentation of an emergency preparedness program was provided to the surveyors during the survey.

Based on staff interview, review of personnel files, and the review of undated policy titled ";Emergency Operations Plan" 2.1.1", it was determined that the Condition of Emergency Preparedness (EP) for Hospice Agencies was not in compliance as a result of the agency's failure to comply with all applicable Federal, State and local EP requirements by not establishing and maintaining a comprehensive EP plan based on and including a documented facility-based and community-based risk assessment, utilizing an all-hazards approach by not establishing and maintaining a comprehensive EP plan to address patient/client population, the type of services the agency has the ability to provide in an emergency, and continuity of operations including delegations of authority and succession plans by not developing and maintaining an emergency preparedness training and testing program that is based on the emergency plan, risk assessment, and the communication plan and testing requirements. --- Findings include: Cross Reference to E0001 for findings related to this citation.

Based on staff interview, review of personnel files, and the review of undated policy titled ";Emergency Operations Plan" 2.1.1", it was determined that the Condition of Emergency Preparedness (EP) for Hospice Agencies was not in compliance as a result of the agency's failure to comply with all applicable Federal, State and local EP requirements by not establishing and maintaining a comprehensive EP plan based on and including a documented facility-based and community-based risk assessment, utilizing an all-hazards approach by not establishing and maintaining a comprehensive EP plan to address patient/client population, the type of services the agency has the ability to provide in an emergency, and continuity of operations including delegations of authority and succession plans by not developing and maintaining an emergency preparedness training and testing program that is based on the emergency plan, risk assessment, and the communication plan and testing requirements. --- Findings include: Cross Reference to E0001 for findings related to this citation.

Based on staff interview, review of personnel files, and the review of undated policy titled ";Emergency Operations Plan" 2.1.1", it was determined that the Condition of Emergency Preparedness (EP) for Hospice Agencies was not in compliance as a result of the agency's failure to comply with all applicable Federal, State and local EP requirements by not establishing and maintaining a comprehensive EP plan based on and including a documented facility-based and community-based risk assessment, utilizing an all-hazards approach by not establishing and maintaining a comprehensive EP plan to address patient/client population, the type of services the agency has the ability to provide in an emergency, and continuity of operations including delegations of authority and succession plans by not developing and maintaining an emergency preparedness training and testing program that is based on the emergency plan, risk assessment, and the communication plan and testing requirements. --- Cross Reference to E0001 for findings related to this citation.

Based on staff interview, review of personnel files, and the review of undated policy titled ";Emergency Operations Plan" 2.1.1", it was determined that the Condition of Emergency Preparedness (EP) for Hospice Agencies was not in compliance as a result of the agency's failure to comply with all applicable Federal, State and local EP requirements by not establishing and maintaining a comprehensive EP plan based on and including a documented facility-based and community-based risk assessment, utilizing an all-hazards approach by not establishing and maintaining a comprehensive EP plan to address patient/client population, the type of services the agency has the ability to provide in an emergency, and continuity of operations including delegations of authority and succession plans by not developing and maintaining an emergency preparedness training and testing program that is based on the emergency plan, risk assessment, and the communication plan and testing requirements. --- Cross Reference to E0001 for findings related to this citation.

Based on review of records and staff interview, it was determined the hospice failed to ensure the requirements for the interdisciplinary group, care planning and coordination of services were met. Specifically, that the initial plan of care (POC) was developed for each patient with full participation of the interdisciplinary team members in consultation with the patient's attending physician; to ensure that hospice care and services furnished to patients and their families followed an individualized written POC established by the hospice interdisciplinary group (IDG); to ensure that the IDG maintains responsibility for directing, coordinating, and supervising the care and services provided and to ensure the care and services provided are based on all assessments of the patient and family needs; to ensure the POC reflected all disciplines and interventions necessary to address the patient's assessed problems and needs; the POC reviews/updates included a specific frequency of visits for the nurse, aide, and social worker, and update of the POC at least every 15 days for 11 patients (P) (P#1, P#2, P#3, P#4, P#5, P#6, P#7, P#8, P#9, P#10, P #11) of 11 sampled patients (P#1, P#2, P#3, P#4, P#5, P#6, P#7, P#8, P#9, P#10, P #11). --- Findings include: Review of the binder titled ";Interdisciplinary Group Meeting" revealed a participate sign in sheet with nurse, medical doctor, social worker, and chaplain signatures for the months of May, June, and July of 2023. No other documentation for the IDG meeting was provided. 1. Review of all clinical records for P#1 revealed the patient was admitted to hospice on 6/12/2023. The clinical records failed to include a review and update of the plan of care since admission. 2. Review of all clinical records for P#2 revealed the patient was admitted to hospice on 3/27/2023. However, the clinical record failed to include initial written plan of care and plan of care for recertification benefit period of 6/22/23-9/19/23. The clinical records failed to include a review and update of the plan of care since admission. 3. Review of all clinical records for P#3 revealed the patient was admitted to hospice on 12/30/2022. The clinical records failed to include an initial plan of care and a review and update of the plan of care since admission. 4. Review of all clinical records for P#4 revealed the patient was admitted to hospice on 4/4/2023. The clinical records failed to include an initial plan of care and update of the plan of care since admission. 5. Review of all clinical records for P#5 revealed the patient was admitted to hospice on 4/12/2023. The clinical records failed to include a review and update of the plan of care since the last recertification benefit period of 4/12/2023 to 7/10/2023. 6. Review of all clinical records for P#6 revealed the patient was admitted to hospice on 2/21/2023. The clinical records failed to include an initial plan of care and update of the plan of care since admission. 7. Review of all clinical records for P#7 revealed the patient was admitted to hospice on 6/15/2023. The clinical records failed to include an initial plan of care and the documentation of a review and update of the plan of care since the admission. 8. Review of all clinical records for P#8 revealed the patient was admitted to hospice on 8/27/2022. The clinical records failed to include an initial plan of care and the documentation of a review and update of the plan of care since the admission date. 9. Review of all closed records for P#9 revealed the patient was admitted to hospice on 12/27/2022. The clinical records failed to include an initial plan of care and the documentation of a review and update of the plan of care since admission. 10. Review of all clinical records for P#10 revealed the patient was admitted to hospice on 12/23/2022. The clinical records failed to include an initial plan of care and the documentation of a review and update of the plan of care since the admission. 11.Review of all clinical records for P#11 revealed the patient was admitted to hospice on 2/8/2023. The clinical records failed to include a review and update of the plan of care since the admission. During an interview on 7/10/2023 at 11:00 a.m. the Director of Nursing (DON) revealed patient documentation for eleven out of eleven patients that had been performed on paper was in the process of being scanned into the Electronic Medical Records (EMR) system. During an office interview conducted on 7/13/2023 at 12.00 p.m., the Clinical Director confirmed that the clinical records for eleven out of eleven reviewed lacked documentation of initial plan of care and updated plan of care since the admission. During an interview on 7/13/2023 at 12:00 pm the DON revealed that the team discusses patients status at each IDG meeting but does not have written documents of the discussion of each patient. During an interview on 7/13/23 at 3:00 p.m., the DON stated no further documentation was available. Review of eleven out of eleven patient clinical records revealed the hospice failed to include IDG meeting notes discussing and addressing issues, problems and needs of each patient and family related to the terminal illness and did not allow for an interdisciplinary approach to patient care where each discipline intervened. Findings include: Cross reference to L0536 for findings related to this citation.

Based on review of records and staff interview, it was determined the hospice failed to ensure the requirements for the interdisciplinary group, care planning and coordination of services were met. Specifically, that the initial plan of care (POC) was developed for each patient with full participation of the interdisciplinary team members in consultation with the patient's attending physician; to ensure that hospice care and services furnished to patients and their families followed an individualized written POC established by the hospice interdisciplinary group (IDG); to ensure that the IDG maintains responsibility for directing, coordinating, and supervising the care and services provided and to ensure the care and services provided are based on all assessments of the patient and family needs; to ensure the POC reflected all disciplines and interventions necessary to address the patient's assessed problems and needs; the POC reviews/updates included a specific frequency of visits for the nurse, aide, and social worker, and update of the POC at least every 15 days for 11 patients (P) (P#1, P#2, P#3, P#4, P#5, P#6, P#7, P#8, P#9, P#10, P #11) of 11 sampled patients (P#1, P#2, P#3, P#4, P#5, P#6, P#7, P#8, P#9, P#10, P #11). --- Findings include: Cross reference to L0536 for findings related to this citation.

Based on review of records and staff interview, it was determined the hospice failed to ensure the requirements for the interdisciplinary group, care planning and coordination of services were met. Specifically, that the initial plan of care (POC) was developed for each patient with full participation of the interdisciplinary team members in consultation with the patient's attending physician; to ensure that hospice care and services furnished to patients and their families followed an individualized written POC established by the hospice interdisciplinary group (IDG); to ensure that the IDG maintains responsibility for directing, coordinating, and supervising the care and services provided and to ensure the care and services provided are based on all assessments of the patient and family needs; to ensure the POC reflected all disciplines and interventions necessary to address the patient's assessed problems and needs; the POC reviews/updates included a specific frequency of visits for the nurse, aide, and social worker, and update of the POC at least every 15 days for 11 patients (P) (P#1, P#2, P#3, P#4, P#5, P#6, P#7, P#8, P#9, P#10, P #11) of 11 sampled patients (P#1, P#2, P#3, P#4, P#5, P#6, P#7, P#8, P#9, P#10, P #11). --- Findings include: Cross reference to L0536 for findings related to this citation.

Based on review of records and staff interview, it was determined the hospice failed to ensure the requirements for the interdisciplinary group, care planning and coordination of services were met. Specifically, that the initial plan of care (POC) was developed for each patient with full participation of the interdisciplinary team members in consultation with the patient's attending physician; to ensure that hospice care and services furnished to patients and their families followed an individualized written POC established by the hospice interdisciplinary group (IDG); to ensure that the IDG maintains responsibility for directing, coordinating, and supervising the care and services provided and to ensure the care and services provided are based on all assessments of the patient and family needs; to ensure the POC reflected all disciplines and interventions necessary to address the patient's assessed problems and needs; the POC reviews/updates included a specific frequency of visits for the nurse, aide, and social worker, and update of the POC at least every 15 days for 11 patients (P) (P#1, P#2, P#3, P#4, P#5, P#6, P#7, P#8, P#9, P#10, P #11) of 11 sampled patients (P#1, P#2, P#3, P#4, P#5, P#6, P#7, P#8, P#9, P#10, P #11). --- Findings include: Cross reference to L0536 for findings related to this citation.

Based on review of records and staff interview, it was determined the hospice failed to ensure the requirements for the interdisciplinary group, care planning and coordination of services were met. Specifically, that the initial plan of care (POC) was developed for each patient with full participation of the interdisciplinary team members in consultation with the patient's attending physician; to ensure that hospice care and services furnished to patients and their families followed an individualized written POC established by the hospice interdisciplinary group (IDG); to ensure that the IDG maintains responsibility for directing, coordinating, and supervising the care and services provided and to ensure the care and services provided are based on all assessments of the patient and family needs; to ensure the POC reflected all disciplines and interventions necessary to address the patient's assessed problems and needs; the POC reviews/updates included a specific frequency of visits for the nurse, aide, and social worker, and update of the POC at least every 15 days for 11 patients (P) (P#1, P#2, P#3, P#4, P#5, P#6, P#7, P#8, P#9, P#10, P #11) of 11 sampled patients (P#1, P#2, P#3, P#4, P#5, P#6, P#7, P#8, P#9, P#10, P #11). --- Findings include: Cross reference to L0536 for findings related to this citation.

Based on review of records and staff interview, it was determined the hospice failed to ensure the requirements for the interdisciplinary group, care planning and coordination of services were met. Specifically, that the initial plan of care (POC) was developed for each patient with full participation of the interdisciplinary team members in consultation with the patient's attending physician; to ensure that hospice care and services furnished to patients and their families followed an individualized written POC established by the hospice interdisciplinary group (IDG); to ensure that the IDG maintains responsibility for directing, coordinating, and supervising the care and services provided and to ensure the care and services provided are based on all assessments of the patient and family needs; to ensure the POC reflected all disciplines and interventions necessary to address the patient's assessed problems and needs; the POC reviews/updates included a specific frequency of visits for the nurse, aide, and social worker, and update of the POC at least every 15 days for 11 patients (P) (P#1, P#2, P#3, P#4, P#5, P#6, P#7, P#8, P#9, P#10, P #11) of 11 sampled patients (P#1, P#2, P#3, P#4, P#5, P#6, P#7, P#8, P#9, P#10, P #11). --- Findings include: Cross reference to L0536 for findings related to this citation.

Based on review of quality assessment and performance improvement (QAPI) data, undated policy titled ";Quality Assessment and Performance Improvement (QAPI) Plan", and staff interview, it was determined the agency failed to ensure that the requirements for QAPI were met. The cumulative effects of these systemic problems resulted in the hospice's inability to effectively monitor and evaluate the care and services it provided to the patients and their caregivers and ensure the provision and availability of all services that effectively met the patients' and their caregivers' needs. --- Findings include: Review of undated policy titled ";Quality Assessment and Performance Improvement (QAPI) Plan" revealed the following: · Hospice to collect and analyze data to include high risk, high volume, and problem prone processes to improve identified processes and outcomes of care. · Hospice to collect data about incident reporting. · Data collection to include established priorities for improvement. Organizational functions with major processes include provision of care, treatment and services. Also Infection prevention and control monitoring to include Surveillance/Identification/Reporting/ Prevention System. · Hospice to ";document what performance improvement projects are being conducted, the reasons for conducting these projects and the measurable progress achieved on them". · The QAPI program will be evaluated annually by the Governing Body as a part of the annual program evaluation. · The Governing Body has designated responsibility for operating the QAPI program to the Director of Nursing (DON)/Director, who, in turn, assigns certain QAPI activities to other staff members. Review of QAPI documentation revealed the agency failed to provide collection of data, identified priorities for improvement, reported incident reports or adverse events, performance improvement projects, review by the governing body, and an individual responsible for QAPI activities. The agency failed to include data collection on effectiveness or safety of services and care provided. Interview with Director of Nursing (DON) on 7/13/2023 at 3 p.m., revealed no further documentation was available.

Based on review of quality assessment and performance improvement (QAPI) data, undated policy titled ";Quality Assessment and Performance Improvement (QAPI) Plan", and staff interview, it was determined the agency failed to ensure that the requirements for QAPI were met. The cumulative effects of these systemic problems resulted in the hospice's inability to effectively monitor and evaluate the care and services it provided to the patients and their caregivers and ensure the provision and availability of all services that effectively met the patients' and their caregivers' needs. --- Findings include: Cross reference to L0559 for findings related to this citation.

Based on record review, staff interviews, review of personnel files of agency staff, and review of agency undated policy titled ";Infection Control Surveillance System: Prioritized Risks Defined" and ";Infection Control Plan", it was determined the agency failed to maintain an infection control surveillance plan that documented, reported and monitored infections for 11 patients (P) (#1, #2, #3, 4, #5, #6, #7, #8, #9, #10, and #11) of 11 sampled patients (#1, #2, #3, 4, #5, #6, #7, #8, #9, #10, and #11) and provided training for staff. --- The findings include: Review of the undated policy titled ";Infection Control Surveillance System: Prioritized Risks Defined", revealed the following: ";POLICY Hospice will implement an infection control surveillance system for patients and staff. The definition of infections is based on the most common infections prevalent to services that are high volume, frequent infectious complications and have a high potential for prevention by staff and/or have an increased risk for negative patient outcomes. PROCEDURE 1. Hospice will perform targeted infection control surveillance as follows: Patient infections to be reported at time of admission: chicken pox, german measles, hepatitis B, small pox, TB, COVID 19 or any reportable communicable disease (as defined by local health department). Patient infections to be reported while patient is on service: wound infections that develop 30 days or greater after admission which require an antibiotic or identified by lab test or MD that may or may not require an antibiotic; central-line associated bloodstream infections, all infections associated with tubes and lines, and all infections that are identified as infections to be reported at admission. Employee infections to be reported if an employee develops or has a known exposure to: conjunctivitis, MRSA, VRE, and any reportable communicable disease as defined by the local health department. Written reporting of infections will occur through documentation on the applicable log (patient or employee). 3. At least quarterly, the Director and infection control and QAPI committees will review and assess the infection control logs. Data will be aggregated and analyzed on the Infection Control Quarterly Data Aggregation and Analysis: Patients and Employees form." Review of agency undated policy titled ";Infection Control Plan" revealed the following: ";Procedure Educates employees in the infection control program. Advises employees of any revisions or when changes occur. Provides record keeping in accordance with regulations. Ensures that provisions of equipment and supplies necessary to minimize the risk of infection with bloodborne pathogens or other potentially infectious materials are available to all employees at risk of exposure. Establishes a process for educating patient/caregivers regarding infection control policies/ procedures. Establishes a surveillance program for infections acquired while receiving Hospice care. Reviews the programs effectiveness annually and revise as necessary. Establishes policies/procedures that will reduce the spread of infections to employees and patients. Monitors staff adherence to recommended policies, procedures and protective measures. When monitoring reveals a failure to follow recommended precautions: Counseling, education and/or retraining will be provided. If necessary, appropriate disciplinary action will be taken. Screens staff as required by law and regulation for exposure and/or immunity to infectious diseases that staff may come in contact with. Refers staff who are exposed to or who potentially have an infectious disease to physicians for assessment, testing, prophylaxis treatment, counseling and/or immunization." Upon request of the personnel files of the agency staff, infection control policies and procedures, surveillance plan, and infection control implementation and surveillance data, the Clinical Director failed to provide the infection control surveillance log. Review of the personnel file of agency staff (#1, #2, #3, 4, and #5) revealed that the agency failed to include education of the staff on the infection control policies and procedures. During an interview on 7/13/2023 at approximately 3.00 p.m., the Clinical Director (CD) failed to provide infection control implementation and surveillance data and confirmed that the agency staff were not trained on the agency infection control policies and procedures.

Based on record review, staff interviews, review of personnel files of agency staff, and review of agency undated policy titled ";Infection Control Surveillance System: Prioritized Risks Defined" and ";Infection Control Plan", it was determined the agency failed to maintain an infection control surveillance plan that documented, reported and monitored infections for 11 patients (P) (#1, #2, #3, 4, #5, #6, #7, #8, #9, #10, and #11) of 11 sampled patients (#1, #2, #3, 4, #5, #6, #7, #8, #9, #10, and #11) and provided training for staff. --- Findings include: Cross reference to L577 for findings related to this citation.

Based on record review of the agencys staff list, contract list, and staff interview, it was determined that the hospice failed to ensure that dietary counseling was readily available and accessible to meet the patients potential dietary needs. --- Findings include: Record review of the list of contracts and agency staff list, it was determined that the agency failed to include dietary counseling services to meet the dietary needs of the patients. During an interview on 7/13/2023 at 12:00 p.m., the Clinical Director confirmed the surveyor was provided with all available contracts and agency staff list.

Based on review of the agencys staff list, contract list, and staff interview, it was determined that agency failed to ensure physical therapy (PT), occupational therapy (OT), and speech therapy (ST) services was readily available and accessible to meet the potential rehabilitative needs of 11 patients (P) (#1, #2, #3, #4, #5, #6, #7, #8, #9, 10, #11) of 11 sampled patients (P) (#1, #2, #3, #4, #5, #6, #7, #8, #9, 10, and #11). --- Findings include: Cross Reference to L0603 for findings related to this citation. Findings include: Review of list of contracts and agency staff, it was determined that the agency failed to have PT, OT, ST services to meet the rehabilitative needs of the patients. During an interview on 7/13/20 23 at 3:00 p.m., the Clinical Director confirmed the surveyor was provided with all available contracts and agency staff list.

Based on record review of personnel records, and staff interview, it was determined the agency failed to ensure the requirements for the hospice aide services met the personnel requirements and qualification. The agency failed to ensure the hospice Certified Nursing Assistant (CNA) had successfully completed an approved competency evaluation program and to provide documentation of the hospice aides training which includes classroom and supervised practical training, in a laboratory or clinical setting, for which the aide demonstrates knowledge while performing tasks on an individual under the direct supervision of a Registered Nurse (RN). --- Findings include: Record review of personnel file reviews revealed that CNA AA failed to include documentation of successfully completing an approved competency evaluation program to meet state requirements and direct supervision by a Registered Nurse (RN) in a classroom and/or clinical setting to demonstrate knowledge of performing task required to care for hospice patients. During an interview on 7/13/2023 at 3:00 p.m., the Director of Nursing (DON) reveled that the agency had no documentation available for evidence that CNA AA completed an approved competency evaluation program. Findings Include: Cross reference to L607 for findings related to this citation.

Based on record review of personnel records, and staff interview, it was determined the agency failed to ensure the requirements for the hospice aide services met the personnel requirements and qualification. The agency failed to ensure the hospice Certified Nursing Assistant (CNA) had successfully completed an approved competency evaluation program and to provide documentation of the hospice aides training which includes classroom and supervised practical training, in a laboratory or clinical setting, for which the aide demonstrates knowledge while performing tasks on an individual under the direct supervision of a Registered Nurse (RN). --- findings include: Cross reference to L607 for findings related to this citation.

Based on review of clinical records, review of personnel records, review of policy titled HR policy #4.27.1 , 4.28.1,, staff interview, and lack of access to governing body minutes, it was determined the governing body failed to demonstrate organizational management and administration of care and services necessary to effectively monitor and supervise the hospice staff and ensure the overall safety of care and services provided for 11 of 11 hospice beneficiaries and their caregivers. The agency failed to provide evidence of orientation training that addressed the hospice philosophy, failed to assume full responsibility, management and provision of hospice services, failed to provide an initial orientation for each employee that addresses the employee's specific job duties, and failed to assess the competence and skills of staff members who furnished care. Findings include: --- Review of personnel files for staff members #1, #2, #3, #4, and #5 revealed that each file lacked documented evidence that the staff members had received orientation about the hospice philosophy, had received an initial orientation that addresses the employee's specific job duties, lacked documentation of the assessment of competency and skills, lack of in-services training and annual training, to all staff members who furnished care. During an office interview on 7/13/23 at 3 :00 p. m., the Clinical Director was unable to produce the missing documentation of above-mentioned personnel records. HR policy #4.27.1 , 4.28.1 2. The Orientation Checklist will be used to document orientation for all staff, including contract staff.

Based on review of clinical records, review of personnel records, review of policy titled HR policy #4.27.1 , 4.28.1,, staff interview, and lack of access to governing body minutes, it was determined the governing body failed to demonstrate organizational management and administration of care and services necessary to effectively monitor and supervise the hospice staff and ensure the overall safety of care and services provided for 11 of 11 hospice beneficiaries and their caregivers. The agency failed to provide evidence of orientation training that addressed the hospice philosophy, failed to assume full responsibility, management and provision of hospice services, failed to provide an initial orientation for each employee that addresses the employee's specific job duties, and failed to assess the competence and skills of staff members who furnished care. --- Findings include: Cross Reference to E0648 for findings related to this citation.

Based on review of clinical records, review of personnel records, review of policy titled HR policy #4.27.1 , 4.28.1,, staff interview, and lack of access to governing body minutes, it was determined the governing body failed to demonstrate organizational management and administration of care and services necessary to effectively monitor and supervise the hospice staff and ensure the overall safety of care and services provided for 11 of 11 hospice beneficiaries and their caregivers. The agency failed to provide evidence of orientation training that addressed the hospice philosophy, failed to assume full responsibility, management and provision of hospice services, failed to provide an initial orientation for each employee that addresses the employee's specific job duties, and failed to assess the competence and skills of staff members who furnished care. --- Findings include: Cross Reference to E0648 for findings related to this citation.

Based on review of clinical records, review of personnel records, review of policy titled HR policy #4.27.1 , 4.28.1,, staff interview, and lack of access to governing body minutes, it was determined the governing body failed to demonstrate organizational management and administration of care and services necessary to effectively monitor and supervise the hospice staff and ensure the overall safety of care and services provided for 11 of 11 hospice beneficiaries and their caregivers. The agency failed to provide evidence of orientation training that addressed the hospice philosophy, failed to assume full responsibility, management and provision of hospice services, failed to provide an initial orientation for each employee that addresses the employee's specific job duties, and failed to assess the competence and skills of staff members who furnished care. --- Findings include: Cross Reference to L0648 for findings related to this citation.

Based on record reviews, staff interview, and undated policy titled "Certification/Recertification of Terminal Illness, Brief Narrative Statement and Face-to-Face Evaluations" it was determined the hospice failed to ensure the requirements of the Medical Director were met. The hospice's inability to effectively monitor and evaluate the care and services provided to the patients and their caregivers and ensure the provision and availability of all services was not met. Specifically, the agency failed to provide initial physician certification or physician recertification for 11 patients (P) (P#1, P#2, P#3, P#4, P#5, P#6, P#7, P#8, P#9, P#10, P#11) of 11 sampled patients (P#1, P#2, P#3, P#4, P#5, P#6, P#7, P#8, P#9, P#10, P#11). --- Findings include: Review of undated policy ";Certification/Recertification of Terminal Illness, Brief Narrative Statement and Face-to-Face Evaluations" reveals: ";Hospice will obtain written certification of terminal illness for each of the periods listed, even if a single election continues in effect for two, three or four periods. Hospice will obtain the written certification no later than two (2) calendar days after the period begins. If Hospice cannot obtain the written certification within two (2) calendar days, it will obtain oral certification within two (2) calendar days, and written certification prior to submitting a claim for payment 1. Review of clinical record for patient P#1 revealed the patient was admitted to hospice on 6/12/20 23. The clinical record lacked evidence of initial physician certification of terminal illness. 2. Review of clinical record for P#2 revealed the patient was admitted to hospice on 3/27/2023. The clinical record lacked evidence of initial physician certification or recertification of terminal illness. 3. Review of clinical record for P#3 revealed the patient was admitted to hospice on 12/30/2022. The clinical record lacked evidence of initial physician certification or recertification of terminal illness. 4. Review of clinical record for P#4 revealed the patient was admitted to hospice on 4/4/2023. The clinical record lacked evidence of initial physician certification or recertification of terminal illness. 5. Review of clinical record for patient P#5 revealed the patient was admitted to hospice on 4/12/2023. The clinical record lacked evidence of initial physician certification of terminal illness. 6. Review of clinical record for patient #6, revealed the patient was admitted to hospice on 2/21/2023. The clinical record lacked evidence of initial physician certification of terminal illness and recertification with face to face for benefit period dated 6/25/2023 through 8/23/2023. Untitled, unsigned and undated documents in the hard copy of the medical record filed under tab ";physician" revealed patient noted to have a colostomy but no evidence of physician orders for care of colostomy. 7. Review of clinical record for P#7 revealed the patient was admitted to hospice on 6/15/2023. The clinical record lacked evidence of initial physician certification of terminal illness. 8. Review of clinical record for P#8 revealed the patient was admitted to hospice on 8/27/2022. The clinical record lacked evidence of initial physician certification or recertification of terminal illness. 9. Review of clinical record for P#9 revealed the patient was admitted to hospice on 12/27/2022. The clinical record lacked evidence of initial physician certification of terminal illness. 10. Review of clinical record for P#10 revealed the patient was admitted to hospice on 12/23/2022. The clinical record lacked evidence of initial physician certification or recertification of terminal illness. 11. Review of clinical record for P#11 revealed the patient was admitted to hospice on 2/8/2023. The clinical record lacked evidence of initial physician certification or recertification of terminal illness. Review of undated policy ";Certification/Recertification of Terminal Illness, Brief Narrative Statement and Face-to-Face Evaluations" reveals: ";Hospice will obtain written certification of terminal illness for each of the periods listed, even if a single election continues in effect for two, three or four periods. Hospice will obtain the written certification no later than two (2) calendar days after the period begins. If Hospice cannot obtain the written certification within two (2) calendar days, it will obtain oral certification within two (2) calendar days, and written certification prior to submitting a claim for payment." Interview with Director of Nursing (DON) on 7/13/2023 at 3 p.m. revealed that no additional documentation was available. DON was unable to verbalize the physician certification and recertification process and acknowledged that the above requested documents are not available for review.

Based on record reviews, staff interview, and undated policy titled "Certification/Recertification of Terminal Illness, Brief Narrative Statement and Face-to-Face Evaluations" it was determined the hospice failed to ensure the requirements of the Medical Director were met. The hospice's inability to effectively monitor and evaluate the care and services provided to the patients and their caregivers and ensure the provision and availability of all services was not met. Specifically, the agency failed to provide initial physician certification or physician recertification for 11 patients (P) (P#1, P#2, P#3, P#4, P#5, P#6, P#7, P#8, P#9, P#10, P#11) of 11 sampled patients (P#1, P#2, P#3, P#4, P#5, P#6, P#7, P#8, P#9, P#10, P#11). --- Cross reference L0664 as it relates to no evidence of initial certification of terminal illness for 11 of 11 patients.

Based on record reviews, staff interview, and undated policy titled "Certification/Recertification of Terminal Illness, Brief Narrative Statement and Face-to-Face Evaluations" it was determined the hospice failed to ensure the requirements of the Medical Director were met. The hospice's inability to effectively monitor and evaluate the care and services provided to the patients and their caregivers and ensure the provision and availability of all services was not met. Specifically, the agency failed to provide initial physician certification or physician recertification for 11 patients (P) (P#1, P#2, P#3, P#4, P#5, P#6, P#7, P#8, P#9, P#10, P#11) of 11 sampled patients (P#1, P#2, P#3, P#4, P#5, P#6, P#7, P#8, P#9, P#10, P#11). --- Cross reference L0664 as it relates to physician responsibility for overall medical component of hospice patients care.

Based on clinical record review, policy review and staff interview, it was determined the agency failed to meet the requirements for clinical records for 11 of 11 patients (P) (P#1, P#2, P#3, P#4, P#5, P#6, P#7, P#8, P#9, P#10, P #11). Clinical records lacked physician certifications, comprehensive assessments, reviews, visit notes for all disciplines, and updates to comprehensive assessments and plan of care. Discharged patients lacked documentation of discharge summaries for four of four patients (P#8, P#9, P#10, P #11). The cumulative effects of these systemic failures resulted in the hospices inability to adequately identify and meet the patients physical, psychosocial, spiritual, and emotional needs. --- On 7/10/2023 at 11:00 a.m., the surveyor requested the documentation of initial plan of care (POC), initial certification for terminal illness (CTI), recertification POC, initial and ongoing comprehensive assessments respective to each discipline, visit notes for all disciplines. At 1:45 p.m., the surveyor was told, by the director of nursing (DON), all patient documentation that had been performed on paper was in the process of being scanned into the Electronic Medical Records (EMR) system. On 7/13/2023 at 3:00 p.m. the surveyor received nursing initial and comprehensive assessments for eleven out of eleven patients. No other discipline assessments were provided to the surveyor. Review of clinical record for patient (P)#1 revealed the patient was admitted to hospice on 6/12/2023. The clinical record lacked evidence of initial physician certification of terminal illness. The clinical record lacked the documentation of a review and update of the plan of care since admission. An untitled handwritten note, signed by MD and dated 6/19/2023 was presented as an interdisciplinary care plan update but had no other interdisciplinary team signatures or evidence of interdisciplinary discussion. Review of clinical record for P#2 revealed the patient was admitted to hospice on 3/27/2023. The clinical record lacked evidence of initial physician certification or recertification of terminal illness. The clinical record lacked documentation of initial written plan of care and plan of care for recertification benefit period of 6/22/23-9/19/23. The clinical record lacked the documentation of a review and update of the plan of care since admission. During an interview with the clinical director conducted on 7/12/23, the clinical director stated that P#2 does not have a plan of care. Review of clinical record for P#3 revealed the patient was admitted to hospice on 12/30/2022. The clinical record lacked evidence of initial physician certification or recertification of terminal illness. The clinical record lacked documentation of an initial plan of care and a review and update of the plan of care since admission. Review of clinical record for P#4 revealed the patient was admitted to hospice on 4/4/2023. The clinical record lacked evidence of initial physician certification or recertification of terminal illness. The clinical record lacked documentation of an initial plan of care and a review and update of the plan of care since admission. Review of clinical record for P#5 revealed the patient was admitted to hospice on 4/12/2023. The clinical record lacked evidence of initial physician certification of terminal illness. The clinical record lacked documentation of a review and update of the plan of care since the last recertification benefit period of 4/12/23 to 7/10/23. An email dated 5/19/2023, sent by MD and titled ";Progress Note" was presented as evidence of interdisciplinary care plan update but was unsigned and had no other interdisciplinary team members signatures. Review of clinical record for P#6, revealed the patient was admitted to hospice on 2/21/2023. The clinical record lacked evidence of initial physician certification of terminal illness and recertification with face to face for benefit period dated 6/25/2023 – 8/23/2023. Untitled, unsigned, and undated documents in the paper copy of the medical record filed under tab ";physician". Patient noted to have a colostomy but no evidence of physician orders for care of colostomy. The clinical record lacked an initial plan of care and documentation of a review and update of the plan of care since admission. Review of clinical record for P#7 revealed the patient was admitted to hospice on 6/15/2023. The clinical record lacked evidence of initial physician certification of terminal illness. Review of clinical record for P#8 (closed record), revealed the patient was admitted to hospice on 8/27/2022 and revoked on 11/17/2022. The clinical record lacked evidence of initial physician certification or recertification of terminal illness, an initial plan of care and documentation of a review and update of the plan of care since the admission. The clinical record lacked a discharge summary. Review of clinical record for P#9 (closed record) revealed the patient was admitted to hospice on 12/27/2022 and was discharged 12/27/2022. The clinical record lacked evidence of initial physician certification of terminal illness, an initial plan of care and documentation of a review and update of the plan of care since the admission. The clinical record lacked a discharge summary. Review of clinical record for P#10 (closed record), revealed the patient was admitted to hospice on 12/23/2022 and died 2/19/2023. The clinical record lacked evidence of initial physician certification or recertification of terminal illness, an initial plan of care and documentation of a review and update of the plan of care since the admission. The clinical record lacked a discharge summary. Review of clinical record for P#11 (closed record), revealed the patient was admitted to hospice on 2/8/23 and died 3/19/2023. The clinical record lacked evidence of initial physician certification or recertification of terminal illness. The clinical record lacked an initial plan of care and the documentation of a review and update of the plan of care since the admission lacked a discharge summary. Review of undated policy titled ";Patient Record Content" revealed: During an office interview conducted on 7/13/23 at 12:00 p.m., Director of Nursing (DON) confirmed that clinical records lacked documentation of initial and updated plans of care, physician orders, physician orders, certifications of terminal illness and discharge summaries. The DON acknowledged that clinical records lacked patient identifiers and signatures.

Based on clinical record review, policy review and staff interview, it was determined the agency failed to meet the requirements for clinical records for 11 of 11 patients (P) (P#1, P#2, P#3, P#4, P#5, P#6, P#7, P#8, P#9, P#10, P #11). Clinical records lacked physician certifications, comprehensive assessments, reviews, visit notes for all disciplines, and updates to comprehensive assessments and plan of care. Discharged patients lacked documentation of discharge summaries for four of four patients (P#8, P#9, P#10, P #11). The cumulative effects of these systemic failures resulted in the hospices inability to adequately identify and meet the patients physical, psychosocial, spiritual, and emotional needs. --- Findings Include: Cross reference to L0670 as it relates to lack of initial and updated plan of care, initial comprehensive assessments, updated comprehensive assessments and clinical notes.

Based on clinical record review, policy review and staff interview, it was determined the agency failed to meet the requirements for clinical records for 11 of 11 patients (P) (P#1, P#2, P#3, P#4, P#5, P#6, P#7, P#8, P#9, P#10, P #11). Clinical records lacked physician certifications, comprehensive assessments, reviews, visit notes for all disciplines, and updates to comprehensive assessments and plan of care. Discharged patients lacked documentation of discharge summaries for four of four patients (P#8, P#9, P#10, P #11). The cumulative effects of these systemic failures resulted in the hospices inability to adequately identify and meet the patients physical, psychosocial, spiritual, and emotional needs. --- Findings include: Cross reference to L0670 as it relates to clinical record entries.

Based on clinical record review and staff interview, it was determined that the agency failed to provide a written copy of policies and procedures for the safe management and disposal of controlled drugs and the agency failed to ensure compliance regarding the destruction of controlled drugs following the patient's death for two of two (P) (#10 and #11) sampled deceased patients. --- Findings include: 1.The bereavement record for patient #10 reflected that the patient received hospice services in the home setting from 10/29/21 to 2/19/23. Documentation of a pronouncement form reflected the patient died on 2/19/23. However, the clinical record lacked documentation of drug destruction. 2. The bereavement record for patient #11 reflected that the patient received hospice services from 11/10/22 to 3/19/23 and the patient was prescribed controlled medications which were identified on the medication profile. Documentation of a pronouncement form reflected the patient died at home on 3/19/23. However, the clinical record lacked documentation of drug destruction. During an office interview with the Clinical Director (CD) on 7/13/23 at 11:00 a.m., the CD state that form ";Registrant Record of Controlled Substances Destroyed" is completed at the time of death for each patient, however the form was not provided for this deceased patient at the time of the survey to indicate the family was offered education and assistance with medication destruction. During in an office interview on 7/13/23 at 3.00 p.m., the Clinical Director confirmed that the clinical note lacked documentation of drug destruction.

Based on clinical record review and staff interview, it was determined that the agency failed to provide a written copy of policies and procedures for the safe management and disposal of controlled drugs and the agency failed to ensure compliance regarding the destruction of controlled drugs following the patient's death for two of two (P) (#10 and #11) sampled deceased patients. --- Cross Reference to 0686 for findings related to this citation.

Based on review of personnel files and staff interview, it was determined that the agency failed to obtain a criminal background check (CBC) on two of three (#2 and #4) (#1, #2, #3, #4, and #5) hospice agency staff, who have direct patient contact or access to patient records. --- Findings include: On 7/10/23 at 11:00 a.m., surveyor requested personnel files for the agency staff. 1. Review of personnel file revealed that Certified Nurse Aide (CNA#2) was hired on 5/22/23. The personnel file lacked criminal background check. 2. Review of personnel file revealed that Social Worker (SW#4) was hired on 3/6/23. Th personnel file lacked a criminal background check. Due to the lack of evidence of criminal background checks it was determined the CBC were not done for staff #2 and staff #4. During an interview on 7/13/23 at 3.00p.m., the Clinical Director acknowledged that the personnel file did not contain the criminal background check for the above-mentioned staff.