Every finding on record at Concord Hospice Care, LLC

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current: prescription and over the counter (OTC) drugs; supplements; herbal remedies; other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following: the effectiveness of drug therapy; drug side effects; actual or potential drug interactions; duplicate drug therapy; 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 observation and interview. In 2 of 19 (11%) clinical records reviewed, the agency did not ensure an accurate review of medications the patient was currently taking, in order to identify any potential adverse effects and drug reactions HOME VISIT 3: During the home visit observation on 06/04/2025 with the Registered Nurse (RN) (Personnel Record 5), a medication review was completed by comparing the hospice medication profile (printed on 06/03/2025) to the patient’s current home medications. The patient’s current medication bottles in the home included Eliquis 2.5 mg tablet, give one tablet daily, last filled on 05/07/2025, Furosemide 40mg tablets, give one tablet daily last filled 05/07/2025, Hydralazine HCl 50 mg tablet, give one tablet daily last filled 05/07/2025, and Amlodipine Besylate 5mg tablet, give one tablet daily last filled 05/07/2025. Eliquis, Furosemide, Hydralazine and Amlodipine Besylate were not included on the hospice medication profile and were not included in the medication review process. The daughter stated that these medications were started when the patient was in the hospital in May of 2024. The hospice medication profile included Amiodarone HCl 100 mg tables, give one tablet daily and the patient’s home medication bottle read Amiodarone HCl 200mg tablet, give one tablet daily last filled 05/07/2025. HOME VISIT 4: During the home visit observation on 06/04/2025 with the Medical Social Worker (MSW) (Personnel Record 6), a medication review was completed by comparing the hospice medication profile (printed on 06/03/2025) to the patient’s current home medications. The patient’s current medication bottles in the home included Cetirizine 10mg tablet, give one tablet daily, last filled 05/15/2025, last written 03/31/2025; and Ferrosol 325mg tablet, give one tablet twice daily, last filled 05/15/2025, last written 4/23/2025. Cetirizine and Ferrosol were not included on the hospice medication profile and were not included in the medication review process. The hospice medication profile included Mirtazapine 30mg tablet, give one tablet at bedtime, and the patient’s current medication bottle read Mirtazapine 15mg tablet, give one tablet at bedtime, last filled 05/05/2025. During the medication review the paid caregiver stated that 15mg of Mirtazapine which was one tablet was given to the patient at bedtime. The caregiver confirmed the patient did not receive 30mg of Mirtazapine at bedtime as listed on the hospice medication profile. During a joint record review and interview on 06/05/2025, the Director of Nursing/Alternate Administrator (Personnel Record 2) confirmed that the clinical records did not include documentation that the medications were reconciled and updated to the drug profile.

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 the following: 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 clinical record review and interview. In 1 of 19 (5%) clinical records reviewed, the agency did not ensure the individualized written plan of care included a detailed statement of the scope and frequency of services necessary to meet patient and family needs. CLINICAL RECORD 9: The patient elected the hospice benefit on 04/17/2025. The plan of care dated 04/17/2025 included an order for Skilled Nursing, Medical Social Worker, and Chaplain to provide visits PRN [as needed]. The plan of care did not include a detailed statement of the scope and frequency of visits for the disciplines ordered for the patient. During a joint review of the record and an interview on 06/06/2025, the Director of Nursing/Alternate Administrator (Personnel Record 2) confirmed that the patient's written plan of care did not include the scope and frequency of services for the Skilled Nurse, Medical Social Worker, and Chaplain.

It is required that the Interdisciplinary Group, in collaboration with the individual's attending physician (if any), reviews, revises, and documents the individualized care plan, as frequently as the patient's condition requires, but no less frequently than every 15 calendar days. A revised plan of care includes information from the patient’s updated comprehensive assessment and record of the patient’s progress toward the outcomes and goals specified in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 4 of 19 (21%) clinical records reviewed, the organization did not ensure the Interdisciplinary Group reviewed and revised the plan of care and recorded the patient’s progress towards outcomes and goals specified in the plan of care. CLINICAL RECORD 5: The patient elected the hospice benefit on 10/24/2024. Clinical record review reveled the Interdisciplinary Group (IDG) notes dated 01/23/2025, 02/06/2025, 02/20/2025, 03/06/2025, 03/20/2025, 04/03/2025, 04/17/2025, 05/01/2025, and 05/15/2025 did not include documentation that the Medical Social Worker and Chaplain had reviewed and updated the plan of care related to the patient’s progress towards outcomes and goals specified in the plan of care. CLINICAL RECORD 16: The patient elected the hospice benefit on 09/15/2024. Clinical record review reveled the IDG notes dated 10/11/2024 and 10/25/2024 did not include documentation that the Skilled Nurse, Medical Social Worker, and Chaplain had reviewed and updated the plan of care related to the patient’s progress towards outcomes and goals specified in the plan of care. CLINICAL RECORD 18: The patient elected the hospice benefit on 02/11/2025. Clinical record review reveled the IDG notes dated 10/31/2024, 11/14/2024, 11/27/2024, 12/12/2024, and 12/26/2024 did not include documentation that the Medical Social Worker and Chaplain had reviewed and updated the plan of care related to the patient’s progress towards outcomes and goals specified in the plan of care. CLINICAL RECORD 19: The patient elected the hospice benefit on 02/11/2025. Clinical record review reveled the IDG notes dated 02/14/2025 did not include documentation that the Skilled Nurse, Medical Social Worker, and Chaplain had reviewed and updated the plan of care related to the patient’s progress towards outcomes and goals specified in the plan of care. The IDG notes dated 02/28/2025 and 03/14/2025 did not include documentation that the Chaplain had reviewed and updated the plan of care related to the patient’s progress towards outcomes and goals specified in the plan of care. During a joint review of the records and an interview on 06/06/2025, the Director of Nursing/Alternate Administrator (Personnel Record 2) agreed the clinical records did not include documentation that IDG members had reviewed the plan of care and updated the patient's progress towards outcomes and goals.

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, observation, and interview. In 2 of 4 (50%) home visit observations, the agency did not ensure the staff performed hand hygiene as required by agency policy. Agency policy IC.15 Hand Hygiene, last reviewed 09/01/2024, required in part, "Staff may use an alcohol-based hand rub for routinely decontaminating hands in the clinical situation described below: after contact with body fluids or excretions, mucous membranes, nonintact skin, and wound dressings and used supplies (PPE [personal protection equipment]) if hands are not visibly soiled; after contact with blood, bodily fluids, or contaminated surfaces; and after removing gloves." HOME VISIT 1: During the home visit observation on 06/04/2025 with the Hospice Aide (HA) (Personnel Record 8), the HA was observed to don (apply) gloves, wash the patient's head and face, and retrieve the laundry hamper with gloved hands for the dirty bathing linens. The HA changed the gloves but did not decontaminate the hands. The HA bathed the patient, changed out the water, and prepared the bed to change the sheet. The HA put the new sheets on one half of the bed. The HA changed the gloves but did not decontaminate the hands and finished changing the bed and brief. The HA continued with the patient's care. The HA removed the gloves, washed the hands with soap and water, turned off the faucet with wet hands, and then used a paper towel to dry the hands. The HA did not follow the agency’s hand hygiene policy, when the HA did not decontaminate hands when soiled gloves were removed and new gloves were applied. HOME VISIT 2: During the home visit observation on 06/04/20254 with the Hospice Aide (HA) (Personnel Record 8), the HA was observed to retrieve a box of gloves from the patient's drawer and place them on the over-the-bed table. The HA put the gloves on, used a wash basin that was grey to empty the catheter bag, and emptied the urine into the commode. The HA rinsed out the wash basin. The HA changed the gloves without decontaminating the hands. The HA retrieved a wash basin that was white from the facility's clean linen closet to use for the bath. The HA stated that those basins will remain in the patient's room. The HA washed the patient's hair, removed one glove, turned off the patient's fan, and put on a new glove. The HA did not decontaminate the hands when soiled gloves were removed and new gloves were applied. During a document review and interview on 06/05/2025, the Director of Nursing/Alternate Administrator agreed that the staff did not follow the agency’s hand hygiene policy.

It is required that consistent with current professional standards of practice, licensed professionals actively participate in the coordination of all aspects of patient care including conducting ongoing interdisciplinary comprehensive assessments, developing and evaluating the plan of care, and contributing to patient and family counseling and education. This standard was not met as evidenced by personnel record review and interview. In 1 of 1 (100%) personnel record reviewed for medical social services, the agency did not ensure that professional standards were consistent with the standards for providing social work services by direct staff only. PERSONNEL RECORD 6: Medical Social Worker date of hire 02/25/2021. Personnel record review revealed a W-4 tax from completed for direct hire employees dated on 04/22/2021. The record also contained W-9 tax forms completed for contracted staff that were signed and dated on 04/26/2021, 01/06/2023, 01/05/2024, and 01/10/2025. There was no documented evidence in the personnel record to verify that the Social Worker as part of the agency’s core services was a direct hire employee. During personnel record review and an interview on 06/04/2025, the Administrator (Personnel Record 1) confirmed that the Social Worker was under contract with the W-9 form completed and there was not another social worker employed for the agency's location. The Administrator stated that it was thought that since the employee was not a full-time employee, they would be considered a contract employee. The Administrator stated that the Social Worker would be contacted to change his employee status.

It is required that hospice “core” services are substantially provided directly by hospice employees in a manner consistent with acceptable standards of practice. “Core” services include nursing services, medical social work, and counseling. The hospice may contract for physician services per standard HCDT 5.I in this chapter. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This condition of participation was not met as evidenced by review of personnel records, contracts, and interviews with the Administrator and the Director of Nursing/Alternate Administrator which revealed the following issues with the provision of core services, including nursing services, medical social services, spiritual counseling, and physician services: Failure to ensure professional standards were consistent with the standards for providing social work services by direct staff only [HCDT.2.I/L585]; Failure to ensure physician employees and those under contract functioned under the supervision of the hospice medical director [HCDT.5.I/L590]; Failure to ensure nursing care and services were provided per the plan of care [HCDT.6.I/L591]; and Failure to ensure patients and their families were provided with spiritual counseling services to meet these needs in accordance with their acceptance of this service [HCDT.11.I/L598]. The cumulative effect of these deficiencies has resulted in the home health organization's inability to ensure the provision of quality of care for the Condition of Participation CFR 418.64: Core Services. The collective deficient practice illustrated systemic process failures that had the potential to affect all patients receiving home health care service from the agency.

It is required that the hospice medical director, physician employees, and contracted physician(s), in conjunction with the patient’s attending physician, are responsible for the palliation and management of the terminal illness as well as conditions related to the terminal illness. All physician employees, and those under contract, must function under the supervision of the hospice medical director. This standard was not met as evidenced by document review, personnel record review, and interview. The agency did not ensure that physician employees and those under contract functioned under the supervision of the hospice medical director. During a review of the hospice program, it was discovered that the agency was operating an alternate delivery site (ADS) that was not approved by Medicare. The Administrator (Personnel Record 1) confirmed during an interview on 06/06/2025 that the ADS had a current census of 7 patients, and had separate hospice staff for this location, including Skilled Nurses, Social Workers, Chaplains, Aides, and a separate Medical Director. Review of the contracts for the Hospice Medical Director (HMD) (Personnel Record 3) and the ADS Medical Director (ADS MD) (Personnel Record 4) revealed the contracts were identical and did not identify which physician was responsible for supervision of the hospice physicians and which physician would act under the supervision of the hospice medical director. The Medical Director Contract Agreement, for the Hospice Medical Director (HMD) (Personnel Record 3), read in part, "This Agreement is entered into this 20th day of April, 2020 by and between (HMD), referred to in this Agreement as 'Physician' and (agency), referred to in this Agreement as 'Hospice'... Responsibilities of Physician: Assume overall responsibility for the medical component of the Hospice's patient care program. Upon admission and on an ongoing basis, will collaborate with the patient's attending Physician for the application and management of the patient's terminal illness and related conditions, as part of the plan of care (POC). If the attending Physician is not available, the Physician (Medical Director) will be responsible for meeting the medical needs of the patient. Provide supervision and oversight for physician employees and those under contract with Hospice." The Medical Director Contract Agreement, for the ADS Medical Director (ADS MD) (Personnel Record 4), read in part, "This Agreement is entered into this 15th day of September 2023 by and between (ADS MD), referred to in this Agreement as 'Physician' and (agency), referred to in this Agreement as 'Hospice'... Responsibilities of Physician: Assume overall responsibility for the medical component of the Hospice's patient care program. Upon admission and on an ongoing basis, will collaborate with the patient's attending Physician for the application and management of the patient's terminal illness and related conditions, as part of the plan of care (POC). If the attending Physician is not available, the Physician (Medical Director) will be responsible for meeting the medical needs of the patient. Provide supervision and oversight for physician employees and those under contract with Hospice." Review of the hospice physician job description for the Hospice Medical Director (HMD) (Personnel Record 3) and the ADS Medical Director (ADS MD) (Personnel Record 4) revealed the job descriptions were identical and did not identify which physician was responsible for supervision of the hospice physicians and which physician would act under the supervision of the hospice medical director. Personnel Record 3: Medical Director, hospice, date of hire/contract 04/20/2020. The Job Description/Performance Evaluation for the Job Title: Medical Director, dated 06/01/2020, included documentation that read in part, "Essential Functions: Assumes overall responsibility for the medical component of the Hospice program, including providing oversight of physician services. Supervises all physician employees and those under contract to the Hospice." The Job Description/Performance Evaluation was last signed by the Hospice Medical Director on 05/05/2025. Personnel Record 4: Medical Director, ADS, date of hire/contract 09/15/2023. The Job Description/Performance Evaluation for the Job Title: Medical Director/Hospice Physician Designee, dated 10/01/2023, included documentation that read in part, "Essential Functions: Assumes overall responsibility for the medical component of the Hospice program, including providing oversight of physician services. Supervises all physician employees and those under contract to the Hospice." The Job Description/Performance Evaluation was signed by the ADS Medical Director on 10/20/2023. During an interview on 06/06/2025, the Hospice Medical Director (HMD) (Personnel Record 3) stated that the coverage area was for the main location. The HMD reported that there is a separate Medical Director (Personnel Record 4) for the alternate delivery location. The [alternate] location functions independently from the [parent location], including the IDG [interdisciplinary group] meetings. The HMD reported that the [alternate location] oversees the nurse practitioners there. During a joint document review and interview on 06/06/2025, the Administrator (Personnel Record 1) confirmed that the physicians are both considered Medical Directors and operate independently of each other. During a document review, it was discovered that the contracts for the physicians at the parent location and the alternate location were identical in terms of responsibilities. Both physicians had the same job description. The records lacked documented evidence that the agency ensured that the physician employees and those under contract functioned under the supervision of the hospice medical director.

It is required that nursing care and services are provided by or under the supervision of a registered nurse and per the patient plan of care. Nursing services ensure that the nursing needs of the patient are met as identified in the patient’s initial assessment, comprehensive assessment, and any updated assessments. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed, the agency did not ensure nursing care and services were provided per the plan of care. CLINICAL RECORD 3: The patient elected the hospice benefit on 09/25/2023 with diagnoses of vascular dementia, Alzheimer's disease, anxiety, and hypertension. The plan of care dated 01/01/2025 included an order for Skilled Nurse frequency of visits 1/week 3/mo. 10 prn [once a week for three months with 10 as needed visits]. Clinical record review revealed a missed visit form (RN - Skilled Nursing Visit) dated 01/24/2025 included the documentation, "No answer to phone call. Unable to reach the primary contact/spouse [name] to schedule nursing visit." A missed visit form (RN - Skilled Nursing Visit) dated 01/29/2025 included the documentation, "Nurse called patient several times, no answer. Nurse traveled to patient home. Someone was in the house with their head to the picture window moving, but did not answer the door. Nurse notified [staff] ...was uncomfortable returning to the home." The clinical record did not include documentation of nursing visits for the weeks of 01/19/2025 to 01/25/2025 and 01/26/2025 to 02/01/2025, and there was no documented evidence in the clinical record of a physician order to discontinue nursing services. During a joint record review and interview on 06/03/2025, the Director of Nursing/Alternate Administrator (Personnel Record 2) confirmed that the nursing services were not provided per the patient plan of care for the weeks listed.

It is required that counseling services include spiritual \counseling. The hospice provides an assessment of the patient’s and family’s spiritual needs. Spiritual counseling to meet spiritual needs is provided in accordance with the patient’s and family’s acceptance of the services and in a manner consistent with the patient and family beliefs and desires. The hospice advises the patient and family of spiritual counseling services and documents the acceptance or refusal of services. The hospice also makes all reasonable efforts to facilitate visits by local clergy, pastoral counselors, or others who can support the patient’s spiritual needs. This standard was not met as evidenced by clinical record review and interview. In 2 of 15 (13%) clinical records reviewed, the agency did not ensure that patients and their families were provided with spiritual counseling services to meet these needs in accordance with their acceptance of this service. CLINICAL RECORD 5: The patient elected the hospice benefit on 10/24/2024. The plans of care for the benefit periods dated 10/24/2024, 01/22/2025, and 04/22/2025 included an order for “Chaplain 1/mo. 3/mo. with 2 prn [once a month for three months with two as needed visits] for change in status." The plans of care were reviewed at IDG [interdisciplinary group] meetings dated 11/14/2024, 12/12/2024, 02/06/2025, 03/06/2025, 04/03/2025, and 05/15/2025; and no changes were made to the plan of care orders for the Chaplain. Clinical record review revealed no documented evidence that the Chaplain provided visits to the patient for the months of October 2024, November 2024, December 2024, January 2025, February 2025, March 2025, April 2025, and May 2025 and there were no physician orders in the clinical record to discontinue Chaplain services. CLINICAL RECORD 6: The patient elected the hospice benefit on 02/24/2024. The Registered Nurse documented on the initial assessment dated 02/24/2024 that the "family would like to speak with Chaplain as well for coping." The plan of care dated 02/24/2024 included an order for "Chaplain 2/mo. with 1 prn [two times a month with one as needed visit] for Spiritual Counselor interventions." The plan of care was reviewed at the IDG meetings dated 03/05/2024 and 04/04/2025 and no changes were made to the order for Chaplain services. The plans of care dated 04/18/2024 and 05/30/2024 included an updated Chaplain order for "Chaplain 2/mo. with 3 prn [two times a month with three as needed visits] for Spiritual Counselor interventions." Clinica record review revealed no documented evidence that the Chaplain provided visits to the patient for the months of February 2024, March 2024, April 2024, May 2024, and June 2024 and there were no physician orders in the clinical record to discontinue Chaplain services. During a joint clinical record review and an interview on 06/06/2025 the Director of Nursing/Alternate Administrator confirmed that there was no documented evidence that spiritual counseling services were provided during the times identified.

It is required that hospice aides are supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. The hospice aide does not need to be present. This standard was not met as evidenced by clinical record review and interview. In 3 of 16 (19%) clinical records reviewed with hospice aide services provided, the agency did not ensure that the Registered Nurse made on-site aide supervisory visits to the patient’s home no less frequently than every 14 days. CLINICAL RECORD 2: The patient elected the hospice benefit on 04/07/2025 and hospice aide services started on 04/08/2025. Clinical record review revealed the first aide supervisory visit was documented by the Registered Nurse on 04/24/2025, a total of 16 days after the first aide visit and 2 days outstanding. The next aide supervisory visit was dated 05/14/2025, a total of 20 days after the 04/24/2025 supervisory visit and 6 days outstanding. CLINICAL RECORD 7: The patient elected the hospice benefit on 07/30/2024 and hospice aide services started on 07/30/2024. Clinical record review revealed an aide supervisory visit was documented on 02/19/2024 and aide services were discontinued on 03/10/2024. There was no documented evidence of an aide supervisory visit from 02/19/2024 to 03/10/2024, a total of 19 days and 5 days outstanding. CLINICAL RECORD 10: The patient elected the hospice benefit on 01/09/2025 and hospice aide services started on 01/10/2025. Clinical record review revealed an aide supervisory visit was documented on 02/17/2025 and the next aide supervisory visit was dated 03/07/2025, a total of 18 days and 4 days outstanding. An aide supervisory visit was dated 05/13/2025 and the next aide supervisory visit was dated 05/29/2025, a total of 15 days and 1 day outstanding. During a joint clinical record review and interview on 06/06/2025, the Director of Nursing/Alternate Administrator (Personnel Record 2) confirmed that the registered nurse did not make on-site supervisory visits every 14 days as required.

It is required that the hospice documents and demonstrates viable and ongoing efforts to recruit and retain volunteers. This standard was not met as evidenced by document review and interview. The hospice did not ensure the volunteer program documented ongoing efforts to retain volunteers. Review of the agency’s volunteer program revealed no documented evidence of the agency’s efforts to retain volunteers for 2024 and year to date for 2025. During an interview on 06/05/2025, the Volunteer Coordinator confirmed that the retention efforts were not documented for 2024 and year to date for 2025. The findings were reviewed with the Administrator (Personnel Record 1) on 06/06/2025, who also confirmed that the agency did not have documentation of volunteer retention efforts for 2024 and through May of 2025. Upon reviewing the volunteer program, the documentation lacked evidence of efforts to retain volunteers for 2024 and through May 2025 for the parent and alternate delivery sites.

It is required that a hospice operating multiple locations, also known as alternative delivery sites (ADS), ensures that each location is approved by Medicare as a multiple location before providing hospice care and services to Medicare patients. This standard was not met as evidenced by document review and interview. The agency was operating a second location and providing care to patients without documentation of approval for the second location by Medicare. During document review and interviews with the Administrator (Personnel Record 1) on 06/06/2025 it was discovered that the agency was operating an alternate delivery site (ADS) and providing hospice care to patients at a separate location that was located approximately 240 miles from the main office. The agency did not have documentation of Medicare approval for the ADS. The Administrator confirmed that the ADS had a current census of 7 patients, out of a total census of 21 patients, and explained that approximately 33% (62 patients) of the unduplicated admission for the last 12 months were patients at the ADS. The Administrator also explained that the ADS had separate hospice staff for this location, including Skilled Nurses, Social Workers, Chaplains, Aides, and a separate Medical Director. The ADS conducted its own interdisciplinary group (IDG) meetings remotely or at a predetermined location. The agency ships patient supplies to the patient's homes in the ADS area. There was an Inpatient Respite Facility Contracts for the ADS site dated 12/08/2023 and 04/30/2025, and an Independent Contract Agreement for therapy for the ADS site dated 10/30/2024. The agency’s admission packet provided to patients at admission included the parent location and the ADS location as service locations, included one 24-hour phone number for both locations. The agency had no documented evidence to show that an alternate delivery site had been approved by Medicare before providing hospice care and services to Medicare patients. During a document review and interview on 06/06/2025, the Administrator (Personnel Record 1) confirmed that the agency lacked documentation for an alternate delivery site. The Administrator stated that the location had been identified as an Administrative Support Site for the past several years. A discussion occurred related to the definitions of an administrative support site and an alternate delivery site. After the discussion, the Administrator agreed that the site is an Alternate Delivery Site. During a document review, it was discovered that the agency was operating without the designation or approval as an ADS located approximately 240 miles from the main office. The alternate location has a separate staff, including nursing, social workers, chaplain, aides, and a separate medical director. The alternate location conducts its interdisciplinary group (IDG) meetings remotely or at a predetermined location. The agency drop-ships all supplies to the patients in this site area. The alternate location comprises 33% of the agency's active census and 24% of the unduplicated admission census. The admission packet has the primary and alternate locations as service locations. There was one 24-hour phone number for both locations. There was an Inpatient Respite Facility Contract for the alternate site, dated 12/08/2023 and 04/30/2025, and an Independent Contract Agreement for therapy, dated 10/30/2024. The agency lacked documentation to show that an alternate delivery site had been approved by Medicare before providing hospice care and services to Medicare patients.

It is required that a hospice may contract for medical director services with either a self-employed physician or a physician employed by a professional entity or physician group. The contract specifies the physician who assumes the medical director responsibilities and obligations. This standard was not met as evidenced by document review and interview. The agency did not ensure the hospice physician’s contract specified which physician assumed the Medical Director responsibilities. During a review of the hospice program, it was discovered that the agency was operating an alternate delivery site (ADS) that was not approved by Medicare. The Administrator (Personnel Record 1) confirmed during an interview on 06/06/2025 that the ADS had a current census of 7 patients, and had separate hospice staff for this location, including Skilled Nurses, Social Workers, Chaplains, Aides, and a separate Medical Director. Review of the contracts for the Hospice Medical Director (HMD) (Personnel Record 3) and the ADS Medical Director (ADS MD) (Personnel Record 4) revealed the contracts were identical and did not identify which physician which physician would assume the Medical Directors responsibilities and obligations. The Medical Director Contract Agreement, for the Hospice Medical Director (HMD) (Personnel Record 3), read in part, "This Agreement is entered into this 20th day of April 2020 by and between (HMD), referred to in this Agreement as 'Physician' and (agency), referred to in this Agreement as 'Hospice'... Responsibilities of Physician: Assume overall responsibility for the medical component of the Hospice's patient care program. Upon admission and on an ongoing basis, will collaborate with the patient's attending Physician for the application and management of the patient's terminal illness and related conditions, as part of the plan of care (POC). If the attending Physician is not available, the Physician (Medical Director) will be responsible for meeting the medical needs of the patient. Provide supervision and oversight for physician employees and those under contract with Hospice." The Medical Director Contract Agreement, for the ADS Medical Director (ADS MD) (Personnel Record 4), read in part, "This Agreement is entered into this 15th day of September 2023 by and between (ADS MD), referred to in this Agreement as 'Physician' and (agency), referred to in this Agreement as 'Hospice'... Responsibilities of Physician: Assume overall responsibility for the medical component of the Hospice's patient care program. Upon admission and on an ongoing basis, will collaborate with the patient's attending Physician for the application and management of the patient's terminal illness and related conditions, as part of the plan of care (POC). If the attending Physician is not available, the Physician (Medical Director) will be responsible for meeting the medical needs of the patient. Provide supervision and oversight for physician employees and those under contract with Hospice." During an interview on 06/06/2025, the Hospice Medical Director (HMD) (Personnel Record 3) stated that the coverage area was for the main location. The HMD reported that there is a separate Medical Director (Personnel Record 4) for the alternate delivery location. The [alternate] location functions independently from the [parent location], including the IDG [interdisciplinary group] meetings. The HMD reported that the [alternate location] Medical Director oversees the nurse practitioners there. During a joint document review and interview on 06/06/2025, the Administrator confirmed that the physicians are both considered Medical Directors and operate independently of each other. The Administrator confirmed that the contracts did not specify the physician who assumes the medical director responsibilities and obligations for the entire hospice. During a document review, it was discovered that the contracts for the physicians revealed that both contracts lacked identification of the Medical Director who assumes the Medical Director's responsibilities and obligations, as both contracts contain identical verbiage. The Job Descriptions were identical in verbiage.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. 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 15 (7%) clinical records reviewed with Chaplain services provided, the organization did not ensure the clinical record included physician’s orders for Chaplain services. CLINICAL RECORD 12: The patient elected the hospice benefit on 10/30/2024. Clinical record review revealed the Chaplain documented visits to the patient on 03/07/2025, 04/04/2025, and 05/02/2025. The plan of care and the clinical record did not include a physician order for chaplain services. During a joint review of the record and an interview on 06/06/2025, the Director of Nursing/Alternate Administrator (Personnel Record 2) agreed that the clinical record did not include a physician order for chaplain services.

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 11 (9%) clinical records reviewed.revealed the hospice did not ensure that the comprehensive assessment that included the spiritual needs was completed. Record # 7 was reviewed and identified that patient elected hospice care on 6/22/2022 with a primary diagnosis of Alzheimer's Disease. Review of the record revealed a spiritual assessment was not completed at the last date of this survey. The record lacked evidence as to the reason the spiritual assessment was not completed. Policy Initial and Comprehensive Assessment Agency policy PE.1 titled "Patient Assessment" states, in part, "The Interdisciplinary Group (IDG) in consultation with the patient's attending physician (if any), will complete the comprehensive assessment no later than five (5) calendar days after the election of the hospice benefit." During an Interview with employee #3 on 8/11/2022, the Alternate Administrator confirmed this finding and stated that "this was overlooked" it was revealed the agency did not ensure the comprehensive assessment was completed to identify the spiritual needs related to the patient’s terminal illness.

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. 2 of 9 (22%) applicable records of hospice aides revealed the hospice did not ensure the hospice aides were provided clear and specific written instructions for the aide assignments, thus leaving the aide to make decisions that outside of the aide’s scope of practice. Clinical Record # 7 was reviewed and identified the patient elected hospice care on 6/22/2022. The Hospice Aide care plan dated 7/23/2022 ordered visit frequency was 5 times a week. Tasks ordered included foot care, shampoo hair, and nail care "as needed." This patient's primary diagnosis was Alzheimer's Diseas and the patient was unable to make their needs known. Clinical Record # 8 was reviewed and identified the patient elected hospice care on care on 5/27/2022. The Hospice Aide care plan dated 7/21/2022 ordered visit frequency was 3 times a week. Tasks ordered included foot care, back rub, nail care, and shave "as needed." This patient's primary diagnosis was Alzheimer's Disease and the patient was unable to make their needs known. During an interview on 8/11/2022, the Alternate Administrator (Staff # 3) confirmed this finding and stated the team did not consider "as needed" as being out of compliance and will educate the team to specify when tasks are to be assigned to HHAs. revealed the agency failed to order hospice services consistent with state law and regulations requiring specific directions of when an HHA will perform as assigned task.