Every finding on record at Copper Sky Hospice LLC

It is required that the hospice Interdisciplinary Group, in consultation with the individual's attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed, the agency did not ensure that the Interdisciplinary Group completed an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care. CLINICAL RECORD 1: A review of the clinical record revealed that the patient elected the hospice benefit and was admitted to hospice care on 10/02/2024. The Skilled Nurse (SN) comprehensive assessment was documented on 10/02/2024. The SN comprehensive assessment included documentation that the patient required Spiritual Counselor (SC) and Social Work (SW) services. An order for SC and SW evaluation was included in the initial Plan of Care (POC). There was a documented SW evaluation visit on 10/16/2024 and a documented SC visit documented on 10/09/2024. There was no additional documentation in the record addressing the delay of SC and SW services. Both evaluations were provided beyond the five-calendar day after-election requirement for the comprehensive assessment. The Director of Clinical Services (DCS) (Personnel Record 2) was interviewed on 02/12/2025 and stated, "There was a reason for the delay in social work and chaplain services, but the clinicians did not document any refusals of service by the patient or his caregiver or communication of delay in services to the patient's physician."

Hospice care and services provided to patients and families follow the individualized plan of care established by the hospice IDG in collaboration with the attending physician (if any), the patient or patient representative, if any of them so desire, and the primary caregiver in accordance with the patient’s needs. This standard was not met as evidenced by clinical record review and interview. In 4 of 14 (29%) clinical records reviewed, the agency did not ensure that Skilled Nursing visits were provided and documented as ordered in the Plan of Care. CLINICAL RECORD 1: A review of the clinical record revealed that the patient elected the hospice benefit and was admitted to hospice care on 10/02/2024. The Interdisciplinary Group (IDG) revised the plan of care (POC) on 01/02/2025. The Skilled Nursing (SN) visit frequency order from 01/02/2025-01/15/2025 was "2 visits in 7 days". There were documented SN visits on 01/03/2025, 01/07/2025, 01/10/2025, and 01/14/2025. The next IDG meeting was held on 01/15/2025, and the SN visit frequency was again updated to "2 visits in 7 days" from 01/15/2025-01/29/2025. No orders were documented in the record covering the SN visits documented on 01/10/2025 and 01/14/2025. CLINICAL RECORD 2: A review of the clinical record revealed that the patient elected the hospice benefit and was admitted to hospice care on 09/19/2024. The Interdisciplinary Group (IDG) revised the plan of care (POC) on 12/18/2024. The Skilled Nursing (SN) visit frequency order from 12/18/2024-01/01/2025 was "2 visits in 7 days". There were documented SN visits on 12/20/2024, 12/24/2024, 12/27/2024, and 12/31/2024. The next IDG meeting was held on 01/02/2025, and the SN visit frequency was again updated to "2 visits in 7 days" from 01/02/2025-01/15/2025. No orders were documented in the record covering the SN visits documented on 12/27/2024 and 12/31/2024. CLINICAL RECORD 3: A review of the clinical record revealed that the patient elected the hospice benefit and was admitted to hospice care on 01/12/2025. The initial Plan of Care (POC) dated 01/12/2025-03/12/2025 included a Skilled Nursing (SN) visit frequency order "2 visits in 7 days". There were documented SN visits on 01/12/2025, 01/13/2025, 01/16/2025, and 01/20/2025. The next IDG meeting was held on 01/15/2025, and the SN visit frequency was again updated to "2 visits in 7 days" from 01/15/2025-01/29/2025. No orders were documented in the record covering the SN visits documented on 1/16/2025, and 01/20/2025. CLINICAL RECORD 8: A review of the clinical record revealed that the patient elected the hospice benefit and was admitted to hospice care on 09/05/2024. The Interdisciplinary Group (IDG) revised the plan of care (POC) on 12/04/2024. The Skilled Nursing (SN) visit frequency order from 12/04/2024-12/18/2024 was "1 visits in 7 days". There were documented SN visits on 12/04/2024, 12/10/2024, and 12/17/2024. The next IDG meeting was held on 12/18/2024, and the SN visit frequency was again updated to "1 visits in 7 days" from 12/18/2024-01/01/2025. No orders were documented in the record covering the SN visits documented on 12/10/2024 and 12/17/2024. The Director of Clinical Services (DCS) (Personnel Record 2) was interviewed on 02/12/2025 and stated, "We have been working with [the electronic medical record vendor] for months trying to figure out how to get the visit frequency orders written during IDG correctly."

It is required that a hospice aide provides services ordered by the Interdisciplinary Group, included in the plan of care, permitted to be performed under state law and regulation, and consistent with the hospice aide training. This standard was not met as evidenced by clinical record review and interview. In 2 of 13 (15%) clinical records reviewed where the patient received Hospice Aide services, the agency did not ensure that the patient received Hospice Aide visits as ordered on the Plan of Care. CLINICAL RECORD 1: A review of the clinical record revealed that the patient elected the hospice benefit and was admitted to hospice services on 10/02/2024. The updated visit frequency for the Hospice Aide (HA) at the Interdisciplinary Group (IDG) meeting on 01/02/2025 was five weekly visits for 01/02/2025-01/15/2025. Three HA visits were documented the week of 01/02/2025, which did not meet the visit frequency written in the IDG order. The IDG updated the HA visit frequency again on 01/15/2024 to five visits each week 01/15/2025-01/29/2025. Three HA visits were documented during the week of 01/15/2025, which did not meet the visit frequency written in the IDG order. CLINICAL RECORD 7: A review of the clinical record revealed that the patient elected the hospice benefit and was admitted to hospice services on 06/12/2024. The updated visit frequency for the Hospice Aide (HA) at the Interdisciplinary Group (IDG) meeting on 09/11/2024 was two visits weekly from 09/11/2024-09/25/2024. There was one documented HA visit during the week of 09/11/2024, which did not meet the visit frequency written in the IDG order. The Director of Clinical Services (DCS) (Personnel Record 2) was interviewed on 02/12/2025 and stated, "We have been working with [the electronic medical record vendor] for months trying to figure out how to get the visit frequency orders written during IDG correctly."

It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. The hospice documents the cost savings achieved through volunteers. This standard was not met as evidenced by document review and interview. A review of the volunteer program cost savings report revealed that the agency did not ensure that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. DOCUMENT: The agency's documentation of volunteer utilization was reviewed. Volunteer utilization was 0.003% of the total patient care hours of all paid hospice employees and contract staff for the calendar year 2024. The agency's Owner/Volunteer Coordinator (VC) (Personnel Record 9) was interviewed on 02/13/2025. The VC stated, "We need to increase the number of available volunteers and increase volunteer utilization." A review of the volunteer program cost savings report revealed that the agency did not ensure that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff.

It is required that Hospice care and services provided to patients and families follow the individualized plan of care established by the hospice IDG in collaboration with the attending physician (if any). This standard was not met as evidenced by interview and clinical record review. 2 of 6 (33%) clinical records reviewed revealed the hospice did not ensure nursing visits followed the visit frequencies included the plan of care and/or physician's orders. Record #18034 was reviewed and identified the nursing visit frequency of "1-2 in the next 7 days" with no PRN visit frequency on the "IDG Review" 4/13/22. Review of the clinical record revealed an extra nursing visit on 4/26/22. During interview on 5/12/22, the Clinical Director confirmed the missing nursing visit frequency to cover the extra nursing visit. . Record #26656 was reviewed and identified the nursing visit frequency of "1-2 in the next 7 days" with no PRN visit frequency on the "IDG Review" 4/13/22. Additionally, the nursing visit frequency of "1-2 in the next 7 days" with no PRN visit frequency on the "IDG Review" 4/27/22. Review of clinical record revealed extra nursing visits on 4/26/22 and 5/10/22. During interview on 5/20/22, the Clinical Director confirmed the missing nursing visit frequency to cover the extra nursing visits. Additionally, in 1 of 6 (17%) clinical records reviewed revealed the hospice did not ensure social worker visits followed the visit frequencies in the plan of care. Record #18034 was reviewed and identified no social worker visit frequency on the "IDG Review" plan of care dated 4/13/22. Review of clinical record revealed a social worker visit on 4/26/22 with no social worker visit frequency ordered and/or included in the plan of care. During interview on 5/20/22, the Clinical Director confirmed there was no visit frequency to cover the 4/26/22 social worker visit. During interview on 5/20/22, Clinical Director stated, "We had orders for the extra nursing and social worker visits, however, we are new to this electric medical record system and have been working with technical support to enter visit frequencies on the plan of care to cover every 14 days and not every 7 days, since our IDG meeting is held every 14 days". Additionally, in 1 of 1 (100%) applicable clinical records with volunteer visit frequencies revealed the hospice did not ensure volunteer visits followed the visit frequency in the plan of care. Record #18034 was reviewed and revealed the volunteer visit frequency of "one visit in the next 7 days" on the "IDG Review" plan of care 4/13/22. Documentation in the clinical record revealed a missing volunteer visit during the timeframe 4/13/22 through 4/20/22. The plan of care was updated 4/27/22 for "no volunteer" visit frequency. Review of the record revealed a volunteer visit had been provided to the patient last on 4/9/22 During interview on 5/20/22, the Clinical Director confirmed the missing volunteer visit and stated, "The IDG discussed that the volunteer was no longer needed and the volunteer visit frequency was not updated until 4/27/22".

It is required that a hospice aide provides services ordered by the Interdisciplinary Group (IDG) and included in the plan of care. This standard was not met as evidenced by interview and clinical record review. 4 of 6 (67%) clinical records reviewed revealed the hospice did not ensure the hospice aide was compliant with the visit frequency included in the plan of care. Record #16714 was reviewed and the clinical record identified the Hospice Aide visit frequency of "two visits in the next 7 days" on the "IDG Update" 4/13/22. Review of the clinical record revealed one missing visit during the time frame 4/13/22 through 4/20/22. During interview on 5/19/22, Clinical Director confirmed the missing Hospice Aide visit note and stated, "The patient refused one of the visits and refusal is not documented". Record #26656 was reviewed and the clinical record identified the Hospice Aide visit frequency of "two visits in the next 7 days" on the "IDG Update" 4/13/22. Additionally, the Hospice Aide visit frequency of "two visits in the next 7 days" on the "IDG Update" 4/27/22. Review of the clinical record revealed extra Hospice Aide visits on 4/21/22, 4/26/22, 5/5/22 and 5/10/22. Record #92040 was reviewed and the clinical record identified the Hospice Aide visit frequency of "two visits in the next 7 days" on the "IDG Update" 4/13/22 . Additionally the Hospice Aide visit frequency was "two visits in next 7 days" on the "IDG Review" 4/27/22. Review of the clinical record revealed extra aide visits on 4/21/22, 4/26/22, 5/5/22 and 5/10/22. Record #38781 was reviewed and the clinical record identified the Hospice Aide visit frequency of "two visits in the next 7 days" on the "IDG Update" 4/27/22. Review of the clinical record revealed extra aide visits on 5/5/22 and 5/10/22. During interview 5/20/22, the Clinical Director stated "we had orders for the extra hospice Aide visits, however, we are new to the electronic medical record system and have been working with technical support to enter visit frequencies to cover every 14 days and not every 7 days, since our IDG meeting is held every 14 days".