Every finding on record at Compassionate Care Hospice of the Chesapeake Bay, LLC

Upon patient record review, 1 of 19 (Patient #11) did not contain a current/comprehensive Medication Profile: Patient #11: The RN 08/13/25 SOC documentation included, "Recent laceration to right forehead, with x7 resulting stitches. Now open to the air, with the application of topical ATB by caregiver." This topical ATB Ointment was not added to the Medication Profile.

Upon patient record review, 1 of 19 (Patient #11) did not contain evidence that a Registered Nurse had been designated to ensure the continuous ongoing assessment of the patient and family's needs, and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family: Patient #11: The RN 08/13/25 SOC documentation included, "Recent laceration to right forehead, with x7 resulting stitches. Now open to the air, with the application of topical ATB by caregiver." The next subsequent SN visits dated 08/14 and 08/20/25 did not document a nurses assessment of this area of concern.

Upon patient record review, 3 of 19 (Patients #2, 7, and 9) did not contain evidence that the Hospice had developed an individualized written Plan of Care for each patient. The Plan of Care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The Plan of Care must include all services necessary for the palliation and management of the terminal illness and related conditions: Patient #2: SOC 02/20/25. The record contains a completed DPOA-Medical form. This Advance Directive information is not included on either the POC dated 08/19-10/17/25, nor the IDG POC dated 09/03/25. Patient #7: The 08/19/25 SOC CTI reflected that the patient was a DNR; with a copy of a Virginia State DNR form dated 08/19/25 within the clinical record. However, the 09/03/25 IDG POC only contained the Advance Directive of Living Will, and not the DNR status of this patient. Patient #9: The record contained both a completed Living Will and a DPOA-Medical form. However, these Advance Directive(s) information is not included on either the POC beginning 08/14/25, nor the IDG POC dated 09/02/25.

Upon patient record review, 1 of 19 (Patient #13) did not contain evidence that the Plan of Care included all services necessary for the palliation and management of the terminal illness and related conditions, including the following: A detailed statement of both the scope and frequency of the services necessary to meet the specific patient and family needs: Patient #13: A verbal order was obtained on 08/28/25 for, "Volunteer requested. Effective 09/01/25 Volunteer 1x per month x1." Both the 90-day 08/20/25 SOC POC, and the 09/02/25 IDG POC included the following, "Volunteer services available as needed: (delete those services not applicable). 1) Companion; 2) House chores; 3) Emotional/Spiritual support; 4) Telephone contact; 5) Music Therapy; 6) Food preparation; 7) Caregiver respite; 8) Shopping errands; 9) Oral History/Memory Project; and 10)Veteran activities. This potential scope of Volunteer services had not been individualized. Additionally, the 09/02/25 IDG POC did not include a planned/ordered Volunteer frequency.

Upon patient record review, 1 of 19 (Patient #1) did not contain a Plan of Care which included all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments: Patient #1: Both the Hospice POC dated 08/20-11/17/25, and the IDG POC dated 09/03/25, included, "Foley 16 F/10cc. SN to perform insertion." This is an incomplete order as it does not include a date or frequency at which the ordering Physician is wanting the Foley inserted and/or re-placed.

Upon personnel record review, 1 of 13 (Personnel #8) did not contain evidence that an Aide Skills Competency evaluation had been conducted per CMS guidelines: Personnel #8: DOH was 08/27/24. Multiple Aide skills/tasks were evaluated for competence on 09/06/2024 and 09/20/24. However, the following skill/tasks were not evaluated: Sponge, tub, and shower bath.

Upon observation, and interview with the Administrator, there was not evidence of the use of Volunteers, providing day to day administrative and/or direct patient care services, in an amount that at a minimum equals 5 percent of the total patient care hours of all paid Hospice employees and contract personnel. The Volunteer Report for Calendar Year 2024 reflected a 3.2% rate.

Upon patient record review, 1 of 19 (Patient #3) did not have evidence that the hospice assumes responsibility for professional management of the resident's hospice services in accordance with the hospice plan of care. The hospice is responsible for providing all hospice services including: • Ongoing assessment, care planning, monitoring, coordination and provision of care by the Hospice IDG • Assessment, coordination and provision of any needed general inpatient or continuous care • Consultation about the patient's care with facility staff • Coordination by the hospice RN for the implementation of the plan of care for the patient • Provision of hospice aide services, if these services are determined necessary by the IDG to supplement the nurse aide services provided by the facility • Provision, in a timely manner, of all supplies, medications, and DME needed for the palliation and management of the terminal illness and related conditions • Financial management responsibility for all medical supplies, appliances, medications and biologicals related to the terminal illness and related conditions • Determination of the appropriate level of care to be given to the patient (routine homecare, inpatient, or continuous care) • Arranging any necessary transfers from the facility, in consultation with the facility personnel Patient #3: The IDG POC dated 09/03/25 included, "Oxygen 4 lpm for shortness of breath." The SN's SNF visit note of 09/05/25 documents that, "Patient is using 5.5 lpm of Oxygen upon SN arrival." The subsequent 09/06, 09/07, and 09/08/25 SNV's also document the patient actively using Oxygen at 5 lpm. There was no documentation at any four of these SN visits of care coordination with the SNF staff, to clarify the variance of the Oxygen dosage. During surveyor record review on 09/10/25, the Hospice contacted the SNF, and was told that the SNF had received a Physician order to increase Oxygen to 5-7 lpm on 09/04/2025.

Upon personnel record review, 1 of 13 (Personnel #8) did not contain evidence of Criminal Background Checks having been obtained in accordance with Virginia State requirements as follows: A. Section 32.1-162.9:1 of the Code of Virginia requires Hospice providers, as defined in § 32.1-162.1 of the Code of Virginia, to obtain a criminal record report on applicants for compensated employment from the Virginia Department of State Police. Section 32.1-162.9:1 also requires that all applicants for compensated employment in a Hospice program provide a sworn statement regarding their criminal history. B. The criminal record report shall be obtained within 30 days of compensated employment. It is the Hospice program's responsibility to ensure that its compensated employees have not been convicted of any of the barrier crimes listed in § 32.1-162.9:1 of the Code of Virginia. C. The Hospice program shall not accept a criminal record report dated more than 90 days prior to the date of compensated employment. D. Only the original criminal record report shall be accepted. Personnel #8: DOH was 08/27/24. The Hospice was not able to locate documented evidence of his having had a Virginia State CBC conducted.

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 IS A CONTINUING PRIOR REQUIRED ACTION. This standard was not met as evidenced by observations, a review of documents, and interviews. In 1 of 1 (100%) observation during a home visit, the hospice did not ensure the aide changed gloves and performed hand hygiene in accordance with agency policy. Agency policy PCP-001, titled "Hand Hygiene," states in the relevant part, in the section titled Guidelines, "(11) Change gloves during patient care if moving from a contaminated body site to a clean body site...after contact with wound dressings." Home Visit 1: During the home visit observation on 2/6/2023, the hospice aide (Staff 1) was observed performing a bed bath for a facility patient (Record 1) with a hospice election of benefit date of 1/19/2023. The hospice aide performed perineal care with remnants of a bowel movement, removed dirty gloves, pulled new gloves from the scrub pocket and donned them, then proceeded to wash the lower back and sacral area around and on top of wound dressings, then placed a clean gown on the patient. The aide was not observed washing her hands after removing gloves, before donning new gloves, moving from a contaminated body site to a clean body site, and after contact with wound dressings. The hospice aide continued with patient care. Agency policy PCP-001, titled "Hand Hygiene", states in relevant part, in the section titled Guidelines, "(11) Change gloves during patient care if moving from a contaminated body site to a clean body site...after contact with wound dressings." Home Visit 1: During the home visit observation on 2/6/2023, the hospice aide (Staff 1) was observed performing a bed bath for a facility patient (Record 1) with a hospice election of benefit date of 1/19/2023. The hospice aide performed perineal care with remnants of a bowel movement, removed dirty gloves, then pulled new gloves from scrub pocket and donned, then proceeded to wash lower back and sacral area around and on top of wound dressings, then placed a clean gown on the patient. The aide was not observed washing her hands after removing gloves, before donning new gloves, moving from a contaminated body site to a clean body site and after contact with wound dressings. The hospice aide continued with patient care.

It is required that medical social services are provided based on a psychosocial assessment, according to the patient’s and family’s needs and acceptance of these services, per the plan of care and under the direction of a physician. The psychosocial assessment is revised as new information is acquired and as progress toward goals is made. This standard was not met as evidenced by a review of clinical records and interviews. In 1 of 5 (20%) records reviewed, the hospice did not ensure medical social services were provided to patients and families in accordance with the plan of care. Clinical Record 2: This patient elected the hospice benefit on 9/27/2022. The initial Registered Nurse documentation on 9/27/2022 revealed the patient/representative accepted social work services. The initial Plan of Care on 9/27/2022 ordered MSW 1M1. The Medical Social Worker (MSW) documented a missed visit notification on 9/30/2022: "No answer phone, no answer, called and left a message to schedule a visit with pt.'s wife." There was no documented evidence of a declination of medical social services. There was no documented evidence of a medical social worker visit between 9/27/2022-1/31/2022. The Director of Operations was interviewed during a joint record review on 2/6/2023 and agreed there was no documented evidence that the medical social worker visits were declined, no follow-up after the one phone call, and no documented evidence that medical social services were provided based on the patient’s and family’s acceptance of these services and per the plan of care. Clinical Record 2: This patient elected the hospice benefit on 9/27/2022. The initial registered nurse documentation on 9/27/2022 revealed the patient/representative accepted social work services. The initial Plan of Care on 9/27/2022 ordered MSW 1M1. A missed visit notification was documented by the social worker on 9/30/2022, "No answer phone, no answer, called and left a message to schedule visit with pts wife." There was no documented evidence of declination of medical social services. There was no documented evidence of a social worker visit between 9/27/2022-1/31/2022. The Director of Operations was interviewed during joint record review on 2/6/2023 and agreed, there was no documented evidence that the social worker visits were declined, no follow up after the one phone call, no documented evidence that social services were declined, and no documented evidence that medical social services were provided based on the patient’s and family’s acceptance of these services and per the plan of care.

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary and the patient's record, if requested. THIS IS A CONTINUING PRIOR REQUIRED ACTION. This standard was not met as evidenced by a review of clinical records, document reviews, and interviews. In 1 of 2 (50%) clinical records reviewed where the patient was a live discharge from the hospice agency, the discharge summary was not forwarded to the patient's attending physician. Agency policy AA-013A, titled "Discharge," states in part, "...(E) a copy of the discharge summary...will be sent to the attending physician...." Clinical Record 5: This patient elected the hospice benefit on 8/28/2022. The record documented a signed revocation on 10/7/2022. There was no documented evidence that the discharge summary was forwarded to the attending physician. The Director of Operations was interviewed during a joint record review on 2/6/2023 and agreed there was no documented evidence the discharge summary was sent to the attending physician. Agency policy AA-013A, titled "Discharge", states in part, "...(E) a copy of the discharge summary...will be sent to the attending physician...." Clinical Record 5: This patient elected the hospice benefit on 8/28/2022. The record contained documentation of a signed revocation on 10/7/2022. There was no documented evidence that the discharge summary was forwarded to the attending physician. The Director of Operations was interviewed during joint record review on 2/6/2023 and agreed, there was no documented evidence the discharge summary was sent to the attending physician.

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 representative. 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. The plan of care reflects the participation of the hospice, the SNF/NF or ICF/IDF, and the patient and family to the extent possible. All hospice care is provided in the facility in accordance with the hospice plan of care. Any changes to the hospice plan of care are discussed with the patient or representative and SNF/NF or ICF/IDF representatives and are approved by the hospice before implementation. THIS IS A CONTINUING PRIOR REQUIRED ACTION. This standard was not met as evidenced by a review of clinical records, document reviews, and interviews. In 1 of 1 (100%) clinical record review of a patient residing in a Skilled Nursing Facility (SNF), the plan of care did not specify which provider was responsible for performing treatment orders for wound care or Foley catheter care. The nursing facility services agreement states in the relevant part, section 1, titled Definitions, "part (i) Plan of care the plan of care will identify which provider is responsible for performing the respective functions that have been agreed upon and included in the Plan of Care." Clinical Record 1: The record for this facility patient, with an election date of the hospice benefit of 1/19/2023, included a plan of care for the current benefit period, 1/19/2023-4/18/2023. The plan of care did not include documented evidence of which provider would be responsible for treatment orders for wound care or Foley catheter care. The Director of Operations was interviewed during a joint record review on 2/6/2023 and agreed the plan of care did not specify which provider was responsible for providing the wound care or Foley catheter care. The nursing facility services agreement states in relevant part, section 1 titled Definitions, "part (i) Plan of care the plan of care will identify which provider is responsible for performing the respective functions that have been agreed upon and included in the Plan of Care." Clinical Record 1: The record for this facility patient, with an election date of the hospice benefit of 1/19/2023, included a plan of care for the current benefit period, 1/19/2023-4/18/2023. The plan of care did not include documented evidence of which provider would be responsible for treatment orders for wound care or Foley catheter care. The Director of Operations was interviewed during joint record review on 2/6/2023 and agreed, the plan of care did not specify which provider was responsible for providing the wound care or foley catheter care.

It is required that the hospice maintains an emergency preparedness training program that is based on the emergency preparedness plan, risk assessment, policies and procedures, and the communication plan. The training program is reviewed and updated at least every two (2) years. The hospice EP training program includes the following: For all new hospice employees and those providing services under arrangement, initial training in EP policies and procedures consistent with their expected roles; demonstration of staff knowledge of emergency procedures; EP training of all hospice employees and individuals providing services under arrangement at least every two (2) years; more frequent training occurs if there is a significant update of EP policies and procedures; a periodic review and rehearsal of the hospice’s EP plan with hospice employees (including non-employee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others; and, documentation of each training including the date(s), participants, and content. This standard was not met as evidenced by interview and personnel record review. 2 of 13 (15%) records reviewed failed to evidence documented initial training on emergency preparedness on-hire or annually in accordance with the agency's policy. Agency policy HR-003A titled "Competency Plan", revision date 9/3/2020, states in part, under the section titled Operational Guidelines, and the sub-section titled Job-specific competencies, "...(3) orientation to the agency or department that includes, but is not limited to...(c) emergency/disaster preparedness." Page 3 of 6 of same policy, displayed in a visual grid titled Annual Training, documented the emergency preparedness education requirement for clinical, agency office, business development, corporate and contract employees. Staff 13: During the employee education transcript review on 8/18/2022, there was no documentation of emergency preparedness education completed on-hire or thereafter for this contract employee (Medical Director) with a date of hire of 12/15/2020. Staff 9: During the employee education transcript review on 8/18/2022, there was no documentation of emergency preparedness education completed on-hire for this per diem employee (respiratory therapist) with a date of hire of 1/24/2022. An interview with the Area Director of Operations confirmed the missing emergency preparedness education for these employees during a joint review of the agency's transcripts of on-hire and annual education.

It is required that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the patient’s terminal illness that are addressed to promote the patient’s well-being, comfort and dignity throughout the dying process. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 13 (8%) records reviewed did not evidence a documented comprehensive spiritual assessment. Clinical Record 5: This patient, with a hospice election of benefit dated 2/12/2022, declined chaplain services and did not have documentation of a spiritual assessment. Neither the RN initial visit note, dated 2/12/2022 or the MSW evaluation dated 2/16/2022 evidenced a documented spiritual assessment. An interview with the clinical manager during joint record review confirmed the spiritual assessment not completed on the patient's admission to hospice.

It is required that each patient’s individualized written plan of care reflects patient and family goals, identifies planned interventions based on problems identified in the initial and updated comprehensive assessments, includes all services necessary for the palliation and management of the terminal illness and including the treatment necessary to meet the needs of the patient and medical supplies and appliances necessary to meet the needs of the patient. This standard was not met as evidenced by a review of clinical records and interview. In 5 of 5 (100%) records reviewed where the patients were recertified for hospice more than once by the hospice agency, revealed the plans of care (POC) were missing treatment orders, medical supplies and durable medical equipment (DME). The initial plan of care for each patient included all of the required elements including all diagnoses, allergies, diet, functional limitations, medications, treatment orders, care plan problems, interventions, goals, medical supplies and DME. For each of the recertification records reviewed, the plans of care included only medications, visit frequency orders, care plan goals and interventions. The attending physician signatures were obtained for the recertification plans of care without the updated information. Clinical Record 3: This patient with a hospice election of benefit dated 1/14/2022 had documented recertification plans of care for benefit periods 2 (4/14/2022-7/12/2022) and 3 (7/13/2022-9/10/2022) that were missing the required elements of medical supplies and DME. Clinical Record 11: This patient with a hospice election of benefit dated 2/13/2022 had documented recertification plans of care for benefit period 3 (5/14/2022-7/12/2022) and 4 (7/13/2022-9/10/2022) that were missing the required elements of treatment orders for the patient's colostomy and Foley catheter, medical supplies and DME. Clinical Record 8: This patient with a hospice election of benefit dated 2/27/2022 had documented recertification plans of care that were missing the required elements of treatment orders for the patient's Foley catheter and wound care, DME and medical supplies for benefit periods 2 (4/27/2022-7/25/2022) and 3 (7/26/2022-9/23/2022). Clinical Record 7: This patient with a hospice election of benefit dated 11/5/202 had documented recertification plans of care with missing medical supplies and DME for benefit periods 2 through 10 (dated respectively, 2/3/2021-5/3/2021; 5/4/2021-7/2/2021; 7/3/2021-8/31/2021; 9/1/2021-10/30/2021; 10/31/2021-12/29/2021; 12/30/2021-2/27/2022; 2/28/2022-4/28/2022; 4/29/2022-6/27/2022; and 6/28/2022-8/26/2022). Clinical Record 0: This patient with a hospice election of benefit dated 1/13/2021 had documented recertification plans of care with missing elements of medical supplies and DME for benefit periods 2 through 8 (dated respectively, 4/13/2021-7/11/2021; 7/12/2021-9/9/21; 9/10/21-11/8/21; 11/9/21-1/7/22; 1/8/22-3/8/22; 3/9/22-5/7/22; 5/8/22-5/16/22). An interview with the clinical manager confirmed the updated treatment orders, medical supplies and durable medical equipment were missing on the recertification plans of care. The initial plan of care for each patient during the record review contained all of the elements including all diagnoses, allergies, diet, functional limitations, medications, treatment orders, care plan problems, interventions, goals, medical supplies and DME. For each of the records reviewed with recertification, the plans of care had documented only medications, frequency orders, care plan goals and interventions. The attending physician signature was obtained for the updated plans of care without the updated information.

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 a review of documents, and observation on home visits. 1 of 3 (33%) visits revealed the hospice aide failed to change gloves and perform hand hygiene in accordance with agency policy. Agency policy PCP-001, titled "Hand Hygiene", states in relevant part, in the section titled Guidelines, "(11) Change gloves during patient care if moving from a contaminated body site to a clean body site." Home Visit 2: During the home visit observation on 8/16/2022, the hospice aide (Staff 3) was observed performing a bed bath for a facility patient (Record 9) with a hospice election of benefit date of 1/27/2022. The hospice aide did not change gloves after performing perineal care and after the patient had a bowel movement. The hospice aide continued with patient care.

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 a review of clinical records, interviews and observation on home visits. 1 of 6 (17%) records with hospice aide services revealed the registered nurse did not develop or update the hospice aide plan of care with specifics regarding tasks assigned. Clinical Record 8: The hospice aide care plan dated 2/22/2022 for a patient with a hospice election of benefit date of 1/27/2022, did not contain specific instructions for haircare or skincare. On Home Visit 2, it was observed that the hospice aide performed haircare by wetting hair without shampoo. The hospice aide stated that shampoo causes the patient to itch. The hospice aide also applied barrier cream to the sacral area. Neither of these specific tasks were included or updated on the hospice aide plan of care. Interview with the clinical manager during joint record review confirmed that the hospice aide care plan needed to be updated to include specific instructions of haircare and the barrier cream application.

It is required that a hospice aide provides services: ordered by the Interdisciplinary Group; included in the plan of care. This standard was not met as evidenced by a review of clinical records, interviews and observations. 1 of 1 (100%) observed visits of a hospice aide providing direct patient care, the hospice aide performed specific tasks not included on the hospice aide plan of care. Home Visit 2 During the home visit on 8/16/2022, the hospice aide was observed performing a bed bath for facility patient with hospice election of benefit date of 1/27/2022. The hospice aide performed haircare by wetting the patient's hair without shampoo. The hospice aide stated that shampoo causes the patient to itch. The hospice aide also applied barrier cream to the sacral area. Neither interventions of haircare and barrier cream were assigned on the hospice aide care plan dated 2/22/2022.

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 a review of clinical records, interviews and observation on home visits. In 5 of 6 (83%) records reviewed with hospice aide services accepted, the hospice aide failed to document details of what was reported to the registered nurse (RN) after documenting completion of assigned tasks of reporting pain and observation changes to the RN. Additionally, in 1 of 6 (17%) records reviewed with hospice aide services accepted, the hospice aide failed to report to the nurse assigned tasks not completed. On interview with the clinical manager, she stated the expectation is for the hospice aide to enter a narrative note detailing what was reported to nurse. Discussion with the clinical leadership revealed the hospice aide assigned tasks in the electronic medical record, document either yes or no of its completion. Clinical Record 5: This patient, who elected the hospice benefit on 2/12/2022 received hospice aide services. The hospice aide visit notes dated 5/12/2022 and 4/28/2022, documented "yes" to completing reporting pain and any observations to RN. There was no additional documentation detailing what specifically was reported to the RN. Clinical Record 9: This patient, who elected the hospice benefit on 5/19/2022 was receiving hospice aide services. The hospice aide visit notes dated 5/24/2022 and 6/1/2022 documented yes (Y) to completion of assigned tasks of reporting pain to the nurse and any observations to RN. There was no documentation on either visit note detailing what was reported to the nurse. Clinical Record 3: This patient, who elected the hospice benefit on 1/14/2022 had a documented hospice aide visit frequency of once a week for the second (2nd) benefit period dated 4/14/2022 through 7/12/2022. The hospice aide visit note dated 6/28/2022 documented the patient declined and refused the assigned tasks of assist with bed bath, oral/denture care, skin/back care and peri-care. There was no documentation by the hospice aide reporting to the nurse or supervisor of assigned tasks not completed. The hospice aide visit note dated 7/5/2022 documented an assigned task not completed "due to already completed". The incomplete tasks were assist with bed bath, oral care/denture care, skin/back care, and peri-care. The hospice aide visit note dated 7/12/2022 documented assigned tasks not completed due to patient refusal. The incomplete tasks were assist with bed bath, oral/denture care, skin/back care, peri-care. There was no documentation of the hospice aide notifying the nurse or supervisor of the assigned tasks not completed due to patient refusal. NOTE: On 7/21/2022, the RN documented discontinuing hospice aide services due to the patient refusing visits twice on 7/14/2022 and 7/21/2022. Clinical Record 11: This patient, who elected the hospice benefit on 2/13/2022, accepted and received hospice aide services. The hospice aide visit notes dated 7/21/2022, 7/28/2022, 8/2/2022, 8/4/2022 and 8/9/2022 documented "yes" to completing the assigned task of reporting pain to nurse. There was no detailed documentation of what was reported to the nurse. Clinical Record 0: This patient, who elected the hospice benefit on 1/13/2021 received hospice aide services. The hospice aide visit dated 4/6/2021, documented "yes" to completion of the assigned task of reporting pain to the nurse and any observations to RN. There was no detailed documentation of what was reported to the nurse. Clinical Record 8: During the observed home visit on 8/16/2022, the hospice aide performed a bed bath for a facility patient. The patient voiced pain to the left foot/leg and pain to the sacral area when touched and cleansed by hospice aide. On review (8/17/2022) of the hospice aide visit note dated 8/16/2022 it was noted the visit note did not evidence documentation detailing the pain reported to the RN. There was documentation of yes (Y) to completing the assigned task of report pain to the nurse. There was no documentation by RN on the nursing visit note dated 8/16/2022 regarding a detailed report by the hospice aide about the patient's foot/leg or sacral wound area pain.

It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services and, as necessary, provides in-service training and education programs where required. This standard was not met as evidenced by a review of documents, review of personnel records and interview. 3 of 13 (23%) personnel records reviewed did not contain documentation of on-hire or annual competency evaluations for direct patient care employees in accordance with policy. Agency policy HR-003A, titled "Competency Plan" states in relevant part "...job-specific competencies are developed and verified...during orientation to the agency or department...and annual competencies." Staff 6: Record review of the full-time volunteer coordinator with a date of hire of 12/7/2020 was missing documented on-hire and annual competency evaluations. Staff 8: Record review of the full-time bereavement coordinator with a date of hire of 1/6/2020 was missing documented on-hire and annual competency evaluations. Staff 9: Record review of a per diem respiratory therapist with a date of hire of 1/24/2022 was missing an on-hire competency evaluation. Interview with the Area Director of Operations confirmed competency evaluations were missing for the employees.

It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid/MediCal-certified facility, the hospice forwards to the receiving facility a copy of the hospice discharge summary described in HCDT 40.I and the patient’s record, if requested. This standard was not met as evidenced by a review of clinical records, document reviews and interviews. In 2 of 2 (100%) records reviewed where the hospice patient was a live discharge from the agency and transferred to another Medicare facility, the hospice failed to forward to the receiving facility a copy of the discharge summary. Agency policy AA-013A, titled "Discharge" states in part, "...(F) when the patient is discharged to another organization, relevant medical information is provided to that agency...including...(c) summary of care provided by the hospice agency." Clinical Record 4: The patient signed the hospice election of benefit on 4/26/2022. There was documentation present about the patient moving to a different facility and transferred to another hospice per family choice effective 6/24/2022. There was no documentation that the discharge summary and clinical information was forwarded to the receiving hospice or facility. Clinical Record 9: This patient elected the hospice benefit on 5/19/2022. The family chose to send the patient to the hospital emergency room due to decline in patient's status, they signed a revocation form effective 6/17/2022. There was no documented evidence that a discharge summary and clinical information was forwarded to the hospital. An interview with the clinical manager during joint clinical record review confirmed the discharge summaries for Records 2 and 4 were not sent to receiving facilities.

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary and the patient's record, if requested. This standard was not met as evidenced by a review of clinical records, document review and interview. In 3 of 3 (100%) records reviewed where the patient was a live discharge from the hospice agency, the discharge summary was not forward to the patient's attending physician. Agency policy AA-013A, titled "Discharge", states in part, "...(E) a copy of the discharge summary...will be sent to the attending physician...." Clinical Record 2: This patient, who elected the hospice benefit on 11/27/2021 was discharged by they agency, due to extended prognosis, on 5/13/2022. There was no documented evidence that the discharge summary was forwarded to the attending physician. Clinical Record 4: This patient who elected the hospice benefit on 4/26/2022, moved to a different facility and transferred to another hospice per family choice effective 6/24/2022. There was no documented evidence that the discharge summary was forwarded to the attending physician. Clinical Record 9: This patient elected the hospice benefit on 5/19/2022. The record contained documentation of the family's choice to send the patient to the emergency room due to a decline in the patient's status; they signed the revocation form effective 6/17/2022. There was no documented evidence that the discharge summary was forwarded to the attending physician. An interview with the clinical manager during joint record review confirmed the discharge summaries for Records 2, 3 and 4 were not sent to the attending physicians.

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 representative. 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. The plan of care reflects the participation of the hospice, the SNF/NF or ICF/IDF, and the patient and family to the extent possible. All hospice care is provided in the facility in accordance with the hospice plan of care. Any changes to the hospice plan of care are discussed with the patient or representative and SNF/NF or ICF/IDF representatives, and are approved by the hospice before implementation. This standard was not met as evidenced by a review of clinical records, review of documents, and interview. 2 of 2 (100%) records of patients residing in a SNF revealed the plans of care failed to specify which provider was responsible for performing treatment orders for wound care, colostomy care or Foley catheter care. The nursing facility services agreement, effective February 11, 2022, states in relevant part, section 1 titled Definitions, "part (i) Plan of care specifically includes (iv) drugs and treatment necessary to meet the needs of the Hospice patient (v) medical supplies and appliances necessary to meet the needs of the Hospice patient...the plan of care will identify which provider is responsible for performing the respective functions that have been agreed upon and included in the Plan of Care." Clinical Record 8: The record for this facility patient, with an election date of the hospice benefit of 1/27/2022, included a plan of care for the current benefit period, 7/26/2022-9/23/2022. The plan of care was missing evidence of which provider would be responsible for treatment orders for wound care or Foley catheter care. Clinical Record 11: The record for this facility patient, with an election date of the hospice benefit of 2/13/2022 included a plan of care for the current benefit period, 7/19/2022 to 9/10/2022. The plan of care was missing evidence of which provider would be responsible for treatment orders for Foley catheter or colostomy care.

It is required that the designated IDG member provides the SNF/NF or ICF/IDF with the following information for each patient/resident: the most recent hospice plan of care; hospice election form and any advance directives; physician certification and recertification of the terminal illness; names and contact information for hospice staff involved in the patient’s care; instructions on how to access the hospice’s 24-hour on-call system; hospice medication information; and hospice physician and attending physician (if any) orders. This standard was not met as evidenced by a document review, interview and observation on home visits to patients residing in a SNF. 2 of 3 (75%) visits revealed the facility hospice binders for the patients did not contain all required hospice documentation. The nursing facility services agreement, effective February 11, 2022, states in part (page 7-9 of 34), under section 3, Responsibilities of the Hospice, "...(e) Provision of Information (i) Plan of Care, Medications and orders (ii) Election Form (iii) Certifications (iv) Contact Information: names and contact information for hospice personnel involved in providing hospice services; and (v) on-call system, instructions on how to access hospice’s 24-hour on-call system." Home Visit 2: On 8/16/2022, during the observed home visit for patient with a hospice election date of 1/27/2022 (Clinical Record 9), the facility patient's clinical binder located at the nurses station was reviewed. The following required hospice documentation was missing: the current plan of care, physician certifications and recertification, hospice physician orders and the hospice election form. The binder did contain a current medication list, the patient's advance directives and an orange "alert" form with the hospice's 24 hour contact information, however the hospice staff information was also missing from the binder. NOTE: The hospice RN requested the hospice election of benefit form from the facility's business office and filed it in the patient's binder prior to exiting the facility. Home Visit 0: On 8/16/2022, during the observed home visit for patient with a hospice election date of 2/13/2022 (Clinical Record 10), the facility patient's binder located at the nurses station was reviewed. The following required hospice documentation was missing: the current plan of care, physician certifications and recertification, hospice physician orders and the hospice election election of benefit form. The binder did contain a current medication list, the patient's advance directives and an orange "alert" form with the hospice's 24 hour contact information with the hospice staff names involved.