Every finding on record at Convenient Hospice Services Inc.

It is required that per policy and procedure, the hospice responds to alleged violations involving anyone working on the hospice’s behalf by immediately investigating all alleged violations, and taking immediate action to prevent further potential violations while the alleged violation is being verified. This standard was not met as evidenced by clinical record review, document review and interview. Review of the clinical record and complaint log revealed that the agency did not ensure that the complaint process was followed after receiving a complaint according to agency policies and procedures. Document 2: Policy Number A: 18 titled, Complaints/Grievances effective 01/2019 stated in part "Upon receiving a patient/family/caregiver complaint, the receiving person shall: Immediately forward the complaint to the administrator for processing. Administrator or designee will be responsible for follow up, investigation, resolution and documentation. Complete a complaint report documenting: date and time of complaint, date and time of alleged occurrence, name and address of person reporting complaint, name of staff receiving complaint, description of alleged incident, name and discipline of staff allegedly involved in the incident, and inform complainant that investigation shall ensure immediately, and they will be notified by the agency administrator of the findings and course of action within 15 days." Document 3: A review of the complaint logs on 06/27/2024 revealed that there were no complaints documented from January 2024 through the date of the review. Clinical Record 4: The election of care was dated 02/10/2022. The clinical record included an "Unattended discharge note" dated 04/07/2024 that stated in part “Writer received a call from facility Director of Nursing (DON) [Name] on 4/6/24 that the facility was requesting to transfer pt to [Hospice Agency]. The DON reported that she felt the pt needed daily visits and expressed her concern regarding communication between hospice and the falls. Personnel Record 3: In a joint record review, document review, and interview on 06/27/2024, the Alternate Administrator confirmed the finding that the complaint process was not followed after receiving the concern/complaint. A review of the clinical record and complaint log revealed that the agency did not ensure that the complaint process was followed after receiving a complaint according to agency policies and procedures.

It is required that the written Patient Bill of Rights includes the right to be informed about the scope of services the hospice provides and any specific limitations on those services. This standard was not met as evidenced by document review and interview. Review of the admission binder and admission packet (supplement to the admission binder) revealed that the agency did not ensure the written Patient Bill of Rights included information about the scope of counseling services the hospice provided and any specific limitations to those services. Document 1: The admission binder and the admission packet supplement were reviewed on 06/26/2024. The document included the scope of services the hospice provided including skilled nursing care, rehabilitation services, home health aide service, and social services. The document did not include information about counseling services or any limitations to counseling services. Document 2: Policy Number: C: 110 titled, Scope of Services, effective 01/2019 stated in part, "An interdisciplinary group of professionals and volunteers will develop, with each patient and family/caregiver, a plan of care, which will include, as appropriate, the following services: d. Counseling." Policy Number: A: 45 titled, Patient Bill of Rights and Responsibilities effective 01/2019 stated in part, "The patient has a right to the following: Receive information about the scope of services that the hospice will provide and specific limitations on those services." Personnel Record 3: The alternate clinical director confirmed findings in a joint document review and interview on 06/26/2024 and stated in part "We do provide bereavement and spiritual counseling, we will get that added to the scope of services." A review of the admission binder and admission packet (supplement to the admission binder) revealed that the agency did not ensure the written Patient Bill of Rights included information about the scope of counseling services the hospice provided and any specific limitations to those services.

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current prescription and over-the-counter (OTC) drugs, supplements, herbal remedies, and other alternative treatments that could affect drug therapy. The medication review process includes the identification of the effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy, and drug therapy associated with laboratory monitoring. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by clinical record review, document review, interview and observation. In 1 of 3 (33%) home visit observations it was revealed that the agency did not ensure that the drug profile included the patient's current prescription and over-the-counter (OTC) drugs, supplements, herbal remedies, and other alternative treatments that could affect drug therapy and as a result, the current medication profile was not reviewed for the effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy, and drug therapy associated with laboratory monitoring. Document 2: Policy Number: C: 80 titled, Medication Profile effective 01/2019 stated in part, "A drug regimen review will be performed at the time of initial and comprehensive assessment, when updates to the comprehensive assessments are performed, and with the addition of a new medication. The review will identify drug/food interactions, potential adverse effects and drug reactions, ineffective drug therapy, duplicative drug therapy, and noncompliance with drug therapy." Home Visit 2: During the home visit observation/clinical record 2 on 06/26/2024 with the registered nurse (personnel record 2), a review of the medications was completed with the in-home caregiver (patient interview 2). The caregiver presented three additional medications not included on the hospice medication profile updated on 06/14/2024. The medications included: cranberry extra with vitamin C 120 mg and 500 mg cranberry exact gel one tablet twice daily, culturelle 15 billion cfu's probiotic one capsule twice daily, and elderberry 50 mg gummy daily. The caregiver was asked how long the patient had been receiving the medications and stated in part "Oh a long time, at least a year." The registered nurse confirmed that the hospice medication profile did not include Cranberry soft gels, Culturelle, or Elderberry. Personnel Record 3: During a joint clinical record review and interview on 06/26/2024, the Alternate Clinical Director confirmed the finding and stated, "We will get those added."

It is required that the hospice’s policies and procedures define a system of communication and integration that sustains coordination of services and provides documentation of exchange of information. The policies and procedures ensure that sharing of information occurs between all disciplines providing care and services in all settings and is ongoing whether or not the care and services are provided directly or under arrangement. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 14 (7%) clinical records reviewed it was revealed that the agency did not ensure that information sharing occurred between disciplines providing care and services. Document 2: Policy Number: C: 68 titled, Interdisciplinary Group Coordination of Care, effective 01/2019, stated in part, "Continuity of care will be maintained throughout the patient's course with hospice. Exchange of information between hospice staff and contracted providers will be documented in the clinical record." Clinical Record 4: The election of care was dated 05/10/2024. The psychosocial visit documentation completed on 06/22/2024 stated in part "Patient is to be discharged from hospice services and requires a coordinated transfer of services. Reason for live discharge: extended prognosis". The clinical record lacked evidence that coordination of care occurred between disciplines regarding discharge from hospice. The spiritual counselor visit documentation completed on 06/21/2024 stated in part "Patient was kind felt isolated and emotionally hurt." The clinical record lacked evidence that the hospice interdisciplinary group was updated on assessment findings. Personnel Record 3: In a joint record review and interview on 06/26/2024, the Alternate Administrator confirmed the findings that the clinical record lacked evidence of coordination of care and sharing of assessment findings with members of the Interdisciplinary Group.

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 including hand hygiene. This standard was not met as evidenced by clinical record review, document review and observation. In 2 of 3 (67%) home visit observations it was revealed that the agency did not ensure that standard precautions including hand hygiene were followed according to accepted standards of practice and agency policy to prevent the transmission of infections and communicable disease. Document 2: Policy Hand Washing (no effective date) stated in part "Policy 1. Agency requires that its employees, who provide personal care, wash their hands: a. when arriving on the job site; d. before and after caring for individual clients; and e. between task and procedures on the same client to prevent cross-contamination of different body sites. 2. Procedures i. Dry hands on a clean cloth towel or on a paper towel and j. Use a dry section of the towel to turn off the tap." Home Visit 1: During the home visit with the hospice aide (personnel record 9), the hospice aide was observed washing hands and donning gloves. The hospice aide collected items for the bed bath, turned on the faucet, and filled the basin with her donned gloves. The hospice aide proceeded with bathing the patient using one washcloth for soapy water for cleaning and a second washcloth used for rinsing (utilizing one washbasin). The hospice aide used the same towel to dry and cover the patient. The hospice aide cleansed the patient's face, chest, arms, legs, and peri area and then changed the water. The hospice aide resumed bathing starting with the buttock area, then rinsed the washcloth in the basin and washed the patient's back. The hospice aide did not change gloves, wash her hands, or use separate washcloths between tasks to prevent cross-contamination of different body sites. The hospice aide care plan effective 04/28/2024 included instructions and stated in part "Incontinent Care-Patient dependent with care: fill wash basin with warm water and soap, utilize wash cloth to cleanse peri area and buttocks. Change water, wash hands, and change gloves. Rinse with a clean washcloth and dry with a towel". Home Visit 2: During the home visit with the Clinical Director/Registered Nurse on 06/26/2024, the nurse was observed washing her hands, drying her hands with a paper towel, and then turning the faucet off with her dry hands. Personnel Record 3: In an interview and joint document review on 06/26/2024, the Alternate Clinical Director confirmed the findings and stated, "We will review this policy and educate."

It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid-certified facility, the hospice forwards to the receiving facility a copy of the hospice discharge summary and the patient’s record if requested. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records reviewed of patients that were transferred to another hospice it was revealed that the agency did not ensure that a hospice discharge summary was sent to the receiving facility. Clinical Record 12: Election of care 05/02/2023. The patient was transferred to another hospice on 09/13/2023. The clinical record lacked evidence that a discharge summary was provided to the receiving facility. Personnel Record 3: In a joint clinical record review and interview on 06/27/2024, the Alternate Clinical Director (personnel record 3) confirmed findings that the clinical record did not include documentation that a discharge summary was sent to the receiving facility.

It is required that the hospice discharge summary provided to a facility receiving a hospice patient for care—or to the patient’s community attending physician upon hospice discharge—includes at least the following: a summary of the patient’s hospice stay, including treatments, symptoms, and pain management, the patient’s current plan of care, the patient’s latest physician orders, and any other documentation that will assist in the post-discharge continuity of care or that is requested by the receiving facility or the attending physician. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) discharged clinical records reviewed of patients that were transferred to another hospice it was revealed that the agency did not ensure a hospice discharge summary included all required elements. Clinical Record 12: The election of care was dated 05/02/2023. The patient was transferred to another hospice on 09/13/2023. The clinical record lacked evidence that the discharge summary included a summary of the patient’s hospice stay, including treatments, symptoms, and pain management; the patient’s current plan of care; the patient’s latest physician orders; and any other documentation that would assist in the post-discharge continuity of care or that was requested by the receiving facility or the attending physician. Personnel Record 3: In a joint clinical record review and interview on 06/27/2024, the Alternate Administrator (personnel record 3) confirmed findings that the clinical record did not include documentation that a discharge summary including a summary of the patient’s hospice stay, including treatments, symptoms, and pain management, the patient’s current plan of care, the patient’s latest physician orders, and any other documentation that would assist in the post-discharge continuity of care or that is requested by the receiving facility or the attending physician was sent to the receiving facility.