Every finding on record at Cole Legacy, Inc

It is required that each patient’s individualized written plan of care reflects patient and family goals; identifies planned interventions based on problems identified in the initial and updated comprehensive assessments, and includes all services necessary for the palliation and management of the terminal illness, including the following: a) Intervention to manage pain and symptoms; This standard was not met as evidenced by clinical record review and interview. 1 of 14 (7%) clinical records reviewed revealed that the agency did not ensure that the plan of care was individualized, reflecting problems identified in the assessments, with measurable outcomes. Clinical Record 1: A comprehensive assessment was completed on 4/23/23. The documentation revealed that the patient had a suprapubic catheter that was changed monthly. The SN assessment documented that the patient's suprapubic catheter needed to be changed monthly. The plan of care did not include interventions related to suprapubic catheter and monthly suprapubic changes. The plan of care was missing goals, interventions, and orders for the suprapubic catheter. Director of Nursing confirmed on 8/15/2023 that the plan of care did not include an order for the suprapubic catheter. 1 of 14 (7%) of clinical records did not address problems identified in the initial assessment on the written plan of care.

It is required that each patient’s individualized written plan of care includes drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. 2 of 14 (14%) of 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 3: The patient elected hospice care on 7/12/23.The initial comprehensive assessment completed by the RN on 7/12/2023 documented that the patient was dependent on oxygen at 4L per NC. The plan of care identified hypoxia and SOB as a problem with an intervention "Administer supplemental oxygen as ordered." Oxygen concentrator and Oxygen portable tank included on the plan of care under DME. The plan of care does include oxygen on the medication list, but did not include orders or interventions to provide direction related to the flow of oxygen. Clinical Record 5: The patient elected hospice care on SOC 7/19/23. The initial assessment completed by the RN on 7/19/2023 documented that the patient required oxygen. The admitting diagnosis was COPD. The interventions included "Administer supplemental oxygen as ordered". The plan of care did not include orders for dose and route of oxygen. Oxygen was not included on the plan of care medication list. Oxygen was ordered on day of admission, but did not get included on Plan of care. The SN nursing visit notes documented the use of oxygen through the date of this review as of 8/17/2023. During an interview on 8/16/2023, the Director of Nursing confirmed that the plan of care did not include the oxygen on records # 3 and 5. 2 of 14 (14%) of clinical records reviewed revealed that the agency did not ensure that the plan of care included all drugs and treatment necessary to meet the needs of the patient.

It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including 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. 3 of 14 (21%) of clinical records reviewed revealed the agency did not ensure Durable Medical Equipment (DME) and/or medical supplies were documented on the patient's individualized plans of care. Clinical Record 1: The patient election of the hospice benefit dated 4/23/2023 had a SN Assessment dated 4/23/2023 revealed that the patient has a suprapubic catheter that is changed monthly. Plan of care dated 4/23/2023- 7/21/23 did not include catheter supplies on the plan of care. Clinical Record 2: The SOC assessment on 7/19/2023 revealed that patient was admitted for COPD and required continuous oxygen and that oxygen sats fell to 88% after one minute without oxygen. Oxygen and oxygen supplies were not included on the plan of care under DME or supplies. DME and supplies were left blank on the plan of care dated 7/19/23 - 10/16/23. Clinical Record 6: The patient election of the hospice benefits dated 7/25/23 with a diagnosis of Hypoxia had a SN assessment documenting that the patient required oxygen per NC. Oxygen 2-5 LPM per NC ordered on the plan of care. There was no documented evidence that the DME or supplies were listed on the plan of care. Director of Nursing confirmed on 8/15/2023 that clinical records 1, 2, and 6 did not include the medical supplies necessary on the individualized plan of care. 3 of 14 (21%) of clinical records reviewed revealed that the agency did not ensure that the medical supplies and appliances necessary to meet the needs of the patient were included on the patient's individualized plan of care.

It is required that consistent with current professional standards of practice, licensed professionals actively participate in the coordination of all aspects of patient care including conducting ongoing interdisciplinary comprehensive assessments, developing and evaluating the plan of care, contributing to patient and family counseling and education. Hospice “core” services are substantially provided directly by hospice employees in a manner consistent with acceptable standards of practice. “Core” services include nursing services, medical social work, and counseling. THIS IS A CMS CONDITION LEVEL FINDING This CONDITION was not met as evidenced by document review, interview, and personnel record review. 2 of 4 (50%) applicable core personnel files reviewed revealed the hospice failed to ensure that all core services, including medical social work and spiritual counseling, were provided by direct employees of the hospice. Personnel record #2: The social worker(SW) was hired on 2/5/2020. A review of the personnel file on 8/15/2023 did not contain a 1099, a tax withholding form, or a contract for the social worker to identify the type of employee at the time of this review. The CEO reported within the first hour while filling out CMS 417 that SW was a contracted employee and paid as a contracted employee instead of as a regular employee. Upon clarification the CEO stated, 'Well, the social worker told me that I could not afford her unless she was a contracted worker, so, the SW has always been contract”. “The CEO confirmed that the decision was made “to make the social worker a contracted employee because I thought it would be easier, it's completely on me, I didn't realize it was against the regulation." On 8/16/2022, the CEO presented a tax withholding form dated and signed by the social worker on 8/16/2023. Personnel record # 3: The chaplain was hired on 11/25/2020. A review of the personnel file included a tax withholding form that was established upon hire. Within the first hour, the CEO while completing CMS 417 stated that the chaplain was a contracted employee and paid as a contracted employee instead of regular employee. The CEO explained that initially the chaplain was a regular employee but had switched to a contract employee in 2022 because it was “easier”. However, she did not provide a 1099 form or an updated tax withholding form as of 8/17/2023. During a home visit on 8/16/2023, the social worker stated, "I work here and several hospice agencies under contract." The cumulative effect of the deficiencies demonstrates the agency's failure to ensure systems are in place for core services/IDG to provide services to meet the patient/family needs and places a potential place patients/families at risk for unmet needs, unmet goals, and poor outcomes. The hospice did not ensure that all core services including medical social work and spiritual counseling were provided by direct employees of the hospice.

It is required that a hospice ensures that “non-core” services are available and provided directly by the hospice or under arrangement. The following “non-core” services are provided in a manner consistent with current standards of practice ; Speech-language pathology services. THIS IS A CMS CONDITION LEVEL DEFICIENCY This CONDITION was not met as evidenced by document review and interview. The agency failed to ensure that the noncore service of speech therapy was available by the hospice or under arrangement in a manner consistent with current standards. Contract 2: Contract with therapy company labeled "Business Associate Agreement" included an agreement for PT and OT services. The contract noted services covered and charges for services broken down by Physical Therapy and Occupational Therapy but does not include Speech Therapy in any way. CEO stated in interview on 8/16/2023, "I thought it was all inclusive." CEO confirmed on 8/17/23 that the agency did not have a contract that included Speech Therapy and stated she would get one in place today. The cumulative effect of this deficiency could negatively impact the organizations ability to provide services to meet the patients needs and effective quality patient care services. The agency did not ensure that the noncore service of speech therapy was available by the hospice or under arrangement in a manner consistent with current standards.

It is required that hospice nursing services, physician services, drugs and biologicals are made routinely available on a 24-hour basis, seven (7) days per week. All covered services are available on a 24-hour basis when reasonable and necessary to meet the needs of the patient and family. This standard was not met as evidenced by document review and interview. The agency did not ensure that all covered services are available on a 24 hour basis when reasonable and necessary to meet the needs of the patient and family. Contract 1: The review of the medical director contract labeled Business Associate Agreement. did not include language that physician services are available 7 days a week 24 hours a day. CEO stated in interview on 8/16/2023, "He is on call 24 hours a day 7 days a week. The staff call him or use Tiger text. I can write up a new contract right now to include what we need." The agency did not ensure that all covered services are available on a 24 hour basis when reasonable and necessary to meet the needs of the patient and family.

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. 1 of 14 (7%) records reviewed revealed the agency did not ensure the clinical record contained physician orders for all medications and treatments provided to the patient. Clinical Record 1: The patient with an election of benefit dated 4/23/2023 had an initial assessment completed; the RN documented the patient had a suprapubic catheter requiring a monthly change. The SN visit note on 5/19/2023 documented that a suprapubic catheter change was completed on the same date. The plan of care did not contain orders for suprapubic catheter changes. The clinical record lacked evidence documenting suprapubic catheter orders as of 5/17/2023. No additional documentation was presented prior to the conclusion of the site visit. During a joint record review on 8/15/2023, the Director of Nursing confirmed that physician orders for a suprapubic catheter were not included in the patient record. 1 of 14 (7%) records reviewed revealed that the agency did not ensure that the clinical record contained physician orders for all services needed.

It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid certified facility, the hospice forwards to the receiving facility a copy of the hospice discharge summary described in HCDT 40.I. This standard was not met as evidenced by clinical record review and interview. 1 of 2 (50%) clinical files reviewed with live discharges revealed the agency did not ensure that a discharge summary was provided to receiving Medicare/Medicaid certified facility. Clinical Record 13: Patient admitted to the hospital on 8/2/2023 for the treatment of pneumonia per family request. There was no documented evidence that the clinical record contained a discharge summary or documentation that discharge summary was sent hospital. During an interview with the CEO and Director of Nursing, the CEO reported, "No we did not send one. Director of Nursing asked, "Do we have to send one or wait until they ask for it?." CEO and Director of Nursing confirmed that sending a discharge summary has not been routine and only happened when an alternate hospice asked for a discharge summary. 1 of 2 (50%) clinical files reviewed with live discharges revealed that the agency did not ensure that a discharge summary was provided to receiving Medicare/Medicaid certitifed facility.

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 and interview. 2 of 2 (100%) of written contracts for supplemented staffing reviewed revealed that the hospice did not ensure that contract language included that all employees who have direct patient contact or access to patient records obtain criminal background checks. Contract 2: A review of the hospice's therapy contract titled “Business Associate Agreement” revealed that there was no clause between the contracted entity and the hospice documenting that physical therapist and occupational therapist were required to obtain criminal background checks on therapy employees who have direct hospice patient contact or access to hospice patient records. Contract 1: A review of the hospice's Medical Director was titled "Business Associate Agreement." executed on 8/212/2022 revealed that there was no clause between the Medical Director and the Hospice documenting that Medical Director was required to obtain a criminal background check for any Medical Director who has direct hospice patient contact or access to hospice patient records. The Medical Director contract was signed on 8/12/2022 by the current medical director Contracts for Medical Director and Therapy services revealed that the agency did not ensure that the contracts contained required language for the contracted staff to obtain criminal Background checks.