Every finding on record at Clp Regency of Texas, LLC

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current prescription and over-the-counter (OTC) drugs, supplements, herbal remedies, other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following, the effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy, drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and, as appropriate, preventive measurements are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added, or changes are made to existing medication. This standard was not met as evidenced by clinical record review, observation, and interview. 3 of 6 (50%) observed home visits revealed the agency did not ensure medication reconciliations were completed and medications updated to the medication profiles. HOME VISIT 1/CLINICAL RECORD 1: The patient's date of election of the hospice benefit was 12/10/2024. The hospice medication profile, printed on 03/16/2026, listed Hydrocodone 5 mg-Acetaminophen 325 mg tablet, take 1 tablet orally every 6 hours as needed for pain, dated 08/07/2025; and Oxycodone 5 mg tablet, take 1 tablet 2 times daily orally, dated 08/07/2025. During the observed home visit on 03/17/2026 with the Medical Social Worker (Personnel Record 9), the hospice medication profile was compared with the group home medication list. The medication list at the group home included Oxycodone 5 mg tablet, take 1 tablet orally 4 times a day, started 12/03/2025. The group home director reported that Hydrocodone-Acetaminophen was discontinued in December 2025 when Oxycodone was started. The hospice clinical record lacked evidence that a medication reconciliation occurred at the time of each comprehensive assessment and/or when a new medication was added or when changes were made to existing medications. HOME VISIT 4/CLINICAL RECORD 12: The patient's date of election of the hospice benefit was 12/02/2025. The hospice medication profile, printed on 03/18/2026, listed Levocetirizine 5 mg tablet, take one tablet orally at bedtime dated 03/13/2024; and Montelukast 10 mg tablet, take one tablet orally daily dated 03/13/2024. During the observed home visit on 03/18/2026 with the Registered Nurse (Personnel Record 8), the medications in the home were reviewed. Claritin 10 mg tablet, take one tablet by mouth in the morning, started approximately 3 weeks prior; Azo D-Mannose, take two capsules daily, started 4 months prior; and Azo Cranberry 1 capsule daily, started 4 months prior; these were not listed on the hospice medication profile. The patient's caregiver stated that the Levocetirizine and Montelukast were stopped 3 months ago. The caregiver also stated that the Claritin was started for seasonal allergies, and the Azo D-Mannose and Azo Cranberry were started after the patient had bladder infections. The clinical record lacked evidence that a medication reconciliation occurred at the time of each comprehensive assessment and/or when new medications was added or when changes were made to existing medications. HOME VISIT 6/CLINICAL RECORD 3: The patient's date of election of the hospice benefit was 12/10/2024. The hospice medication profile, printed on 03/19/2026, listed Atorvastatin 40 mg tablet, take 1 tablet at bedtime orally, dated 09/02/2025; and Trazadone 50 mg tablet, take 1 tablet at bedtime orally, dated 09/02/2025. During the observed home visit on 03/20/2026 with the Hospice Aide (Personnel Record 15), the medications in the home were reviewed. The patient's caregiver stated that the Atorvastatin was stopped when the patient went to respite in February 2025. The caregiver stated that they felt it was time to stop the medication. The caregiver stated that they give the patient 2 tablets of Trazodone every other night and that the patient has taken it this way for a while, which seems more effective for him. The clinical record lacked evidence that a medication reconciliation occurred at the time of each comprehensive assessment and/or when a new medication was added or when changes were made to existing medications. During a joint record review and interview on 03/20/2026, the Area Executive for Clinical Operations confirmed that there was no documented evidence the medications were reconciled at the time when new medications were added, or changes were made to existing medications.

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as hand hygiene. This standard was not met as evidenced by document review, interview and observation. 3 of 6 (50%) home visit observations revealed the agency did not ensure the staff followed the agency's hand hygiene policy. Agency Policy: "Infection Control: Bag Technique and Standard Precautions", procedure number IPC.11_A2, last reviewed 09/19/2025, stated in part, "When washing hands with soap and water. Wet your hands with clean running water (warm or cold), turn off the tap, and apply soap. Lather your hands by rubbing them together with the soap. Lather the backs of your hands, between your fingers, and under your nails for at least 20 seconds. Do you need a timer? Hum the "Happy Birthday" song from beginning to end twice. Rinse your hands well under clean, running water. Dry your hands using a clean paper towel or air-dry them. Faucet to be turned off with paper towel used to dry hands. If the air-dry method is used, turn faucet off with elbows, hands up no contact to face or hair. Repeat process 1-5, before and after patient contact, before and after entering your bag, before and after donning and doffing gloves, before and after any patient procedure, or after contact with inanimate objects in the patient environment." HOME VISIT 2: During the observed home visit on 03/17/2026 with the Registered Nurse (RN - Personnel Record 7), the RN was observed to wash the hands with soap and water, rinsing the hands, turning off the faucet with wet hands, and dried the hands with paper towels. The RN did not use paper towels to dry hands and then turn off the water, nor turn off the faucet with the elbow and air-dry the hands in accordance with policy. HOME VISIT 4: During the observed home visit on 03/18/2026 with the RN (Personnel Record 8), the RN was observed to wash the hands with soap and water, rising the hands, turning off the faucet with wet hands, and dried the hands with a hand towel that was hanging on the towel holder on the wall. The RN did not use paper towels to dry hands and turn off the water, nor turn off the faucet with the elbow and air-dry the hands in accordance with policy. HOME VISIT 6: During the observed home visit on 03/20/2026 with the Hospice Aide (HA - Personnel Record 15), the HA was observed to wash the hands with soap and water, turn off the faucet with wet hands, open the hall closet with wet hands, remove a clean towel, and dry the hands. The HA did not use paper towels to dry the hands and turn off the water, nor turn off the faucet with the elbow and air-dry the hands in accordance with policy. During an a joint document review and interview on 03/20/2026, the Area Executive for Clinical Operations agreed the staff did not follow the hand hygiene policy.

It is required that the individual furnishes hospice aide services on behalf of a hospice only after successfully completing a competency evaluation program. The hospice maintains documentation that each hospice aide has met the requirements. This standard was not met as evidenced by document review, interview and personnel record review. 2 of 2 (100%) personnel records of hospice aides (HA) reviewed revealed the agency did not ensure that competency evaluations were completed prior to the HAs performing care independently. Agency Policy: UNV-P01 "Management and Staff Training" policy number UNV-P01, last reviewed 12/26/2024, stated in part, "Direct Care colleagues will receive a competency evaluation aimed at the discipline-specific skills or behaviors necessary for effective care delivery at the conclusion of the onboarding process...Hospice Aides (HA's) will also receive observed skills evaluation prior to independent care to verify the aide can satisfactorily provide patient care services." PERSONNEL RECORD 13: The HA's date of hire was 05/07/2024. There was no documented evidence that a skills competency evaluation was completed on hire in accordance with policy. An attestation statement had been entered in the HA’s record in December 2025 stating that the initial competency was not found during a mock audit. There was a documented initial competency evaluation, completed on 03/16/2026, and entered in the record. PERSONNEL RECORD 15: The HA’s date of hire was 04/15/2024. There was no documented evidence that a skills competency evaluation was completed on hire in accordance with hospice policy. An attestation statement had been entered in the HA’s record in December 2025 stating that the initial competency was not found during a mock audit. There was an initial competency evaluation, completed on 03/16/2026, and entered in the record. During a joint personnel record and document review and interview on 03/19/2026, the Business Office Manager (BOM) agreed that the employees did not have the initial competency documentation required by hospice policy. The BOM stated that a mock audit discovered the competencies were missing. An attestation was used to document the record audit and the items that were missing in December 2025. The BOM confirmed that the initial competencies for both hospice aides were not completed and entered into the records until 03/16/2026. During a joint record review and an interview on 03/20/2026, the Area Executive of Clinical Operations agreed, there was no documented evidence a hospice aide skills competency evaluation was completed at hire for the 2 hospice aides.

It is required that the hospice patient has the right to exercise the rights as stated in the Bill of Rights without discrimination or reprisal. This standard was not met as evidenced by clinical record review, document review, and interview. The hospice did not ensure the patient's right to voice grievances regarding treatment or care was exercised. Document 6: A review of the hospice's 2023 complaint log revealed no evidence of complaints reported by the patient's daughter or the SN that documented the daughter's complaints. Clinical Record 22: The Skilled Nurse (SN) visit notes dated 3/26/23 and 3/28/2023 documented the patient's daughter complained about inconsistent care and staff, and that eight of the nine nursing visits for the period of 3/1/2023 through 3/29/2023 were completed by different nurses. There was no documentation the hospice was notified and responded to the complaints as reported by the daughter. During an interview, the Area Executive of Clinical Operations confirmed the daughter's complaints were not documented in the log. The agency did not ensure to provide care that optimized comfort and dignity as evidenced by mulitple complaints citing discomfort and dissatification with a lack of consisitent caregivers and poor communication.

It is required that the hospice conducts and documents a patient-specific comprehensive assessment that identifies the patient’s need for hospice care and services, and the patient’s need for physical, psychosocial, emotional, and spiritual care. The assessment includes all areas of hospice care related to the palliation and management of the terminal illness and related conditions. THIS IS A CMS CONDITION-LEVEL DEFICIENCY This Condition was not met, as evidenced by clinical records review, document review, and interview, which revealed issues with the completion of initial and comprehensive assessments of patients in the following areas: Failure of the hospice Interdisciplinary Group to demonstrate completion of spiritual and psychosocial assessments, as part of the initial comprehensive assessment, within five (5) calendar days after the election of hospice care [HCPC.9.I/L523]; failure of the hospice Interdisciplinary Group to ensure the initial comprehensive assessment included a review of all of the patient's medications for adverse effects, significant side effects, and contraindications [HCPC.15.I/L530]; and failure of the hospice Interdisciplinary Group to demonstrate completion of an initial bereavement assessment [HCPC.13.I/L531]. The cumulative effect and scope of these deficiencies could negatively impact the organization’s ability to identify and meet the care needs of the patients and ensure continuity of care and service coordination.

It is required that the hospice Interdisciplinary Group, in consultation with the individual's attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review and interview. 4 of 23 (17%) clinical records reviewed, the hospice did not ensure that the initial spiritual and psychosocial portions of the initial comprehensive assessment were completed no later than five (5) calendar days after the election of hospice care Clinical Record 1: The patient elected hospice care on 8/29/2022. The Medical Social Worker (MSW) completed the psychosocial assessment on 9/12/2022, 14 days after the election of hospice care. A coordination note documented that the MSW called the patient on 9/8/2022 to schedule the appointment. Additionally, the Chaplain completed the spiritual assessment on 10/16/2022, 48 after the election of hospice care. There was no evidence of communication or documentation to explain the delay in the assessment visits. Clinical Record 3: The patient elected hospice care on 11/10/2023. The MSW completed the psychosocial assessment on 11/19.2022, 9 days after the election of hospice care. There was no evidence of communication or documentation to explain the delay in the assessment visit. Clinical Record 6: The patient elected hospice care on 3/30/2023. There was evidence of a documented missed visit note from the Chaplain dated 4/8/2023. The Chaplain completed the spiritual assessment on 4/25/2023, 26 days after the election of hospice care. There was no further evidence of communication or documentation to explain the delay in the assessment visit. Clinical Record 16: The patient elected hospice care on 2/9/2023. The Chaplain completed the spiritual assessment on 2/23/2023, 14 days after the election of hospice care. There was no documentation in the clinical record to explain the reason for the delay. During an interview on 5/3/2023, the Director of Clinical Services (DCS) confirmed the finding and stated the problem was identified and the hospice is working to correct it. 9 of 23 ( 39%) of clinical records revealed that the agency did not ensure that the initial comprehensive assessment was completed within 5 days of the election of hospice care.

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current prescription and over-the-counter (OTC) drugs, supplements, herbal remedies, [and] other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following: the effectiveness of drug therapy; drug side effects; actual or potential drug interactions; duplicate drug therapy; [and] drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and, as appropriate, preventive measurements are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by clinical record review and interview. 5 of 23 (22%) clinical records reviewed, the hospice did not ensure that the comprehensive assessment included a complete review of the patient's current prescription medications. Clinical Record 1: The patient elected hospice care on 8/29/2022. The recertification comprehensive assessment completed by the Registered Nurse (RN) on 4/12/2023 documented that the patient was using oxygen at 6 liters per minute per nasal cannula. The skilled nursing visit note dated 4/26/2023 documented that the patient remained oxygen dependent. The drug profile dated 4/26/2023 did not include documentation of oxygen use. Clinical Record 2: Clinical Record 2: The Skilled Nurse (SN) visit note dated 10/26/2022 documented the patient was using oxygen intermittently. In addition, the SN documented that the patient's caregiver reported the patient mainly used oxygen for comfort at night. The drug profile did not include documentation of oxygen use. Clinical Record 16: The patient elected hospice care on 2/9/2023. The initial comprehensive assessment dated 2/9/2023 documented the patient had an oxygen (O2) saturation of 96 on room air with no shortness of breath. The Skilled Nurse (SN) coordination note dated 4/28/2023 read in part, "Uses walker at all times and needs O2 after walking even short distance like across the hall to the bathroom." The plan of care dated 2/9/2023 included oxygen supplies. The drug profile did not include documentation of oxygen use. Clinical Record 18: The patient elected hospice care on 2/14/2023. The initial comprehensive assessment completed by the Registered Nurse (RN) on 2/14/2023 documented the nurse was ordering an oxygen concentrator for the home. The plan of care update dated 2/15/2023 read in part, "Instruct and monitor use of oxygen." The drug profile did not include documentation of oxygen use. Clinical Record 19: The patient elected hospice care on 1/13/2023. The initial comprehensive assessment completed by the Registered Nurse (RN) on 1/13/2023 documented the patient used oxygen intermittently. Oxygen supplies were included on the plan of care dated 1/13/2023. The drug profile did not include documentation of oxygen use. During an interview on 5/4/2023, the Alternate Administrator stated, "No, they do not have orders, and it's not on the med list." 5 of 23 (22%) of clinical records reviewed revealed that he agency did not ensure that the comprehensive drug profile included oxygen.

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. 6 of 23 (26%) clinical records reviewed, the agency did not ensure that an initial bereavement assessment was completed. Clinical Record 3: The patient elected hospice care on 11/10/2022. A coordination note completed by the Licensed Vocational Nurse (LVN) on 11/15/2022 read in part, "No bereavement needs." There was no evidence of a bereavement assessment completed until 1/3/2023, following the patient's death on 12/25/2022. Clinical Record 5: The patient elected hospice care on 10/25/2022. The coordination note dated 11/3/2022 documented that the Chaplain had the flu and could not see the patient. There was no follow-up communication with the patient or evidence of an initial bereavement assessment. Clinical Record 11: The patient elected hospice care on 4/10/2023. A clinical record review revealed no evidence that an initial bereavement assessment was completed as of 5/4/2023. Clinical Record 16: The patient elected hospice care on 2/9/2023. The visit note completed by Chaplain on 2/23/2023 read "No Bereavement Needs." A clinical record review revealed no evidence that an initial bereavement assessment was completed. Clinical Record 18: The patient elected hospice care on 2/14/2023. A clinical record review revealed no evidence that an initial bereavement assessment was completed as of 5/4/2023. Clinical Record 20: The patient elected hospice care on 2/21/2023. A clinical record review revealed no evidence that an initial bereavement assessment was completed as of 5/4/2023. During an interview on 5/4/2023, the Director of Clinical Services confirmed the finding and stated, "We have a PIP for that." 7 of 23 (30%) of clinical records reviewed reveal that the agency did not ensure that an initial bereavement assessment was completed.

It is required that the hospice designates an Interdisciplinary Group or groups who, in consultation with the patient's attending physician, prepare a written plan of care (POC) for each patient. The plan of care specifies the hospice care and services necessary to meet the specific needs of the patient and family identified in the comprehensive assessment relative to the terminal illness and associated conditions. THIS IS A CMS CONDITION-LEVEL DEFICIENCY This Condition was not met as evidenced by clinical record review, document review, and interview, which revealed the following issues with the development and implementation of patients’ interdisciplinary care plans: Failure of the written plan of care to include documentation of the necessary drugs and treatments to meet patient needs [HCPC.21.I/L549]; failure of the written plan to include documentation of the medical supplies and appliances necessary to meet the needs of the patient [HCPC.21.I/L550]: and failure of the written plan of care to include planned interventions based on problems identified in the comprehensive assessments [HCPC.21.I/L545]. The cumulative effects of the Hospice Agency's failure to maintain an integrated system of communication to ensure coordination and supervision of the Plan of Care and services delivered have the potential to place patients at risk for unmet care needs, services, and information.

It is required that each patient’s individualized written plan of care identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. Includes all services necessary for the palliation and management of the terminal illness, including the following intervention to manage pain and symptoms. This standard was not met as evidenced by clinical record review and interview. 3 of 23 (13%) clinical records reviewed, the hospice did not ensure the plan of care identified planned interventions based on problems identified in the initial and updated comprehensive assessments. Clinical Record 1: The patient elected hospice care on 8/29/2022. The updated comprehensive assessment completed by the Registered Nurse (RN) on 4/7/2023 documented the patient had a gastrostomy tube (G-Tube) and a Foley catheter. Additionally, the assessment read in part, "Coccyx wound …. Right lower buttock wound …left lateral calf wound is necrotic... eschar gone to right ankle and heel... present to left ankle and heel." The SN visit note dated 4/26/2023 documented that the patient "continued with wounds, oxygen, and G-Tube." The plan of care dated 4/26/2023 did not include documentation of interventions and goals to address the wound, G-Tube, and oxygen. Clinical Record 8: The patient elected hospice care on 4/8/2023 with the diagnosis of malignant neoplasm of the esophagus. The initial comprehensive assessment completed by the RN on 4/8/2023 documented the patient had a gastrostomy tube (G-Tube) in place. The plan of care did not include documentation of interventions and goals to address the G-Tube. Clinical Record 19: The patient elected hospice care on 1/13/2023. The initial comprehensive assessment completed by the RN on 1/13/2023 documented the patient used oxygen intermittently and had a stage one (1) pressure ulcer on the coccyx. Additionally, the RN documented the wound was "covered with Mepilex for protection." The plan of care dated 1/13/2023 did not include documentation of interventions and goals to address the patient's wound and respiratory status. During an interview and a joint review of the plans of care, the Director of Clinical Services confirmed that the plans of care did not include appropriate interventions or orders. 4 of 23 (17%) of clinical records reviewewd revealed that the agency did not ensure that each individualized plan of care included the interventions necessary to manage the conditions, pain and symptoms of each patient.

It is required that the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, 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. 5 of 23 (22%) clinical records reviewed, the hospice did not ensure that the drugs and treatment necessary to meet the patient's needs were included in the individualized plan of care. Clinical Record 1: The patient elected hospice care on 8/29/2022. The recertification comprehensive assessment completed by the Registered Nurse (RN) on 4/12/2023 documented that the patient was using oxygen at 6 liters per minute per nasal cannula. The skilled nursing visit note dated 4/26/2023 documented that the patient remained oxygen dependent. The plan of care dated 4/26/2023 did not include documentation of oxygen with the medications. Clinical Record 2: The Skilled Nurse (SN) visit note dated 10/26/2022 documented the patient was using oxygen intermittently. In addition, the SN documented that the patient's caregiver reported the patient was mainly using oxygen for comfort at night. The plan of care dated 10/25/2022 did not include documentation of oxygen with the medications. Clinical Record 16: The patient elected hospice care on 2/9/2023. The initial comprehensive assessment dated 2/9/2023 documented the patient had an oxygen (O2) saturation of 96 on room air with no shortness of breath. The Skilled Nurse (SN) coordination note dated 4/28/2023 read in part, "Uses walker at all times and needs O2 after walking even short distance like across the hall to the bathroom." The plan of care dated 2/9/2023 included oxygen supplies but did not include documentation of oxygen with the medications. Clinical Record 18: The patient elected hospice care on 2/14/2023. The initial comprehensive assessment completed by the Registered Nurse (RN) on 2/14/2023 documented that the nurse ordered an oxygen concentrator for the home. The plan of care update dated 2/15/2023 read in part, "Instruct and monitor use of oxygen." The POC did not include documentation of oxygen with the medications. Clinical Record 19: The patient elected hospice care on 1/13/2023. The initial comprehensive assessment completed by the Registered Nurse (RN) on 1/13/2023 documented the patient used oxygen intermittently. Oxygen supplies were included on the plan of care dated 1/13/2023, but the POC did not include documentation of oxygen with the medications. During an interview on 5/4/2023, the Alternate Administrator stated, "No, they do not have orders, and it's not on the med list." 5 of 23 (22%) clinical records reviewed revealed that the agency did not ensure that the drugs and treatment necessary to meet the patient needs were included on the patient individualized plan of care.

It is required that each patient’s individualized written plan of care include medical supplies and appliances necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. 2 of 23 (8%) clinical records reviewed, the hospice did not ensure that medical supplies and appliances necessary to meet the needs of the patient were included on the plan of care (POC). Clinical Record 1: The patient elected hospice care on 08/29/22. The initial comprehensive assessment completed by the Registered Nurse 08/29/22 revealed that the patient had a Foley catheter, a peg tube, and two pressure ulcers. The plan of care dated 8/29/2022 did not include medical supplies and appliances. The POC listed "None" for the section labeled "DME/Supplies." Clinical Record 23: The patient elected hospice care on 04/06/23. The skilled nursing (SN) visit note dated 4/20/2023 stated in part, "Foley catheter inserted, drained 750 cc's of urine due to retention." The SN visit note dated 4/20/2023 stated in part, "Patient has redness to all bony prominences, left hip with mild breakdown, covered with Mepilex dressing. The plan of care did not include Foley supplies and dressing supplies. During an interview and a joint review of the plans of care, the Director of Clinical Services (DCS) confirmed that the plan of care did not include medical supplies and equipment.. 2 of 23 (8%) of clinical records reviewed revealed that the agency did not ensure that medical supplies and appliances necessary to meet the needs of the patient were included on the plan of care.

It is required that counseling services include spiritual counseling. The hospice provides an assessment of the patient’s and family’s spiritual needs. Spiritual counseling to meet spiritual needs is provided in accordance with the patient’s and family’s acceptance of the services and in a manner consistent with the patient and family beliefs and desires. The hospice advises the patient and family of spiritual counseling services and documents the acceptance or refusal of services. The hospice also makes all reasonable efforts to facilitate visits by local clergy, pastoral counselors, or others who can support the patient’s spiritual needs. This standard was not met as evidenced by clinical record review and interview. 1 of 23 (4%) clinical records reviewed, the hospice did not ensure spiritual counseling was provided in accordance with the patient’s and family’s acceptance of the services. Clinical Record 22: The patient elected hospice care on 3/1/2022 with the diagnoses of heart failure and chronic obstructive pulmonary disease. The plan of care dated 3/1/2023 included orders for the chaplain "1 x month x 1 month." As of 5/5/2023, there was no evidence of a chaplain visit and no evidence of the patient refusing the chaplain's visit. During an interview on 5/5/2023, the Alternate Administrator/DCS stated no Chaplain visit was documented. 1 of 23 (4%) of clinical records reviewed revealed that the agency did not ensure that the patient and family had counseling services available to minimize stress.

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. 5 of 17(29%) clinical records reviewed of patients receiving hospice aide services, the hospice did not ensure that the hospice aide care plan provided specific instructions to the aide. Clinical Record 1: The patient elected hospice care on 08/29/22. The hospice aide care plan dated 8/29/2022 assigned the hospice aide the tasks, "Bathing (Bed) every visit... Bathing Partial Sponge Bath every visit... Bathing (shower) every visit." The care plan did not provide clear instructions to the hospice aide regarding the type of bath, forcing the aide to make decisions outside of the aide's scope of practice. Clinical Record 6: The patient elected hospice care on 03/30/23. On 04/10/23, the physician ordered, "Cleanse stage 1 pressure ulcer area with wound cleanser, pat dry, apply betadine, and make sure patient does not lie on his back." Additionally, the wound care orders were updated on 04/20/23 and 04/27/23. The hospice aide care plan dated 03/30/23 was not updated to provide the aide with instructions related to handling the wound dressings during personal care and the physician's order to keep the patient off the back. Clinical Record 8: The patient elected hospice care on 04/08/23. The initial comprehensive assessment completed by the RN on 04/08/23 documented that the patient had a gastrostomy tube (G-Tube). The hospice aide care plan completed by the RN on 04/08/23 and updated on 05/02/23 did not include information or instruction to the hospice aide related to the patient's G-Tube. Additionally, a clinical record review revealed that a Foley catheter was inserted on 04/27/23. The hospice aide care plan, updated on 05/02/23, did not include information or instruction to the hospice aide related to the patient's Foley catheter. Clinical Record 22: The patient elected hospice care on 03/01/23. The initial comprehensive assessment completed by the RN on 03/01/23 documented that the patient had a suprapubic catheter. The hospice aide care plan completed by the RN on 03/29/23 did not include information or instruction to the hospice aide related to the patient's suprapubic catheter. Clinical Record 23: The patient elected hospice care on 04/06/23. The initial comprehensive assessment completed by the Registered Nurse (RN) on 04/06/23 documented the patient used oxygen. The hospice aide care plan completed by the RN on 05/06/23 did not include instructions to the aide related to the patient's use of oxygen. During an interview on 05/04/22, the Area Director of Clinical Services and the Director of Clinical Services (DCS) confirmed the finding; the DCS stated they would be educating staff. 5 of 17(29%) clinical records reviewed with HHAs revealed the agency did not ensure that the home health aide care plan was written in a manner that provided clear direction to the aide.

It is required that a hospice aide provides services ordered by the Interdisciplinary Group, and included in the plan of care. This standard was not met as evidenced by clinical record review and interview. 1 of 17 (6%) clinical records reviewed of patients receiving hospice aide services, the hospice did not ensure the hospice aide provided services ordered by the Interdisciplinary Group and included in the plan of care. Clinical Record 23: The patient elected hospice care on 04/06/23. The hospice aide visit note dated 4/11/2023 read in part, "He has a small red area on his stomach, and between his legs, I put some barrier cream on it." The hospice aide care plan did not include the application of barrier cream. During an interview, the Alternate Administrator/DCS confirmed that applying barrier cream to the reddened area was not on the aide care plan. 1 of 17 (6%) of records reviewed with a HHA revealed that the agency did not ensure the aides only provided care that was included on the plan of care.

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. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum physician orders. This standard was not met as evidenced by clinical record review and interview. 2 of 23 (9%) clinical records reviewed, the hospice did not ensure that the clinical record included documentation of physician's orders for all services and treatments. Clinical Record 8: The patient elected hospice care on 4/8/2023. The Skilled Nurse (SN) visit note dated 4/27/2023 documented that a Foley catheter was inserted. A clinical record review revealed no documented evidence of a physician's order to insert the Foley catheter. Clinical Record 23: The patient elected hospice care on 04/06/23. The SN visit note dated 4/20/2023 stated in part, "Foley catheter inserted, drained 750 cc's of urine due to retention...Patient has redness to all bony prominences, left hip with mild breakdown, covered with Mepilex dressing." A clinical record review revealed no documented evidence of a physician's order to insert the Foley catheter and wound care. During an interview on 5/4/2023, the Alternate Administrator stated that there were no orders. 3 of 23 (13%) of clinical records reviewed revealed that the agency did not ensure that the clinical record included physician orders for all services and treatments.

It is required that the clinical patient record, its content, and the information it contains is safeguarded against loss or unauthorized use. The hospice complies with state and federal law and regulation addressing privacy, including the Health Insurance and Portability and Accountability Act (HIPAA) and the Health Information Technology for Economic and Clinical Health Act (HITECH). This standard was not met as evidenced by document review, interview, and observation. The agency policy #IT- 008 "Acceptable Use Policy" stated in part, "Unless a HIPAA compliant and secure IM program such as Tiger text... Employees may not use IM to transmit company classified and EPHI information." 1 of 6 (17%) home visit observations, the agency did not ensure that all staff complied with policies and state and federal regulations related to patient privacy. Home Visit 3: During the home visit on 5/2/2023, the Medical Social Worker (MSW) stated, "I usually do not call patients in a facility... I text their family a report when I am done." The MSW further stated, "Oh, I only use the company cell phone to text, so I thought that was ok." During an interview on 5/3/2023, the Area Quality Director confirmed that the company policy only supports texting with a secure platform. The agency did not ensure that all staff complied with policies and state and federal regulations related to patient privacy.

It is required that the designated IDG member provides the SNF/NF or ICF/IDF with the following information for each patient/resident: the most recent hospice plan of care; hospice election form and any advance directives; physician certification and recertification of the terminal illness; names and contact information for hospice staff involved in the patient’s care; instructions on how to access the hospice’s 24-hour on-call system; hospice medication information; [and] hospice physician and attending physician (if any) orders. This standard was not met as evidenced by clinical record review and interview. 2 of 2 (100%) home visit observations of patients residing in a facility, the hospice did not ensure that the SNF was provided with the physician certification of the terminal illness (CTI). Home Visit 3: During the home visit on 5/2/2023, a review of the patient's facility record revealed no evidence of the patient's CTI. The facility's nurse stated the facility staff did not remove documents from the patient's hospice chart. At the visit, the Registered Nurse (RN) confirmed that the patient's CTI was not in the facility's record. Home Visit 6: During the home visit on 5/3/2023, a review of the patient's facility record revealed no evidence of the patient's CTI. At the visit, the Chaplain confirmed that the patient's CTI was not in the facility's record. During an interview, the Alternate Administrator/Director of Clinical Services stated, "We will have the nurse take them out to the facilities." 2 of 2 (100%) of home visits to patients residing in a facility revealed that the agency failed to ensure that the SNF was provided with the Physician certification of terminal illness(CTI).

It is required that the hospice obtains a criminal background check on all hospice employees who have direct patient contact or access to patient records. Hospice contracts require that all contracted employees who have direct patient contact or access to patient records obtain criminal background checks. This standard was not met as evidenced by document review. 1 of 6 (17%) hospice contracts reviewed, the hospice did not ensure the contract included a statement requiring the contracted entity to obtain a criminal background check on employees with direct patient contact or access to patient records. Contract 6: The contract dated 10/29/2019 between the agency and a staffing company for Registered Nurses, Licensed Vocational Nurses, and Certified Nurses Assistants did not include a statement or clause within the contract requiring the contractor to obtain a criminal background check on any employees with direct patient contact. On 5/4/2023, the Alternate Administrator demonstrated an updated contract signed May 4, 2023, to include language requiring all staff with patient contact to undergo a background check. 1 of 6 (16%) contracts reviewed revealed that the agency did not ensue that all contracts required background checks for all employees who would shave direct access to patients.