Every finding on record at Comfort Plus Hospice Inc

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 IS A CONTINUING REQUIRED ACTION. This standard was not met as evidenced by clinical record review and interview. In 1 of 6 (17%) clinical records reviewed, that included medication changes, the agency did not ensure that the medication profile was updated so that all medications were reviewed for actual or potential interactions. Clinical Record 2: The nursing visit notes dated 8/8/23, 8/18/23, and 8/22/23 documented Miralax to be used daily. The medication profile did not include Miralax, and therefore was not reviewed for potential interactions with the following medication additions: nystatin suspension on 8/16/23; and acidophilus on 8/30/23. During an interview, the Case Manager and Administrator confirmed the finding, and stated that Miralax did not transition to the medication profile during implementation of the electronic medical record.

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. In 1 of 6 (17%) clinical records reviewed, the agency did not ensure that the plan of care included drugs and treatment necessary to meet the needs of the patient. Clinical Record 2: The nursing visit notes dated 8/8/23, 8/18/23, and 8/22/23 documented Miralax to be used daily. The following wound care was documented as provided on 8/3/23: cleaned with soap and water; then TAO (triple antibiotic ointments); and apply foam dressing. The plan of care (POC) dated 7/22/23 - 10/19/23, and updated 8/15/23 and 8/29/23, did not include the following: Miralax or wound care. During an interview on 9/7/23, the Administrator confirmed the finding.

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 IS A CONTINUING REQUIRED ACTION. This standard was not met as evidenced by clinical record review and interview. In 2 of 6 (33%) clinical records reviewed, the agency did not ensure written patient care instructions for the hospice aide were prepared by a Registered Nurse (RN) who is responsible for the supervision of the hospice aide. Clinical Record 2: The Aide Plan of Care (POC) documented 8/1/23, did not include safety for bleeding precautions and fall precautions, as identified in the initial comprehensive assessment. Additionally, the POC did not include safety for thickened liquids, as identified by the interdisciplinary group, specific to the task of "Encourage Fluid." During an interview, the Administrator confirmed the finding, and stated that the wife mixed all drinks prior to staff arrival. . Clinical Record 6: The Aide Plan of Care (POC) documented the following tasks: shower, and walk with assistance. Beginning 8/15/23, a left heel wound required a dressing that was a foam covering, followed by a wrap of soft gauze, and secured with Coban. However, the POC did not provide instructions for the dressing, if it became wet or fell off. Additionally, the nursing notes dated 8/15/23 continuing 3 times a week, documented the patient was using a wheelchair for safety, and was wheelchair bound. The Interdisciplinary Group (IDG) notes dated 8/15/23, documented the patient was using a wheelchair for unsteadiness. The Aide POC did not include a wheelchair for ambulation. During an interview on 9/6/23, the Administrator confirmed the finding, and stated the aide used a handheld shower to prevent the dressing from getting wet, and the facility required the patient to use a wheelchair.

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. In 1 of 6 (17%) clinical records reviewed, the agency did not ensure that the patient clinical record included physician orders. Clinical Record 2: The following wound care was documented as provided on 8/3/23: cleaned with soap and water; then TAO (triple antibiotic ointments); and apply foam dressing. The physician order documented 8/3/23 stated, clean the hip wound with soap and water and apply dressing. There was no evidence of a physician order for the triple antibiotic ointment. During an interview on 9/7/23, the Administrator and Case Manager confirmed the finding and stated, the patient's wife requested the application of TAO (triple antibiotic ointment).

It is required that the hospice develops and maintains an emergency preparedness (EP) plan that is reviewed and updated at least every two (2) years. This standard was not met as evidenced by document review and interview. A document review on 7/26/2023 in the presence of the Administrator revealed the agency did not review and update the emergency plan and policies every two years. Agency policy 2.1. I titled Emergency Operations Plan and Policy (revised 2009 MED-PASS). The Emergency Plan contained a hazard vulnerability risk assessment updated 11/2022. However, the Emergency Preparedness policy was last revised in 2009. A joint document review and interview was conducted with the Administrator on 7/26/2023; it was confirmed all hospice policies were last updated in 2009. A document review on 7/26/2023 in the presence of the Administrator revealed the agency did not review and update the emergency plan and policies every two years.

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. In 2 of 14 (14%) clinical records reviewed, the hospice agency did not ensure the Interdisciplinary Group (IDG) completed the initial comprehensive assessment within five (5) calendar days after the election of the hospice benefit. Clinical Record 2: The patient elected hospice benefit on 1/26/2023. Clinical record review revealed the initial spiritual assessment was dated and signed by the Chaplain on 2/3/2023 and the Social Worker completed the psychosocial assessment on 2/4/2023. The assessments were not completed as part of the initial comprehensive assessment within five calendar days of the patient's election of hospice benefit. A joint record review and interview with the Director of Nursing on 7/24/2023 confirmed the hospice did not ensure the spiritual assessment and psychosocial assessment were completed within five (5) days following the date of election of the hospice benefit. Clinical Record 12: The patient elected the hospice benefit on 4/14/2023. The Social Worked completed the psychosocial assessment on 4/20/2023. The assessment was not completed as part of the initial comprehensive assessment within five calendar days of the patient's election of hospice benefit. A joint record review and interview with the Director of Nursing on 7/26/2023 confirmed the hospice did not ensure the completion of the psychosocial assessment within five (5) days following the date of election of the hospice benefit.

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 document review, interview and observation. In 1 of 3 (33%) home visit observations, the agency did not ensure the accuracy of the medication profile in the home. Agency policy# 8.20 titled Medication Reconciliation (revised 2009 MED-PASS) sub-section two (2) stated in part, "Medications ordered while the patient is receiving care will be compared to the medication list/profile. The medication list/profile will be updated with each new or changed medication." Home Visit 1: The patient elected the hospice benefit on 6/16/2023 and resided at an Assisted Living Facility (ALF). During the home visit observation medication reconciliation was completed by comparing the patient’s hospice medication profile to the patient’s ALF medication profile. The hospice agency medication profile stated in part, "Risperidone half (0.5) milligram (mg). Take one (1) tablet oral (PO) every bedtime (HS)." The ALF medication profile did not contain the medication. The ALF nurse reported the medication was discontinued approximately one week ago. A joint observation and interview with the Director of Nursing on 7/25/2023 confirmed the hospice agency medication profile did not match the medications being administered to the patient.

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, document review and interview. In 14 of 14 (100%) of clinical records reviewed, the hospice agency did not ensure the comprehensive assessment included an initial bereavement assessment of the needs of the patient’s family and other individuals. Agency policy 4.26. titled Bereavement Services Procedure (revised 2009 MED-PASS) sub-section one (1) stated in part, "Hospice will provide bereavement services to the families/caregivers of Hospice patients both before and after the patient's death. The purpose of these services is to facilitate a normal grieving process and to identify and appropriately refer those persons who may be experiencing pathological grief reactions. Bereavement services will be coordinated with the individual's spiritual counselor or the hospice Chaplain." Sub-section two (2) stated in part, "An initial bereavement Risk Assessment will be performed as a part of the Comprehensive Assessment, a plan of care will be developed to include specific counseling to patient and family members to be provided by the Social Worker, Chaplain, or Bereavement counselor. The plan of care will reflect family needs, as well as clear delineation of services to be provided." Clinical Record 1: The patient elected the hospice benefit on 4/17/2023, with a terminal diagnosis of Alzheimer's Dementia. The initial comprehensive assessment did not include an initial bereavement assessment / bereavement risk assessment of the patient’s family or other individuals caring for the patient. The initial bereavement assessment / bereavement risk assessment was completed for the patient and did not include the patient’s family or other individuals. Clinical Record 2: The patient elected the hospice benefit on 1/17/2023, with a terminal diagnosis of Alzheimer's Dementia. The initial comprehensive assessment did not include an initial bereavement assessment / bereavement risk assessment of the patient’s family or other individuals caring for the patient. The initial bereavement assessment / bereavement risk assessment was completed for the patient and did not include the patient’s family or other individuals. Clinical Record 3: The patient elected the hospice benefit on 1/18/2023. The initial comprehensive assessment did not include an initial bereavement assessment / bereavement risk assessment of the patient’s family or other individuals caring for the patient. The initial bereavement assessment / bereavement risk assessment was completed for the patient and did not include the patient’s family or other individuals. Clinical Record 4: The patient elected the hospice benefit on 6/1/2023. The initial comprehensive assessment did not include an initial bereavement assessment / bereavement risk assessment of the patient’s family or other individuals caring for the patient. The initial bereavement assessment / bereavement risk assessment was completed for the patient and did not include the patient’s family or other individuals. Clinical Record 5: The patient elected the hospice benefit on 6/16/2023. The initial comprehensive assessment did not include an initial bereavement assessment / bereavement risk assessment of the patient’s family or other individuals caring for the patient. The initial bereavement assessment / bereavement risk assessment was completed for the patient and did not include the patient’s family or other individuals. Clinical Record 6: The patient elected the hospice benefit on 2/10/2023. The initial comprehensive assessment did not include an initial bereavement assessment / bereavement risk assessment of the patient’s family or other individuals caring for the patient. The initial bereavement assessment / bereavement risk assessment was completed for the patient and did not include the patient’s family or other individuals. Clinical Record 7: The patient elected the hospice benefit on 7/11/2023. The initial comprehensive assessment did not include an initial bereavement assessment / bereavement risk assessment of the patient’s family or other individuals caring for the patient. The initial bereavement assessment / bereavement risk assessment was completed for the patient and did not include the patient’s family or other individuals. Clinical Record 8: The patient elected the hospice benefit on 4/14/2023. The initial comprehensive assessment did not include an initial bereavement assessment / bereavement risk assessment of the patient’s family or other individuals caring for the patient. The initial bereavement assessment / bereavement risk assessment was completed for the patient and did not include the patient’s family or other individuals. Clinical Record 9: The patient elected the hospice benefit on 3/28/2023. The initial comprehensive assessment did not include an initial bereavement assessment / bereavement risk assessment of the patient’s family or other individuals caring for the patient. The initial bereavement assessment / bereavement risk assessment was completed for the patient and did not include the patient’s family or other individuals. Clinical Record 10: The patient elected the hospice benefit on 4/21/2023. The initial comprehensive assessment did not include an initial bereavement assessment / bereavement risk assessment of the patient’s family or other individuals caring for the patient. The initial bereavement assessment / bereavement risk assessment was completed for the patient and did not include the patient’s family or other individuals. Clinical Record 11: The patient elected the hospice benefit on 4/14/2023. The initial comprehensive assessment did not include an initial bereavement assessment / bereavement risk assessment of the patient’s family or other individuals caring for the patient. The initial bereavement assessment / bereavement risk assessment was completed for the patient and did not include the patient’s family or other individuals. Clinical Record 12: The patient elected the hospice benefit on 7/20/2023. The initial comprehensive assessment did not include an initial bereavement assessment / bereavement risk assessment of the patient’s family or other individuals caring for the patient. The initial bereavement assessment / bereavement risk assessment was completed for the patient and did not include the patient’s family or other individuals. Clinical Record 13: The patient elected the hospice benefit on 10/7/2023. The initial comprehensive assessment did not include an initial bereavement assessment / bereavement risk assessment of the patient’s family or other individuals caring for the patient. The initial bereavement assessment / bereavement risk assessment was completed for the patient and did not include the patient’s family or other individuals. Clinical Record 14: The patient elected the hospice benefit on 10/20/2023. The initial comprehensive assessment did not include an initial bereavement assessment / bereavement risk assessment of the patient’s family or other individuals caring for the patient. The initial bereavement assessment / bereavement risk assessment was completed for the patient and did not include the patient’s family or other individuals. During a joint records review and interview on 7/24/2023, the Director of Nursing (DON) confirmed the hospice agency did not complete an initial bereavement risk assessment for the patient’s family or other individuals identified as the bereaved person. The hospice agency was completing an initial bereavement risk assessment on all hospice patients, not those identified as bereaved. During joint records review and interview on 7/24/2023, the Administrator confirmed that the hospice agency's standard practice was to perform an initial bereavement risk assessment on the hospice patient, not the bereaved person. During an interview on 7/26/2023 with the Bereavement Coordinator/Chaplain in the presence of the Administrator. The Bereavement Coordinator/Chaplain reported upon admission to hospice; the agency completed an initial bereavement risk assessment on all patients. But not the bereaved. The Bereavement Coordinator/Chaplain stated, "I didn't realize I was supposed to complete the bereavement risk assessment on the family. I thought I was supposed to complete the assessment on the patient." When questioned regarding what the hospice agency does differently for those considered high risk for bereavement, the Bereavement Coordinator/Chaplain stated, "Nothing is different." Inspection of the Bereavement Policy confirmed the policy did not specify when the initial bereavement risk assessment was to be completed or identify levels of bereavement or standards of care for each identified level per the bereavement risk assessment. A joint record review and interview with the Director of Nursing on 7/24/2023 confirmed the hospice agency did not complete an initial bereavement risk assessment for the bereaved person 100% of the time. It was identified the hospice agency did not complete an initial bereavement risk assessment on any bereaved person(s). The hospice agency was completing an initial bereavement risk assessment on all hospice patients, not those bereaved.

It is required that the hospice designates an Interdisciplinary Group (IDG) composed of individuals who work together to meet the physical, medical, psychosocial, emotional, and spiritual needs of the patient/family facing terminal illness and bereavement. IDG members provide the care and services offered by the organization. THIS IS A CMS CONDITION LEVEL CITATION. This condition of participation was not met as evidenced by review of clinical records, document review and interviews with members of the Interdisciplinary Group (IDG) which revealed the following issues with IDG supervision of the care and services provided to the patient and family: failure to ensure the IDG supervised the care and services provided to the patient and family [HCPC.1.I/L539]; failure to ensure hospice care and services provided to patients and families follow an individualized plan of care established by the Interdisciplinary Group [HCPC.19.I/L543]; failure to ensure the IDG completed the initial comprehensive assessment within five (5) calendar days after election of benefit [HCPC.9.I/L523]; and failure to ensure Hospice Aide services were provided in accordance with the documented plan of care [HCDT.16.I/L626]. The cumulative effect of these deficiencies has resulted in the hospice agency's inability to ensure the provision of quality care for the Condition of Participation CFR 418.56, Interdisciplinary Group, Care Planning and Coordination of Services. The collective deficient practice illustrated a systemic process failure that had the potential to affect all patients receiving hospice care and services from the agency.

It is required that the hospice designates an Interdisciplinary Group (IDG) composed of individuals who work together to meet the physical, medical, psychosocial, emotional, and spiritual needs of the patient/family facing terminal illness and bereavement. The IDG, in its entirety, supervises the care and services provided to the patient and family. This standard was not met as evidenced by document review, clinical record review and interview. In 4 of 14 (28%) clinical records reviewed, the hospice agency did not ensure the IDG, in its entirety, supervised the care and services provided to the patient and family. Agency policy 9.12 titled IDG Care Planning Process (revised 2009 MED-PASS) sub-section three (3) stated in part, "IDG members provide the care and services offered by the hospice. IDG supervises the care and services." Sub-section six (6) stated, "A Registered Nurse (RN) that is a member of the IDG is designated to provide coordination of care and ensure continuous assessment of the patient and family needs, and implementation of the IDG plan of care." Agency policy 9.6 titled Initial Assessment/Comprehensive Assessment (revised 2009 MED-PASS) sub-section one (1) stated in part, "The hospice RN must complete initial assessment within forty-eight (48) hours after the election of the hospice benefit." Sub-section two (2) stated in part, "Each patient admitted will receive a comprehensive assessment. The comprehensive assessment will identify the patient's needs for physical care." Clinical Record 3: The patient elected the hospice benefit on 1/18/2023. The initial spiritual assessment completed by the Chaplain on 1/19/2023 documented, "Patient is open to Chaplain visits." An updated IDG care plan dated 1/30/2023 included an order for Chaplain visits once a week for two weeks. The clinical record lacked documented evidence that Chaplain visits had been provided to the patient. The record did not contain documented evidence of missed visits by the Chaplain and the clinical record did not contain documented evidence of Chaplain visits as of 7/26/2023. A joint record review and interview with the Director of Nursing on 7/24/2023 confirmed the patient did not receive Chaplain visits as ordered per the IDG plan of care. The clinical record included documentation of volunteer visits dated 5/20/2023, 5/27/2023, 6/3/2023, 6/10/2023, 6/19/2023, 6/24/2023, and 7/1/2023. Review of the updated IDG plans of care dated 5/8/2023 through 5/21/2023, 5/22/2023 through 6/4/2023, 6/5/2023 through 6/18/2023, 6/19/2023 through 7/2/2023, and 7/3/2023 through 7/9/2023 documented Volunteer frequency was "offered/declined." A joint record review and interview with the Administrator on 7/24/2023 confirmed the patient received volunteer visits on 5/20/2023, 5/27/2023, 6/3/2023, 6/10/2023, 6/19/2023, 6/24/2023 and 7/1/2023 without Volunteer services being ordered on the IDG care plan. Clinical Record 6: The patient elected the hospice benefit on 2/10/2023, with a primary diagnosis of Malignant Neoplasm of the Pelvis. The initial spiritual assessment dated 2/13/2023, stated "No Chaplain services were requested." The updated IDG care plan dated 7/3/2023 included an order for the Chaplain to visit once a week for one week. The record did not contain documented evidence of a completed or missed Chaplain visit for the week from 7/3/2023 through 7/10/2023. A joint record review and interview with the Director of Nursing (DON) on 7/25/2023 confirmed the record contained a one-time order for a Chaplain visit dated 7/3/2023, but the patient did not receive the visit as ordered on the IDG plan of care. The DON reported she felt the order was entered in error. Clinical Record 2: The patient elected the hospice benefit on 1/26/2023. The updated comprehensive assessments completed by the RN dated 3/9/2023 and 3/16/2023 documented no changes to the IDG plan of care. Clinical record review revealed the Social Worker (SW) completed a SW visit note dated and signed on 3/14/2023. The SW noted stated in part, "Phoned patient's wife for a check in on families coping and management felt stronger. The family plan is to continue to keep the patient at home. Expressed concerns, SW will follow up periodically." The updated comprehensive assessment dated 5/8/2023 completed by the RN included documentation that there were no changes in the IDG plan of care. The updated interdisciplinary care plan for 5/8/2023 through 5/22/2023, included documentation that Social Worker services were "offered and declined." The clinical record included documentation of a Social Worker visit note dated and signed by the Social Worker on 5/9/2023. A joint record review and interview with the Director of Nursing on 7/24/2023 confirmed the Social Worker was providing psychosocial services, but the services were not ordered and documented on the comprehensive assessment or the IDG care plan. Clinical Record 7: The patient elected the hospice benefit on 7/11/2023, with a terminal diagnosis of Neoplasm of the Lung. The hospice plan of care dated 7/11/2023, included an order for hospice aide services to be provided twice a week beginning 7/11/2023. The patient did not receive any hospice aide services the week of 7/11/2023 through 7/15/2023. The first hospice aide visit was completed on 7/18/2023. The IDG did not ensure aide services were provided as ordered on the hospice plan of care. A joint record review and interview with the Director of Nursing on 7/25/2023 confirmed the hospice did not coordinate care with all interdisciplinary group members. The Director of Nursing confirmed the hospice aide was not informed about the hospice aide frequency orders and patient assignment until the interdisciplinary team (IDT) meeting on 7/17/2023. Therefore, the patient's needs were not met the week of 7/11/2023 through 7/15/2023 due to a lack of coordination by the interdisciplinary group. The record did not contain any notification of the missed aide visit to the IDT because the hospice aide did not know the services were ordered.

It is required that hospice care and services provided to patients and families follow the individualized plan of care established by the hospice IDG (Interdisciplinary Group) in collaboration with the attending physician (if any), the patient or patient representative, and the primary caregiver in accordance with the patient’s needs. This standard was not met as evidenced by clinical record review, document review and interview. In 3 of 14 (21%) clinical records reviewed, the hospice agency did not ensure services were provided in accordance with the plan of care, as ordered by the IDG to meet the patient's needs. Agency policy 9.12 titled IDG Care Planning Process (revised 2009 MED-PASS), sub-section two (2) stated in part, "The care plan specifies the care and services necessary to meet the patient and family specific needs identified in the comprehensive assessment as such needs relate to the terminal illness and conditions." Clinical Record 2: The patient elected the hospice benefit on 1/26/2023, with a terminal diagnosis of Cerebral Vascular Accident. The updated IDG care plan for 5/8/2023 through 5/22/2023, included documentation that Social Worker services were "offered and declined." The clinical record contained documentation that a Social Worker visit was provided to the patient on 5/9/2023, per the Social Worker Note dated 5/9/2023. The updated IDG care plan for 3/13/2023 through 3/27/2023, included documentation that Social Worker services were "offered and declined." A Social Worker visit note dated and signed 3/14/2023 started in part, "Phoned patient's wife for a check in on families coping and management and felt stronger. The family plan is to continue to keep the patient at home. Expressed concerns...SW will follow up periodically." A joint record review and interview with the Director of Nursing on 7/24/2023 confirmed the Social Worker performed a patient visit on 3/14/2023 and 5/9/2023 without frequency orders from the IDG. Clinical Record 3: The patient elected the hospice benefit on 1/18/2023. The care plan included an order for Skilled nurse frequency of visits two (2) times weekly. For the week of 2/12/2023, the patient received skilled nurse visits on 2/13/2023, 2/15/2023, and 2/16/2023. A joint record review and interview with the Director of Nursing on 7/24/2023 confirmed the Registered Nurse performed an extra patient visit the week of 2/12/2023 through 2/18/2023 and did not follow the frequency order from the IDG. Clinical Record 7: The patient elected hospice benefit on 7/11/2023. The Initial Comprehensive Interdisciplinary Care plan dated 7/11/2023, ordered hospice aide services two (2) times a week beginning 7/11/2023. The Hospice aide assignment POC was dated 7/11/2023. The patient did not receive any hospice aide services the week of 7/11/2023 through 7/15/2023. The first hospice aide visit was completed on 7/18/2023. A joint record review and interview with the Director of Nursing on 7/25/2023 confirmed the hospice did not provide aide services according to the plan of care.

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, use of gloves, mask, eye protection, or face shield depending on anticipated exposure, safe handling of equipment in the patient’s care environment if it is likely to have been contaminated with body fluids, safe handling of soiled items in the patient’s care environment, and other requirements of applicable state and federal law and regulation This standard was not met as evidenced by document review, interview and observation. In 1 of 3 (33%) home visit observations, the agency did not ensure staff followed standards of practice and agency policy related to hand hygiene. Agency policy 5.7 titled Hand Hygiene Policy and Compliance Program (revised January 2010 MED-PASS), sub-section one (1) stated in part, "Indications for hand hygiene are before and after direct patient care and after contact with contaminated materials." Sub-section five (5) stated in part, "Hospice provides bacteriostatic foam/gel/liquid to all patient care staff." Home Visit 1: The patient elected the hospice benefit on 6/16/2023. The home visit observation was conducted on 7/25/2023 with the hospice aide at an Assisted living facility (ALF) in the presence of the Director of Nursing (DON). The Hospice aide entered the ALF and did not perform hand hygiene with either soap and water or an alcohol-based solution. The hospice aide proceeded to the patient's room and did not perform hand hygiene with either soap and water or an alcohol-based solution. The hospice aide then began moving supplies into the patient's room. The hospice aide removed a dirty chucks pad from the patient's bedside table without gloves and placed the chucks pad into the trash bin, and stated, "This pad isn't dirty yet." The aide then hung the nursing bag from a chair while removing liquid soap from the nursing bag. The hospice aide stated, "They never have soap here, so I bring my own." The solution in the bottle labeled soap was visibly the consistency of water. The hospice aide then performed hand hygiene with the soapy liquid removed from the nursing bag. The site visitor questioned the hospice aide about the consistency of the soapy liquid, and the hospice aide stated, "I do not know why it's watery; maybe it's old." It was noted when the liquid soap bottle was picked up and placed upside down the watery contents came out of the spout and poured into the sink. The hospice aide did not follow agency policy hands were not washed before and after direct contact with the patient and used an unidentified soap to wash hands. A joint observation and interview with the Director of Nursing confirmed the hospice aide did not perform hand hygiene before providing patient care. In addition, the Director of Nursing confirmed the liquid substance in the hand soap container appeared to be watered down and inconsistent with liquid hand soap. The Director of Nursing stated, "I don't know why she used that soap because I gave her hand sanitizer to use on her visits first thing this morning when she came into work."

It is required that counseling services include an organized program for providing bereavement services delivered by or under the supervision of a qualified professional with experience or education in grief or loss counseling. Bereavement services are available to the family and other individuals up to one (1) year following the death of the patient. Bereavement counseling extends to residents of a SNF/NF (skilled nursing facility/nursing facility) or ICF/IDF (intermediate care facility/intellectual disability facility) when appropriate and identified in the bereavement plan of care. The bereavement services reflect the needs of the bereaved per a bereavement plan of care that includes the types of bereavement services to be offered and the frequency of service delivery. This standard was not met as evidenced by clinical record review, document review and interview. In 2 of 3 (67%) bereavement clinical records reviewed, the hospice agency did not ensure bereavement services reflected the needs of the bereaved per the bereavement plan of care. Agency policy 4.26 titled Bereavement Services Procedure (revised 2009 MED-PASS), sub-section one (1) stated in part, "Hospice will provide bereavement services to the families/caregivers of Hospice patients both before and after the patient's death. The purpose of these services is to facilitate a normal grieving process and to identify and appropriately refer those persons who may be experiencing pathological grief reactions. Bereavement services will be coordinated with the individual's spiritual counselor or the hospice Chaplain." Sub-section two (2) stated in part, "An initial bereavement Risk Assessment will be performed as a part of the Comprehensive Assessment, a plan of care will be developed to include specific counseling to patient and family members to be provided by the Social Worker, Chaplain, or Bereavement counselor. The plan of care will reflect family needs, as well as clear delineation of services to be provided." Sub-section three (3) stated in part, "Within two (2) weeks of the patient death, a condolence card will be mailed to the family. Within a month of death, a twelve (12) month bereavement mailing program will be initiated for designated family members." Review of the clinical records including the bereavement assessment form and the agency’s bereavement policy revealed the policy did not provide guidance for the assessed bereavement risk levels identified on the bereavement assessment form and did not delineate care needs for individuals who scored at "high risk" of two (2) per the bereavement risk assessment form. The bereavement risk levels are assessed as a one (1) or two (2) on the bereavement risk assessment form. Bereavement policies have not been updated since 2009 and do not match the bereavement assessment form being used by the agency to assess bereavement risk. Clinical Record 11: The patient elected the hospice benefit on 4/14/2023, with a terminal diagnosis of systemic inflammatory response syndrome. The initial bereavement risk assessment did not include a date the assessment was completed and did not identify the bereaved. The bereavement assessment identified that the bereaved/unidentified person had a high bereavement risk, the bereavement risk level was documented as 2. The patient's death occurred on 6/1/2023. The first bereavement contact documented on the bereavement risk form was a sympathy note on 6/9/2023. The record did not contain a copy of the sympathy card. The record did contain a photocopy of the one-month post-death letter without a date. The record did not contain any documented evidence of contact with the bereaved member post-death. The bereavement plan of care did not address the care needs for the bereaved that was assessed at a high bereavement risk of 2. Clinical Record 12: The patient elected the hospice benefit on 7/20/2022, with a terminal diagnosis of malignant neoplasm of the scalp. The initial bereavement risk assessment did not include a date the assessment was completed and did not identify the bereaved. The bereavement assessment identified that the bereaved/unidentified person had a high bereavement risk, the bereavement risk level was documented as 2. The patient's death occurred on 8/31/2022. The bereavement plan of care did not address the care needs for the bereaved that was assessed at a high bereavement risk of 2. An interview was conducted with the Bereavement Coordinator/Chaplain on 7/26/2023 in the presence of the Administrator. The Bereavement Coordinator/Chaplain reported upon admission to hospice; the agency completed an initial bereavement risk assessment on all patients, but never for the bereaved. The Bereavement Coordinator/Chaplain stated, " I didn't realize I was supposed to complete the bereavement risk assessment on the family. I thought I was supposed to complete the assessment on the patient." When questioned regarding what the hospice agency does differently for those considered high risk for bereavement, the Bereavement Coordinator/Chaplain stated, "Nothing is different." During joint record reviews and interviews with the Director of Nursing (DON) during the survey from 7/24/2023 to 7/26/2023, the DON confirmed the hospice agency did not meet the bereavement needs of all patient's families. The hospice agency did not complete an initial bereavement risk assessment on any bereaved person(s). The hospice agency was completing an initial bereavement risk assessment on all hospice patients, but not the bereaved. In addition, the hospice agency's bereavement policy did not delineate care needs for individuals considered a high risk per the bereavement risk assessment form. A joint record review and interview with the Director of Nursing on 7/24/2023-7/26/2023 confirmed the hospice agency did not meet the bereavement needs of all patient's families 100% of the time. It was identified the hospice agency did not complete an initial bereavement risk assessment on any bereaved person(s). The hospice agency was completing an initial bereavement risk assessment on all hospice patients, not those bereaved. In addition, the hospice agency's Bereavement policy did not delineate care needs for individuals considered a high risk of two (2) per the bereavement risk assessment form.

It is required that the 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, document review, and interview. In 2 of 2 (100%) clinical records reviewed in which spiritual services were accepted, the agency did not ensure spiritual care services were provided. Agency policy 9.12 titled IDG [Interdisciplinary Group] Care Planning Process (revised 2009 MED-PASS), sub-section two (2) stated in part, “the plan of care specified the care and services necessary to meet the patient and family specific needs related to the terminal illness and related conditions." Sub-section three (3) stated in part, "IDG members provide the care and services offered by the hospice. IDG supervises the care and services." Clinical Record 3: The patient elected the hospice benefit on 1/18/2023. The initial spiritual assessment completed by the Chaplain on 1/19/2023 documented, "Patient is open to Chaplain visits." An updated IDG care plan dated 1/30/2023 included an order for Chaplain visits once a week for two weeks. The clinical record lacked documented evidence that Chaplain visits had been provided to the patient. The record did not contain documented evidence of missed visits by the Chaplain and the clinical record did not contain documented evidence of Chaplain visits as of 7/26/2023. A joint record review and interview with the Director of Nursing on 7/24/2023 confirmed the patient did not receive Chaplain visits as ordered per the plan of care. Clinical Record 6: The patient elected the hospice benefit on 2/10/2023, with a primary diagnosis of Malignant Neoplasm of the Pelvis. The initial spiritual assessment dated 2/13/2023, stated "No Chaplain services were requested." The updated IDG care plan dated 7/3/2023 included an order for the Chaplain to visit once a week for one week. The record did not contain documented evidence of a completed or missed Chaplain visit for the week from 7/3/2023 through 7/10/2023. A joint record review and interview with the Director of Nursing (DON) on 7/25/2023 confirmed the record contained a one-time order for a Chaplain visit dated 7/3/2023, but the patient did not receive the visit as ordered on the plan of care. The DON reported she felt the order was entered in error.

It is required that hospice aides are assigned to a specific patient by a Registered Nurse (RN) 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. In 1 of 14 (7%) clinical records reviewed where hospice aide services were accepted, the hospice agency did not ensure the RN prepared patient specific written care instructions for the hospice aide. Clinical Record 2: The patient elected the hospice benefit on 1/26/2023. The hospice aide care plan assignment dated 6/27/2023, included assignment of two (2) types of baths assigned for the patient. The aide care plan assignment stated in part, "complete bed bath" and "partial bed bath." The hospice aide visit note dated 6/28/2023 documented the hospice aide completed a partial bed bath. The hospice aide visit note dated 7/7/2023 documented the hospice aide completed a bed bath. The aide care plan assignment completed by the RN did not provide specific written instructions for the aide assignment, leaving the aide to make the decision on the type of bath to provide to the patient. A joint record review and interview with the Director of Nursing (DON) on 7/24/2023 confirmed the hospice aide care plan assignment contained two types of baths. The DON confirmed the hospice aide determined what type of bath to complete on 6/28/2023 and 7/7/2023.

It is required that a hospice aide provides services ordered by the Interdisciplinary Group, included in the plan of care, permitted to be performed under state law and regulation, and consistent with the hospice aide training. This standard was not met as evidenced by clinical record review and interview. In 2 of 14 (14%) clinical records reviewed where hospice aide services were accepted, the hospice agency did not ensure that hospice aide services were provided in accordance with the documented plan of care. Clinical Record 1: The patient elected the hospice benefit on 4/17/2023, with a terminal diagnosis of Alzheimer's Dementia. The hospice aide care plan assignment dated 4/17/2023 assigned the aide to provide a shower each visit. The hospice aide documented on the aide visit note dated 5/5/2023 a "complete bed bath" was provided to the patient. The hospice aide also documented the patient was “turn/position” during the visit. The aide care plan assignment dated 4/17/2023 did not assign the aide to turn and reposition the patient. A joint record review and interview with the Director of Nursing on 7/24/2023 confirmed the hospice aide performed interventions not ordered by the Interdisciplinary Group on the hospice aide care plan assignment. Clinical Record 7: The patient elected the hospice benefit on 7/11/2023, with a terminal diagnosis neoplasm of the lung. The hospice aide care plan assignment dated 7/11/2023 assigned the hospice aide to provide visits twice a week beginning the week of 7/11/2023. The patient received no hospice aide services from 7/11/2023 to 7/15/2023. The first hospice aide visit was completed the following week, on 7/18/2023. A joint record review and interview with the Director of Nursing on 7/25/2023 confirmed the hospice did not provide aide services according to the plan of care. The Director of Nursing confirmed the record did not contain any documentation of the missed hospice aide visits. It was reported the hospice aide was updated about the hospice aide frequency orders at the Interdisciplinary Group meeting on 7/17/2023. Therefore, the hospice aide was not aware of the assignment until 7/17/2023.

It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a Registered Nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. Hospice aide documentation complies with hospice policies and procedures. This standard was not met as evidenced by clinical record review and interview. In 2 of 14 (14%) clinical records reviewed in which hospice aide services were accepted, the agency did not ensure the hospice aide reported changes in the patient’s needs to the Registered Nurse (RN). Clinical Record 1: The patient elected the hospice benefit on 4/17/2023, with a terminal diagnosis of Alzheimer's Dementia. The hospice aide care plan assignment dated 4/17/2023 assigned the aide to provide the patient with a shower at each visit. Review of the hospice aide visit noted dated 4/21/2023 revealed a shower section on the note was blank, indicating a shower was not provided to the patient. There was no documented evidence the hospice aide notified the RN that the shower was not completed. The hospice aide documented on the aide visit note dated 4/25/2023 that the patient declined a shower. There was no documented evidence that the hospice aide notified the RN that the shower was declined by the patient. A joint record review and interview with the Director of Nursing on 7/24/2023 confirmed the hospice aide did not complete all interventions as assigned on the hospice aide care plan, and the hospice aide did not notify the RN of interventions not completed for the aide visits on 4/21/2023 and 4/25/2023. Clinical Record 2: The patient elected the hospice benefit on 1/26/2023, with a terminal diagnosis of cerebral vascular accident. The hospice aide care plan assignment dated 6/27/2023 assigned the aide to provide “foot care, nail care, toothette oral swab, change incontinent undergarment and assist with feeding and eating activities" at each visit. The hospice aide visit notes dated 6/28/2023 and 7/7/2023 did not document that the intervention "assist with feeding and eating activities" was completed during the visits. The hospice aide visit note dated 6/27/2023 documented foot care, nail care, toothette, and change incontinent undergarment was declined by the patient. There was no documented evidence that the RN was notified of the changes in the care provided by the aide during the aide visits dated 6/27/2023 and 7/7/2023. A joint record review and interview with the Director of Nursing on 7/24/2023 confirmed the hospice aide did not complete all interventions as ordered on the hospice aide care plan, and the hospice aide did not notify the RN of interventions not completed on 6/28/2023 and 7/7/2023.

It is required that Volunteers are used in day-to-day administrative and/or direct patient care roles. Volunteer services are noted in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical record reviewed where volunteer services were accepted, the hospice agency did not ensure volunteer services were noted in the plan of care. Clinical Record 3: The patient elected the hospice benefit on 1/18/2023. The clinical record included documentation of volunteer visits dated 5/20/2023, 5/27/2023, 6/3/2023, 6/10/2023, 6/19/2023, 6/24/2023, and 7/1/2023. Review of the updated plans of care dated 5/8/2023 through 5/21/2023, 5/22/2023 through 6/4/2023, 6/5/2023 through 6/18/2023, 6/19/2023 through 7/2/2023, and 7/3/2023 through 7/9/2023 documented Volunteer frequency was "offered/declined." A joint record review and interview with the Administrator on 7/24/2023 confirmed the patient received volunteer visits on 5/20/2023, 5/27/2023, 6/3/2023, 6/10/2023, 6/19/2023, 6/24/2023 and 7/1/2023 without Volunteer services being ordered on the care plan.

It is required that the hospice organizes, manages, and administers its resources to provide the hospice care and services to patients, families, and caregivers necessary for the palliation and management of the terminal illness and related conditions. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This condition of participation is not met as evidenced by clinical record review, document review, observation and interviews, which revealed significant issues with the organization and administration of services in the following areas: a lack of oversight of the agency's day-to-day operations by the Administrator/Hospice Governance [HSLG.2.I/L651]; failure to provide care and services consistent with applicable standards of practice [HCDT.1.I/L652]; and failure to ensure the comprehensive assessment includes an initial bereavement assessment of the patient’s family and other individuals [HCPC.13.I/L531]. The cumulative effect of this deficiency has resulted in the hospice agency's inability to ensure the provision of quality care for the Condition of Participation CFR 418.100, Organization and Administration of Services. The collective deficient practice illustrated a systemic process failure that had the potential to affect all patients receiving hospice care services from the agency.

It is required that the hospice’s governance (or designated person(s) so functioning) assumes full legal authority and responsibility for the management of the hospice. A qualified administrator appointed by and reporting to the governing body is responsible for the day-to-day operation of the hospice. This standard is not met as evidenced by document review, observation and interview. An inspection of the supply room was conducted in the presence of the Director of Nursing on 7/26/2023. The following supplies were found to be expired: three safety winged blood collection set with twenty-three-gauge needles expiration date 7/30/2021, one seventy percent (70%) Isopropyl alcohol expiration date 12/2020, fifteen one milliliter TB syringes expiration date 5/31/2022, twenty-five Povidone-Iodine Swab sticks expiration date 11/5/2020, and three Sofsorb absorbent wound dressings expiration date 2/10/2022. During a joint interview and inspection of the supply room with the Director of Nursing (DON) on 7/26/2023, the DON confirmed the supplies were expired. The DON reported she was responsible for checking expiration dates but had been too busy to check expiration dates. The Administrator did not ensure the integrity of hospice supplies available for use in provision of care. Agency policy 2.1. I titled Emergency Operations Plan and Policy (revised 2009 MED-PASS). A document review on 7/26/2023 in the presence of the Administrator revealed the agency did not review and update the emergency policies every two years as required by HSEP.2.D/E4. In a joint document review and interview conducted with the Administrator on 7/26/2023; it was confirmed all hospice policies were last updated in 2009. During the survey copies of the Bereavement Policy and Plan of Care Policy were requested. The Administrator phoned the vendor after being instructed the surveyor needed mentioned policies within one (1) hour. The Administrator stated, "They (the vendor) told me I need to update my policies because I am using the old version. I haven't purchased the updated since 2010." Review of the clinical records including the bereavement assessment form and the agency’s bereavement policy revealed the policy did not provide guidance for the assessed bereavement risk levels identified on the bereavement assessment form and did not delineate care needs for individuals who scored at "high risk" of two (2) per the bereavement risk assessment form. The bereavement risk levels are assessed as a one (1) or two (2) on the bereavement risk assessment form. Bereavement policies have not been updated since 2009 and do not match the bereavement assessment form being used by the agency to assess bereavement risk.

It is required that the hospice must be primarily engaged in providing the following care and services and must do so in a manner that is consistent with accepted standards of practice, counseling services including spiritual counseling, dietary counseling, and bereavement counseling and hospice aide, volunteer, and homemaker services. This standard is not met as evidenced by clinical record review, document review and interview. In 4 of 14 (28%) of clinical records reviewed, the hospice did not ensure spiritual counseling, bereavement services and volunteer services were provided as ordered on the plan of care per standards of practice. Clinical Record 3: The patient elected the hospice benefit on 1/18/2023. The initial spiritual assessment completed by the Chaplain on 1/19/2023 documented, "Patient is open to Chaplain visits." An updated IDG care plan dated 1/30/2023 included an order for Chaplain visits once a week for two weeks. The clinical record lacked documented evidence that Chaplain visits had been provided to the patient. The record did not contain documented evidence of missed visits by the Chaplain and the clinical record did not contain documented evidence of Chaplain visits as of 7/26/2023. A joint record review and interview with the Director of Nursing on 7/24/2023 confirmed the patient did not receive Chaplain visits as ordered per the plan of care. The clinical record included documentation of volunteer visits dated 5/20/2023, 5/27/2023, 6/3/2023, 6/10/2023, 6/19/2023, 6/24/2023, and 7/1/2023. Review of the updated plans of care dated 5/8/2023 through 5/21/2023, 5/22/2023 through 6/4/2023, 6/5/2023 through 6/18/2023, 6/19/2023 through 7/2/2023, and 7/3/2023 through 7/9/2023 documented Volunteer frequency was "offered/declined." A joint record review and interview with the Administrator on 7/24/2023 confirmed the patient received volunteer visits on 5/20/2023, 5/27/2023, 6/3/2023, 6/10/2023, 6/19/2023, 6/24/2023 and 7/1/2023 without Volunteer services being ordered on the care plan. The hospice did not provide chaplain and volunteer services as ordered on the plan of care. Clinical Record 6: The patient elected the hospice benefit on 2/10/2023, with a primary diagnosis of Malignant Neoplasm of the Pelvis. The initial spiritual assessment dated 2/13/2023, stated "No Chaplain services were requested." The updated IDG care plan dated 7/3/2023 included an order for the Chaplain to visit once a week for one week. The record did not contain documented evidence of a completed or missed Chaplain visit for the week from 7/3/2023 through 7/10/2023. A joint record review and interview with the Director of Nursing (DON) on 7/25/2023 confirmed the record contained a one-time order for a Chaplain visit dated 7/3/2023, but the patient did not receive the visit as ordered on the plan of care. The DON reported she felt the order was entered in error. Clinical Record 11: The patient elected the hospice benefit on 4/14/2023, with a terminal diagnosis of systemic Inflammatory Response Syndrome. The initial bereavement risk assessment did not include a date the assessment was completed and did not identify the bereaved. The bereavement assessment identified that the bereaved/unidentified person had a high bereavement risk, the bereavement risk level was documented as 2. The patient's death occurred on 6/1/2023. The bereavement plan of care did not address the care needs for the bereaved that was assessed at a high bereavement risk of 2. Clinical Record 12: The patient elected the hospice benefit on 7/20/2022, with a terminal diagnosis of malignant neoplasm of the scalp. The initial bereavement risk assessment did not include a date the assessment was completed and did not identify the bereaved. The bereavement assessment identified that the bereaved/unidentified person had a high bereavement risk, the bereavement risk level was documented as 2. The patient's death occurred on 8/31/2022. The bereavement plan of care did not address the care needs for the bereaved that was assessed at a high bereavement risk of 2. During an interview on 7/26/2023 with the Bereavement Coordinator/Chaplain in the presence of the Administrator. The Bereavement Coordinator/Chaplain reported upon admission to hospice; the agency completed an initial bereavement risk assessment on all patients. But not the bereaved. The Bereavement Coordinator/Chaplain stated, "I didn't realize I was supposed to complete the bereavement risk assessment on the family. I thought I was supposed to complete the assessment on the patient." When questioned regarding what the hospice agency does differently for those considered high risk for bereavement, the Bereavement Coordinator/Chaplain stated, "Nothing is different." Inspection of the Bereavement Policy 4.26 confirmed the policy did not specify when the initial bereavement risk assessment was to be completed or identify levels of bereavement or standards of care for each identified level per the bereavement risk assessment.

It is required that each patient’s record includes, at a minimum physician certification and recertification of terminal illness as required. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed, the hospice agency did not ensure the certification and recertification of terminal illness was accurate. Clinical Record 5: The patient elected the hospice benefit election on 6/16/2023. The initial Interdisciplinary Plan of Care signed and dated by the physician on 6/16/2023, listed “ESRD [End Stage Renal Disease]" as the primary diagnosis. The updated Interdisciplinary Plan of Care dated 6/20/2023, also listed "primary diagnosis ESRD." The Certification of Terminal Illness signed and dated by the physician on 6/16/2023, stated in part, "Certification period 6/16/2023 through 8/14/2023 the terminal diagnosis is ESRD". The narrative section of the Certification of Terminal Illness, signed and dated by the physician on 6/16/2023, stated in part, "82 y.o. [year old] Female with end-stage dementia due to senile degeneration of the brain. She has mental confusion and poor memory. She requires assistance with all ADLs [activities of daily living]. She ambulates with a walker but forgets to use it. She is bowel and bladder incontinent." The updated Interdisciplinary Plans of Care dated 7/7/2023 and 7/18/2023, stated in part, "Primary diagnosis Senile Degeneration of the brain." A joint record review and interview with the Director of Nursing on 7/25/2023 confirmed the inconsistent terminal diagnosis listed in the patient record. The Director of Nursing stated, "We probably had her on services before, and she must have been discharged at some point, and we must have used documents from her other admission for this admission."

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 a review of clinical records and interviews. In 1 of 5 (20%) clinical records reviewed revealed that the agency did not ensure that the initial comprehensive assessment was completed within the five-day requirement, specifically the spiritual care portion. . Clinical Record 2 Patient elected the hospice benefit on 8/2/22. Comprehensive Interdisciplinary Plan of Care form, dated 8/2/22, documented a Chaplain visit frequency of "one" and the section to check for refusal was not marked. The initial spiritual assessment was completed on 8/8/22. Staff 4 In an interview, conducted with the administrator on 11/8/22, it was confirmed that the chaplain should have seen the patient within the five days and there was no documentation justifying why this did not occur.

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. 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 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 a review of clinical records and interviews. In 2 of 5 (40%) clinical records reviewed revealed the agency did not ensure that the comprehensive assessment included current and accurate drug profiles and did not ensure the medication review process was completed and documented on all patients. . Clinical Record 1 Patient elected the hospice benefit on 2/11/22. The "Drug Profile" forms with signed physician reviews dated 9/27/22, 10/11/22, and 10/25/22 listed "Ceftin 500mg PO BID x 7 days" (Ceftin 500 milligrams by mouth twice a day for 7 days) with a start date of 9/19/22, there were no other physician orders regarding continuation of the medication beyond the initial 7 days. The drug profiles for these effective dates also contained the following questions: "Is drug therapy effective?" "Potential Adverse effects? Drug Reactions?" Significant side effects?" Significant drug reaction?" "Potential/actual ineffective drug therapy?" "Understands instructions Pt/Caregiver" "Needs further instruction Pt/caregiver" "Potential noncompliance issues with drugs?" The answer areas were all left blank. Clinical Record 4 Patient elected hospice benefit on 7/11/22. The "Drug Profile" forms with these effective dates (7/19/22, 8/2/22, 8/16/22, 8/30/22, 9/13/22, 9/27/22, 10/11/22, 10/25/22) contained the following questions: "Is drug therapy effective?" "Potential Adverse effects? Drug Reactions?" Significant side effects?" Significant drug reaction?" "Potential/actual ineffective drug therapy?" "Understands instructions Pt/Caregiver" "Needs further instruction Pt/caregiver" "Potential noncompliance issues with drugs?" The answer areas were all left blank. Staff 4 In an interview, conducted on 11/8/22, the administrator confirmed that the drug profile for record 1 had not been updated appropriately to reflect the discontinuation of the antibiotic. It was also confirmed that the agency process for medication reviews was for the physician (or APRN) to review the drug profile and answer all of the medication review questions with each IDT meeting.

It is required that volunteers are used in day-to-day administrative and/or direct patient care roles. Volunteer services provided to patients/families are in a defined role and under the supervision of a designated hospice employee. Volunteer services are noted in the plan of care and documented in the patient record, including the time spent. This standard was not met as evidenced by a review of clinical records and interviews. In 3 of 5 (60%) clinical records reviewed for utilization of volunteer services it was revealed that the agency did not ensure the assessment for the patient's need for volunteer services was documented. . CONTINUING PRIOR REQUIRED ACTION Paper documentation form titled "Comprehensive Interdisciplinary Plan of Care" listed volunteers with an area to write in the visit frequency or check the discipline was "refused, continue to offer", for the following records this section was left blank. Furthermore, the on-going IDT care plan update forms (from admission to current for these three records) also included a section to document volunteer assessment for needs or refusals and the section was left blank. Clinical Record 1 Patient elected the hospice benefit on 2/11/22. Clinical Record 5 Patient elected the hospice benefit on 8/8/22. Clinical Record 4 Patient elected the hospice benefit on 7/14/22. Staff 4 In an interview with the administrator, conducted on 11/8/22, the forms were reviewed, and it was confirmed that this the area in which the staff was to document the assessment of volunteer needs. CONTINUING PRIOR REQUIRED ACTION Paper documentation form titled "Comprehensive Interdisciplinary Plan of Care" listed volunteers with an area to write in the visit frequency or check the discipline was "refused, continue to offer", for the following records this section was left blank. Furthermore, the on-going IDT care plan update forms (from admission to current for these three records) also included a section to document volunteer assessment for needs or refusals and the section was left blank.

It is required that the hospice medical director or physician-designee provides written and signed recertification of the terminal illness to meet the hospice care benefit requirement. Recertification for the hospice care benefit is informed by the medical director or physician designee’s review of the patient’s clinical information. This standard was not met as evidenced by a review of clinical records and interviews. The following records did not meet the regulation "Certification of Terminal Illness: content of certification" which states in CFR 418.22(b)(4) "The physician or nurse practitioner who performs the face-to-face encounter with the patient described in paragraph (a)(4) of this section must attest in writing that he or she had a face-to-face encounter with the patient, including the date of that visit. The attestation of the nurse practitioner or a non-certifying hospice physician shall state that the clinical findings of that visit were provided to the certifying physician for use in determining continued eligibility for hospice care." Clinical Record 1 Patient elected the hospice benefit on 2/11/22. Document titled "Recertification of Terminal Illness" documented Medicare Benefit Period: 4 (10/9/22 to 12/7/22) which included attestation statements that the face-to-face encounter was completed by the certifying physician or the nurse practitioner, both of these sections were left blank. The medical director signed and dated the form on 9/22/22, there was a completed Face-to-Face encounter form dated 9/20/22 which included a signature line but no attestation statement or a statement that the information was provided to the certifying physician. Clinical Record 2 Patient elected the hospice benefit on 8/2/22. Document titled "Certification Narrative Addendum" documented Medicare Benefit Period: 10 (8/2/22 to 10/1/22) and contained an attestation for the narrative which was signed by the medical director and dated on 8/2/22. The record contained a document titled "Adult Progress Note/Follow-up /Palliative Care" which contained a check list review of body systems with narrative notes and was signed by the APRN on 7/26/22. Neither document contained an attestation statement regarding the face-to-face encounter or that the information was provided to the certifying physician. The administrator confirmed that the wrong form was utilized for this certification period. Staff 4 Interview with the administrator, confirmed that the certification documents were incorrect or incomplete. The following records did not meet the regulation "Certification of Terminal Illness: content of certification" which states in CFR 418.22(b)(4) "The physician or nurse practitioner who performs the face-to-face encounter with the patient described in paragraph (a)(4) of this section must attest in writing that he or she had a face-to-face encounter with the patient, including the date of that visit. The attestation of the nurse practitioner or a non-certifying hospice physician shall state that the clinical findings of that visit were provided to the certifying physician for use in determining continued eligibility for hospice care."