Every finding on record at Community Hospice Inc

It is required that a hospice-operated inpatient care facility complies with all applicable federal, state and local health and safety codes, including: The applicable provisions of the Life Safety Code (LSC) of the National Fire Protection Association NFPA 101, Life Safety Code 2012 edition; the Health Care Facilities Code NFPA 99, 2012 edition and Tentative Interim Amendments TIA 12–2, TIA 12–3, TIA 12–4, TIA 12–5, TIA 12–6 – except Chapters 7, 8, 12, and 13 that do not apply to hospice. Clothes dryers (Section 11.5. 1.11) shall be cleaned to maintain the lint trap and keep the mechanical and heating components free from excessive accumulations of lint. This standard was not met as evidenced by interview and observation. Observation of the facility's laundry room revealed that the agency did not ensure fire safety and prevention by ensuring the mechanical and heating components were free from excessive accumulations of lint. Laundry Room: During the facility tour on 06/11/2025, observation of the inpatient facility laundry room revealed a significant accumulation of lint buildup in the dryer lint trap. Chief Clinical Officer observed the lint trap on 06/11/2025 and stated, "Don't throw that away, I want to show it to the person responsible for cleaning it." Observation of the facility's laundry room revealed that the agency did not ensure fire safety and prevention through ensuring clean dryer trap without excessive accumulation.

It is required that the comprehensive assessment includes consideration of the following factors: The nature and condition causing admission, including the presence or lack of objective data and subjective complaints. This standard was not met as evidenced by clinical record review and interview. In 1 of 27 (4%) clinical records reviewed, the agency did not ensure that the initial comprehensive assessment documented all the objective data that would need to be considered for the plan of care and care of the patient. CLINICAL RECORD 22: The initial comprehensive assessment completed on 12/29/2024 did not document evidence of the infusion line. This patient was receiving GIP (general inpatient care) care and the following medications: Morphine 100mg in NACL 0.9%. Infuse 0-15mg IV continuous for pain; IV drip titration begins with 2mg/hr max increase by 1mg/hr and may increase the dose by 1 mg/1 hr; Morphine 1mg/ml injection. Infuse 0.5 - 1.5 mg IV every 2 hours as needed for pain. There was no description of the type of IV (intravenous) line, location of the line, dressing, or care of the line. During the interview with the clinical team, who reviewed the record with the site visit, stated that the patient was receiving care at a hospital, but agreed that the documentation should have included the line location and description of the site.

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, and herbal remedies. This standard was not met as evidenced by clinical record review and interview. In 2 of 30 (7%) clinical records reviewed revealed that the agency did not ensure that all over the counter medications were included on the medication profile. CLINICAL RECORD 12: The patient was admitted on 05/20/2025 with a diagnosis of end stage renal disease. The plan of care dated 05/20/025 included orders for Calmoseptine to buttocks every shift. Calmoseptine was not included on the medication profile. CLINICAL RECORD 14: Patient admitted on 05/02/2025 with a diagnosis of sepsis. The plan of care for 05/02/2025 - 07/30/2025 included an order for Calmoseptine to the inner thighs, bilateral groin, and scrotal irritation every shift. Calmoseptine was not included on the medication profile. The physician ordered on June 5, 2025, for Juven powder 1 pack mixed with 8 oz. of fluid PO BID for supplement and wound healing. Juven powder was not added to the medication profile. In a joint record review on 06/11/2025, the Chief Clinical Officer confirmed that the over-the-counter medication was not included on the medication list for patients 12 and 14.

It is required that each patient’s individualized written plan of care identify planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical records reviewed which included an infusion, the agency did not ensure that the infusion line included documented interventions for care of the line to include assessment, line care, and dressing care. CLINICAL RECORD 22: The initial comprehensive assessment completed on 12/29/2024 did not include documentation of the infusion line. The patient was utilizing the GIP (general inpatient) benefit. The patient was receiving Morphine 100mg in NACL 0.9%. Infuse 0-15mg IV continuous for pain; IV drip titration begin with 2mg/hr max increase by 1mg/1 hr and may increase the dose by 1 mg/hr and morphine 1 mg/ml injection; Infuse 0.5 - 1.5 mg IV every 2 hours as needed for pain. There were no documented interventions for the infusion to include assessment of the line, care of the line, or dressing changes for the line. During the interview with the management team, who reviewed the record with the site visitor, stated that the interventions for the IV access were not documented.

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. In 1 of 27 (4%) Clinical records reviewed in the community program, the agency did not ensure that the patient's plan of care included all medical supplies to meet the patient's needs. CLINICAL RECORD 14: The patient was admitted on 05/02/2025 with a left flank wound with a nephrostomy, a decubitus ulcer on the coccyx and a foley catheter. The plan of care dated 05/02/2025 did not include any supplies for wound care, or catheter care. During the interview with the management team, who reviewed the record with the site visitor stated that the supplies for patient care were missing from the plan.

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. In 1 of 6 (17%) home visits observed, the agency did not ensure staff adherence to the hand hygiene policy. Hand Hygiene policy 9-010.1: Policy document Hand Hygiene 9-010.1 (effective date 5/19/2025) states in part that, "Personnel providing care in the hospice setting will regularly wash their hands." "When hands are not visibly soiled, staff may use an alcohol-based hand rub." "Hand Hygiene will be performed (1) before direct contact with patients." HOME VISIT 5: During the observed visit on 6/10/2025, the chaplain was observed entering the room without utilizing hand sanitizer. He made hand contact with the patient during prayer and comfort. There was no hand sanitization after the visit before exiting the home. In an interview with the Clinical Manager of the home program, on 6/10/2025, it was stated that staff have been educated about hand hygiene but in this case, the chaplain forgot to use hand sanitizer. She stated that she spoke with the chaplain on 06/11/2025 and he stated that he sanitized his hands before he left his car. During home visit #5 completed

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. In 7 of 25 (28%) clinical records reviewed with home health aides revealed that the agency did not ensure that the aide care plan provided clear instructions to meet the patient needs. CLINICAL RECORD 1: The patient was admitted on 01/15/2025 with a diagnosis of senile degeneration of the brain. The physician orders included oxygen. The aide plan of care did not include instructions to the aide regarding the oxygen safety or use. CLINICAL RECORD 9: The patient was admitted on 01/21/2025 with a diagnosis of heart failure. The plan of care dated 01/21/2025 included orders for oxygen and wound care covered with gauze three times per week to the right foot. The aide care plan developed by RN on 01/22/2025 did not inform the aide that the patient had oxygen and there were no oxygen precautions on the aide care plan. The aide care plan included "foot care' but did not provide direction to the aide related to how to manage bath and foot care with the dressing on the right foot. CLINICAL RECORD 12: The patient was admitted on 05/20/2025. The skilled nursing assessment documented that the patient was incontinent and utilized a pure wic system continuously. The aide care plan developed by the RN on 05/21/2025 included a complete bed bath but did not mention the poure wic system or provide the aide with any direction related to the pure wic system. CLINICAL RECORD 14: The patient was admitted on 05/02/2025 with a diagnosis of sepsis. The initial skilled nursing comprehensive assessment completed on 05/02/2025 described a decubitus ulcer of the coccyx, a left-sided surgical flank wound dressing with a nephrostomy tube and a Foley catheter in place. The aide care plan developed on 05/09/2025 included a complete bed bath but did not include instructions to the aide related to the Foley catheter, nephrostomy, or bandages on decubitus. CLINICAL RECORD 16: The patient was admitted on 10/14/2024 with a diagnosis of malignant neoplasm of the colon. The plan of care dated 06/11/2025 included continuous oxygen 2-10 liters per nasal cannula. The aide care plan was revised on 04/06/2025 and did not include any instructions to the aide related to oxygen use or safety. CLINICAL RECORD 19: The patient resided in a skilled nursing facility and elected hospice on 05/13/2025 with metabolic encephalopathy. The skilled nursing assessment on 05/13/2025 indicated that the patient had unstageable pressure ulcers to the left lower back and midline lower posterior medial spine with wound care orders on the plan of care. The aide plan of care included a complete bed bath but did not provide the aide any direction related to the wound care and dressing areas. CLINICAL RECORD 20: The patient resided at home and elected hospice on 04/09/2025 with a diagnosis of chronic obstructive pulmonary disorder. The plan of care dated 04/09/2025 included oxygen 5.5 liters per minute per nasal cannula continuous. The aide care plan created 04/09/2025 did not include mention of oxygen or oxygen precautions. In a joint review of clinical records on 06/11/2025 and 06/12/2025, the Chief Clinical Officer confirmed that the aide care plans did not include required elements to meet the patient needs.

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 1 of 22 (5%) clinical records in which a hospice aide was accepted and had a change to be reported to the nurse, revealed the agency did not ensure that documentation of the change was documented. CLINICAL RECORD 13: The aide plan of care documented on 04/21/2025 ordered incontinent care, perineal care and brush teeth every visit. The frequency for the hospice aide was 2 times a week. The following visit dates the above tasks were documented as refused: 05/09/2025, 05/13/2025, 05/16/2025, and 06/03/2025. There was no documented notification of the nurse, and the nursing assessments did not document that the aide had notified her. During the interview with the clinical team, who also reviewed the record together, stated that nurse notification was not documented.

It is required that when controlled medications are first ordered, a copy of the hospice’s written policies and procedures for the management and disposal of controlled medications is provided to the patient or family or the patient’s legal representative(s). The Interdisciplinary Group discusses the policies and procedures in a language and manner that the patient and family or patient’s legal representative understand, ensures that the safe use and disposal of controlled drugs is understood, and documents in the patient record that the policies and procedures for managing and disposing of controlled medications is provided and discussed. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 4 (25%) clinical review of death records, the agency did not ensure that the disposal of medications was documented at death per the agency policy. AGENCY POLICY: Policy 3-006.1 [review date 05/19/2025] Stated in part, "upon the patient's death, the nurse will offer verbal and written instructions on how to appropriately dispose of medications and will document such in the patient EMR." "The hospice nurse will review methods of disposal with patient/caregiver or designee" CLINICAL RECORD 22: The patient received GIP (general inpatient care) with a date of death of 12/29/2024. The hospice nurse visit documented the notification of the team and death, but no documentation of medication disposal for a patient receiving morphine, lorazepam. During the interview with the clinical team, who reviewed the record with the site visitor, it was stated that drug disposal was discussed on admission, but no documentation at death for the drug disposal. They thought that the facility would have disposed but agreed there was no documentation of drug disposal.

It is required that hospice care of the patient/resident is stated in a written plan of care established and maintained in consultation with SNF/NF or ICF/IID representatives. The hospice plan of care identifies the care and services that are needed and specifies which provider is responsible for performing the functions that are agreed upon and included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 3 of 9 (33%) clinical records reviewed of patients in a skilled nursing facility revealed that the agency did not ensure the care plan identified which provider was responsible for performing functions of the care plan CLINICAL RECORD 17: The patient was admitted to a skilled nursing facility on 06/02/2025 and elected hospice on 06/03/2024. The plan of care for the certification period 06/03/2025-08/31/2025 included orders that read, "Decubitus pressure ulcer stage II midline posterior buttocks gluteal fold: cleanse with normal saline or wound cleanser, rinse, pat dry and cover with foam dressing twice a week or as needed for soiling or dislodging. Paracentesis drain 3 x week using Pleurex 1000 ml bottle. Monitor blood pressure before and after. May also weigh (initial 3160) or abdominal circumference (initial 103 cm at navel). Change dressing to the drain site RLQ using saline/wound cleanser rinse, pat dry, place a drain sponge, and cover dressing. May crush medications that are crushable. The plan of care does not specify which provider was responsible for each intervention. CLINICAL RECORD 18: The patient resided in a skilled nursing facility and elected hospice on 05/21/2025. The plan of care dated 05/21/2025 included orders for a Foley catheter as needed with a 60 ml flush as needed for patency. SN assesses for falls, SN assesses cognitive status. The plan of care did not provide any clarification and direction to specify which provider was responsible for performing ordered care plan tasks. CLINICAL RECORD 19: The patient resided in a skilled nursing facility and elected hospice on 05/13/2025. The plan of care dated 05/13/2025-08/10/2025 included daily wound care for two unstageable wounds. The plan of care did not include any clarification or direction to specify which provider is responsible for performing the ordered care plan tasks. During the interview with the management team, who reviewed the record with the site visitor stated that there was no indication as to who was performing which task.

It is required that the hospice inpatient facility provides meals to each patient that are obtained, stored, prepared, distributed, and served under sanitary conditions. This standard was not met as evidenced by interview and observation. Observation of the facility's patient kitchen and family kitchen revealed that the agency did not ensure that food items were not expired and stored properly. Observation on 06/11/2025 of the inpatient unit kitchen revealed that the refrigerator included cream cheese that expired on 06/04/2025, and cottage cheese that expired on 06/06/2025. The freezer included 5 bags of vegetables that were open and unsealed with no labels. The family kitchen refrigerator contained an egg carton with 11 eggs. The expiration date on the egg carton was April 11, 2025. The Chief Nursing Officer observed the kitchen and refrigerator with the site visitors and confirmed that the cottage cheese and the cream cheese were expired. The Chief Nursing Officer observed and confirmed that 5 bags of vegetables were open in the freezer with no seal and no label. The Chief Clinical Officer observed the expired eggs and confirmed the finding. Observation of the facility's patient kitchen and family kitchen revealed that the agency did not ensure that food items were not expired and stored properly.

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 an RN (Registered Nurse) who is responsible for the supervision of the hospice aide. This is a Continued Required Action. This standard was not met as evidenced by clinical record review and interview. In 3 of 5 (60%) clinical records reviewed with hospice aide services provided, the agency did not ensure the Registered Nurse prepared a hospice aide plan of care that contained clear and specific instructions for care that the patient required. Clinical Record 1: The patient elected the hospice benefit on 03/31/2023 with a terminal diagnosis of senile dementia. The nurse documented on the nursing visit note dated 04/10/2023, a Foley catheter was placed. The aide plan of care assigned the tasks of peri care but did not include Foley catheter care and emptying of the catheter bag. Clinical Record 2: The patient elected the hospice benefit on 12/03/2022. At the start of care, it was documented that the patient was wheelchair (w/c) dependent and required 1 person to assist with transfer. The aide plan of care assigned the tasks of transfer bed to chair and chair to bed but was not specific to 1-person or 2-person assistance with transfer. Clinical Record 4: The patient elected the hospice benefit on 03/20/2023. Documentation at the start of care showed the patient had an ileostomy in a location that leaked, and bag sealing was very difficult. The aide plan of care assigned the aide visit frequency of two times a week and assigned a bed bath but did not include directions to the aide on how to care for the ileostomy, the skin around the ostomy site, and if the bag should be emptied while providing care to the patient. During an interview with the Management Team of Clinical Patient Care Managers, the Vice President of Clinical Services, Education, and Quality team, stated that the aide plans did not have the specifics but that the team coordinated care but agreed that this was not documented.

It is required that hospice care of the patient/resident is stated in a written plan of care established and maintained in consultation with SNF/NF or ICF/IDF representatives. The hospice plan of care identifies the care and services that are needed and specifies which provider is responsible for performing the functions that are agreed upon and included in the plan of care. This is a Continued Required Action This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed of patients that reside in a skilled facility, the agency did not ensure the hospice plan of care identified the care and services that would be provided by the hospice and the nursing facility. Clinical Record 1: The patient elected the hospice benefit on 03/31/2023 with a terminal diagnosis of senile dementia. The patient resided in a nursing facility. The nurse documented on the nursing visit note dated 04/10/2023, a Foley catheter was placed. The hospice plan of care did not identify the care and services that each provider would be responsible for related to the foley catheter. Clinical Record 7: The patient elected the hospice benefit on 03/20/2024. The patient resided in a nursing facility. The patient had an ulcer on the left heel and left calf. Nursing visit notes document wound worsened on the left calf and required 3 times a week wound care. The hospice plan of care did not identify the care that each provider would be responsible to provide related to the wound care. During an interview with the Management Team of Clinical Patient Care Managers, they stated that they had a facility plan. They brought a blank one that identified duties and was used at all facilities but agreed that a copy of the plan was not in the clinical records and that a copy did not get placed in the clinical record, it was kept only at the facility.

It is required that the hospice inpatient facility has documented and dated written reports of Life Safety Code fire drills at varied times on all shifts. The hospice inpatient facility has evacuation diagrams posted and visible to all staff, patients, and family members or visitors. This standard was not met as evidenced by document reviews and interviews. The hospice inpatient unit did not ensure the agency's policy was followed for quarterly fire drills to be conducted on all shifts. A review of the hospice inpatient facility's fire drill logs revealed the inpatient facility did not conduct and document fire drills for either shift during the following quarters:1st quarter 2021; 4th quarter 2021; and 2nd quarter 2022. The hospice policy number 1-007-.1 "Fire Prevention/Disaster Drill," stated in part, "Fire drills will be conducted quarterly for each shift." During an interview on 08/18/2022, the Safety Officer and the Clinical Operations Manager stated that there were three fire drills missed, and they thought fire drills needed to be conducted twice a year. Policy number 1-007-.1 "Fire Prevention/Disaster Drill," Procedure #3, Advance Precautions/Fire Plan Testing states in part, "Fire drills will be conducted quarterly for each shift."

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. 2 of 20 (10%) records reviewed revealed the hospice did not ensure that the chaplain and social worker conducted their assessments within 5 calendar days of the election of hospice care. Record #9 was reviewed and identified the patient elected hospice care on 01/05/2022. The admission visit documented acceptance of chaplain. The chaplain documented a phone call to the patient on 1/12/2022. This call to the patient was the initial documented contact from the chaplain, 7 days outstanding. The patient refused the chaplain, but the initial contact was 2 days late. Record #2 was reviewed and identified the patient elected hospice care on 8/4/2022. The medical social worker's assessment visit was completed on 8/11/2022. There was no documented reason for the visit to be on day 7, 2 days late. During an interview, the Hospice Manager stated that one of the social workers was on maternity leave and another had COVID and that the visit was late.

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 and other alternative treatments that could affect drug therapy. The medication review process includes the identification of 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 a review of clinical records, document reviews and interviews. 1 of 20 (5%) records reviewed revealed the hospice did not ensure the agency policy was followed for medication profile updates. Record #12: A review of the record revealed the nursing visit note dated 1/20/2022 documented the patient was using oxygen at night. The face to face visit completed on 8/15/2022 documented oxygen, "continues to use at night." The medication profile reviewed on 8/18/2022, did not contain oxygen. The agency's policy # 3-002.1 "Medication Profile" (approval 4/27/2022), stated in part, "Medication profiles will be updated whenever there has been a change in the the patient plan of care that impacts/changes the patient medication orders. The patient medication profile reflects the current medications, new medications and /or discontinued medications." During an interview, the manager of the team stated that the oxygen was on the medication profile at the admission, but was discontinued on 02/15/2022. The case manager thought oxygen was still on the medication profile and missed that it had been discontinued and should have been restarted. Agency Policy - Medication Profile 3-002.1 [approval 4/27/2022] stated in part, "Medications profiles will be updated whenever there has been a change in the the patient plan of care that impacts/changes the patient medication orders. The patient meidcation profile reflects the current medications, new medications and /or discontinued medications.

It is required that the hospice designates a registered nurse member of the IDG to ensure the implementation of the interdisciplinary plan of care. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 20 (5%) records reviewed revealed the hospice did not ensure that the individualized plan of care was followed. Record #5 was reviewed and identified the patient elected hospice care on 7/1/2022. The physician ordered monthly weights on 7/1/2022.The agency defined monthly as every 30 days. The patient's weight was documented as 132 pounds on 7/1/2022. As of the record review on 8/17/2022, no other weight was documented, 48 days outstanding. Interview with the Hospice Director and Director of Clinical Services stated that the weight was probably obtained by the facility and the nurse did not document it.

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. This standard was not met as evidenced by a review of clinical records, and document reviews. In 4 of 20 (20%) records reviewed revealed the hospice did not ensure the plan of care reflected the patient's goals and interventions based on problems and needs identified on the initial or updated comprehensive assessment. Record #4 was reviewed and identified the patient elected hospice care on 5/3/2022. The initial comprehensive assessment completed on 5/3/2022, identified an abrasion on the patient's shin that continued to leak fluid and 3+ pitting edema in both lower extremities. The clinical visit notes reviewed documented the concern of skin breakdown was still present as of 08/18/2022. The initial plan of care and the updated plans of care as of 8/18/2022, did not include the patient's skin integrity problems. In addition, the patient had a paracentesis ([fluid drainage) procedure completed on 06/03/2022. The plan of care was not updated to include this problem. Record #15 was reviewed and identified the patient elected hospice care on 6/4/2022. The initial comprehensive assessment completed on 6/4/2022, revealed a wound on the patient's neck that was treated with soap and water, and covered with a band aid. The wound continued thru 8/18/2022 with care being provided, but no goals or interventions were included on the initial plan of care or the updated plans of care. Record #13 was reviewed and identified the patient elected hospice care on 12/10/2021. The initial comprehensive assessment completed on 12/10/2021, documented that the patient's skin was very fragile. The clinical visit note dated 12/16/2021, documented a skin tear that was cleaned with normal saline and a band aide applied. On 12/22/2021, a large amount of bruising was documented on the patient's left elbow. The clinical visit note dated 02/20/2022, documented the patient had a fall that resulted in a skin tear. The plan of care and updated plans of care did not include interventions or goals related to the patient's skin integrity problems. Additionally, on 02/08/2022, the patient complained of constipation with several medication changes to assist with the constipation. The plans of care were not updated with interventions or goals related to constipation. Record #1 was reviewed and identified the patient elected hospice care on 4/22/2022. The initial comprehensive assessment completed on 4/22/2022, identified that the patient had a contracted hand with skin interruption. Initially, a dressing change was taught to the caregivers. The caregivers felt the dressing change was too complicated, so the wound care was changed to, "clean with saline and gauze and nystatin." The initial plan of care and the updated plans of care as of 8/18/2022, did not include the patient's skin integrity problems. The agency's policy #2-056.1 (approved 4/27/2022), stated in part, "All patient care problems/needs will be prioritized with corresponding goals and anticipated dates for reaching those goals." Agency Policy 2-056.1 [approved 4/27/2022] stated in part, "All patient care problems/needs will be prioritized with corresponding goals and anticipated dates for reaching those goals"

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 a detailed statement of the scope and frequency of services necessary to meet specific patient and family needs. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 20 (5%) records reviewed revealed the hospice did not ensure the plan of care documented the scope and frequency of services for the chaplain. Record #5: The initial plan of care dated 7/5/2022 documented the visit frequency for the chaplain as "1 month 3." The initial chaplain visit completed on 7/5/2022 documented that chaplain services were declined by the patient following the first visit. The plans of care dated 7/19/2022 and 8/1/2022 documented the visit frequency for the chaplain as "1 month 3" through 9/28/2022. The Interdisciplinary plan of care documentation continued to document a frequency for the chaplain who made no further visits per the patient's request. Interview with the Director of Clinical Services stated that the frequency for chaplain was incorrect and continued incorrect documentation through 08/18/2022 to be documented on the updated plans of care.

It is required that a hospice aide provides services are ordered by the interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 11 (9%) records reviewed of patients with documented acceptance of a hospice aide revealed the aide did not document care that was ordered by the interdisciplinary group. Record #0: The ordered aide visit frequency was "2 times a week." The plan of care ordered the task of shampoo be provided by the aide during each visit. The hospice aide visits completed on 7/27/2022 and 8/5/2022, documented "Not applicable" (NA) for the task of shampoo. The shampoo was not provided and the "not applicable" determination was documented by the aide. There was no evidence that the plan of care was changed and no evidence of communication between the aide and the registered nurse to report the change. During an interview, the Director of Clinical Services stated that maybe the software provider would remove N/A as an option.

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 physician orders. This standard was not met as evidenced by a review of clinical records and interviews. 2 of 20 (20%) records reviewed revealed the hospice did not ensure all physician orders were documented for patient care. Record #15: The skilled nurse visit note dated 6/2/2022, documented that Eliquis was held for 3 days. The record did not contain evidence of a physician order to hold the Eliquis, as of 8/19/2022. Record #12: The pediatric patient was admitted with tube feedings via a gastrostomy tube (G-tube). Initially, the mother administered the tube feedings via the G-tube at 53 cubic centimeters (cc) per hour. On 11/22/2021, the tube feeding administered via the G-tube was documented as 54cc per hour. In addition, starting on 1/27/2022 and continuing through 8/15/2022, the tube feedings administered via the G-tube were documented as 55cc per hour. The record did not contain evidence of physician orders for the tube feeding rate changes, as of 08/18/2022. During an interview, the case manager stated that she thought she had put the orders in, but agreed they were not in the software on 8/18/2022. During an interview, the Chief Clinical Officer stated that the software had lost some data, but was not sure that it happened during this time.

It is required that If the care of a patient is transferred to another Medicare/Medicaid-certified facility, the hospice must forward, to the receiving facility, a copy of the hospice discharge summary, and the patient's clinical record, if requested. This standard was not met as evidenced by a review of clinical records, document reviews and interviews. 1 of 1 (100%) record reviewed of a patient transferred to another organization revealed the agency did not ensure to send a copy of the transfer summary to the receiving facility. Record #12: The pediatric patient was taken to the hospital by the mother following the nursing visit completed on 7/8/2022t, as the child became more short of breath. On 7/11/2022, the medical social worker documented following a phone call with the patient's mother that the patient at hospital. Phone contact continued with the mother and the hospital with potential discharge date of 7/21/2022. The record was missing evidence that a transfer summary were sent to the hospital. The agency's policy # 2-091.1 "Provision of Care" (approved 4/27/2022) stated in part, "The transferring clinician will complete a transfer summary that includes, as appropriate... the reason for transfer, the physical and psychosocial status at the time of transfer, a summary of the care provided and the progress toward achieving goals, current plan of care, latest physician orders continued symptom management...Completed transfer summaries will be mailed;/faxed/emailed to the receiving organization within 72 hours of transfer and the original will be filed in the EMR." During an interview, the Chief Clinical Officer stated that they did not realize they were to send paperwork. Agency Policy Perovision of Care 2-091.1 [aproved 4/27/2022] stated in part, "The transferring clinician will complete a transfer summary that summary that includes, as appropriate: the reason for transfer, the physical and psychosocial status at the time of transfer, a summary of the care provided and the progress toward acheiving goals, current plan of care, latest physician orders continued symprom management." "Completed transfer summaries will be mailed;/faxed/emailed to the receiving organization within 72 hours of transfer and the orilginal will be filed in the EMR."