Every finding on record at Cornerstone Hospice, LLC

Based on record review and interview, the hospice failed to ensure its policy and procedure included processes and contact information for an integrated emergency preparedness response with Federal, State, Tribal, Regional and Local emergency management officials for all patients, employees and volunteers. --- Findings: A review of administrative records showed no policy and procedure which included processes and contact information for an integrated emergency preparedness response with Federal, State, Tribal, Regional and Local emergency management officials for the hospice. On 08/28/24 at 10:00 a.m., Staff A stated the hospices Emergency Preparedness Plan did not include policy and procedures which included processes and resource contact information for an integrated emergency preparedness response with Federal, State, Tribal, Regional and Local emergency management officials.

Based on record review and interview, the hospice failed to ensure emergency preparedness disaster declaration, table-top exercises, drills, community drills or plan activation events were conducted for 05/01/2022 to 12/31/22, calendar year 2023 and 01/01/24 to 08/27/24 for all patients, volunteers, and employees. --- Findings: A review of administrative records related to emergency preparedness showed no documentation of emergency preparedness disaster declaration, table-top exercises, drills, community drills or plan activation events for 05/01/2022 to 12/31/22, calendar year 2023 and 01/01/24 to 08/27/24. On 08/28/24 at 10:00 a.m., Staff A stated the hospice had no emergency preparedness disaster declaration, table-top exercises, drills, community drills or plan activation events for 05/01/2022 to 12/31/22, calendar year 2023 and 01/01/24 to 08/27/24.

Based on record review and interview, the hospice failed to ensure it provided services for the palliation and management of the terminal illness for 14 (Patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13 and #14) of 14 patients. --- Findings: Patient #1 A review of the clinical record showed an election of the hospice benefit/SOC on 07/12/24. Documentation showed no spiritual assessment, and no psychosocial assessment was conducted and showed no follow up care and services were offered or provided by a MSW or Chaplain. Documentation showed no declined chaplain or MSW visits, no physician notifications, and no changes in orders. Patient #2 A review of the clinical record showed an election of the hospice benefit/SOC on 03/20/24. Documentation showed no spiritual assessment, and no psychosocial assessment was conducted and showed no follow up care and services were offered or provided by a MSW or Chaplain. Documentation showed no declined chaplain or MSW visits, no physician notifications, and no changes in orders. Patient #3 A review of the clinical record showed an election of the hospice benefit/SOC on 08/22/24. Documentation showed no spiritual assessment, and no psychosocial assessment was conducted and showed no follow up care and services were offered or provided by a MSW or Chaplain. Documentation showed no declined chaplain or MSW visits, no physician notifications, and no changes in orders. Patient #4 A review of the clinical record showed an election of the hospice benefit/SOC on 07/25/24. Documentation showed no spiritual assessment, and no psychosocial assessment was conducted and showed no follow up care and services were offered or provided by a MSW or Chaplain. Documentation showed no declined chaplain or MSW visits, no physician notifications, and no changes in orders. Patient #5 A review of the clinical record showed an election of the hospice benefit/SOC on 03/22/24. Documentation showed no spiritual assessment, and no psychosocial assessment was conducted and showed no follow up care and services were offered or provided by a MSW or Chaplain. Documentation showed no declined chaplain or MSW visits, no physician notifications, and no changes in orders. Patient #6 A review of the clinical record showed an election of the hospice benefit/SOC on 08/20/24. Documentation showed no spiritual assessment, and no psychosocial assessment was conducted and showed no follow up care and services were offered or provided by a MSW or Chaplain. Documentation showed no declined chaplain or MSW visits, no physician notifications, and no changes in orders. Patient #7 A review of the clinical record showed an election of the hospice benefit/SOC on 02/23/23. Documentation showed no spiritual assessment, and no psychosocial assessment was conducted and showed no follow up care and services were offered or provided by a MSW or Chaplain. Documentation showed no declined chaplain or MSW visits, no physician notifications, and no changes in orders. Patient #8 A review of the clinical record showed an election of the hospice benefit/SOC on 06/19/24. Documentation showed no spiritual assessment, and no psychosocial assessment was conducted and showed no follow up care and services were offered or provided by a MSW or Chaplain. Documentation showed no declined chaplain or MSW visits, no physician notifications, and no changes in orders. Patient #9 A review of the clinical record showed an election of the hospice benefit/SOC on 05/22/23. Documentation showed no spiritual assessment, and no psychosocial assessment was conducted and showed no follow up care and services were offered or provided by a MSW or Chaplain. Documentation showed no declined chaplain or MSW visits, no physician notifications, and no changes in orders. Patient #10 A review of the clinical record showed an election of the hospice benefit/SOC on 08/06/24. Documentation showed no spiritual assessment, and no psychosocial assessment was conducted and showed no follow up care and services were offered or provided by a MSW or Chaplain. Documentation showed no declined chaplain or MSW visits, no physician notifications, and no changes in orders. Patient #11 A review of the clinical record showed an election of the hospice benefit/SOC on 07/25/22. Documentation showed no spiritual assessment, and no psychosocial assessment was conducted and showed no follow up care and services were offered or provided by a MSW or Chaplain. Documentation showed no declined chaplain or MSW visits, no physician notifications, and no changes in orders. Patient #12 A review of the clinical record showed an election of the hospice benefit/SOC on 02/27/24. Documentation showed no spiritual assessment, and no psychosocial assessment was conducted and showed no follow up care and services were offered or provided by a MSW or Chaplain. Documentation showed no declined chaplain or MSW visits, no physician notifications, and no changes in orders. Patient #13 A review of the clinical record showed an election of the hospice benefit/SOC on 02/19/24. Documentation showed no spiritual assessment, and no psychosocial assessment was conducted and showed no follow up care and services were offered or provided by a MSW or Chaplain. Documentation showed no declined chaplain or MSW visits, no physician notifications, and no changes in orders. Patient #14 A review of the clinical record showed an election of the hospice benefit/SOC on 06/24/22. Documentation showed no spiritual assessment was conducted and showed no follow up care and services were offered or provided by a MSW or Chaplain. Documentation showed no declined chaplain or MSW visits, no physician notifications, and no changes in orders. On 08/28/24 at 10:42 a.m. to 11:30, Staff B stated: 1. The Chaplain had not conducted the initial spiritual assessment for patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13 and #14 within the five-day timeframe required to complete the initial comprehensive assessment; 2. The MSW had not conducted the initial psychosocial assessment for patients #1, 2, 3, 5, 6, 7, 8, 9, 10, 11, 12, 13 and #14 within the five-day timeframe required to complete the initial comprehensive assessment; 3. The hospice didnt have a MSW or Chaplain and we (the Hospice) thought that if the hospice was looking for an MSW and Chaplain the nurse could complete the psychosocial and spiritual parts of the comprehensive assessments and; If the patients or patient family members requested a MSW or Chaplain we would refer them to services outside of the hospice, or our (the hospice) volunteer chaplain would see them.

Based on record review and interview, the hospice failed to ensure: Initial spiritual assessments were conducted by the Chaplain within the five-day timeframe required to complete the initial comprehensive assessment for 14 (Patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13 and #14) of 14 patients. 2 Initial psychosocial assessments were conducted by the MSW within the five-day timeframe required to complete the initial comprehensive assessment for 13 (Patients #1, 2, 3, 5, 6, 7, 8, 9, 10, 11, 12, 13 and #14) of 14 patients. The failed practice had the potential to effect the hospices ability to identify immediate patient needs and provide necessary care and services to meet those needs for all patients. See tag L523. Based on record review and interview, the hospice failed to ensure development of a bereavement POC for 14 (Patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13 and #14) of 14 patients. The failed practice had the potential to effect the hospices ability to identify and address bereavement issues that would impact the patient, family or other caregivers ability to cope with the patients death for all patients. See tag L531. Based on record review and interview, the hospice failed to ensure the IDG developed and initiated a POC after the SOC for 14 (Patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13 and #14) of 14 patients. The failed practice had the potential to effect the hospices ability to evaluate the patient's response to the care, treatment and services provided to meet desired patient outcomes for all patients. See tag L533. --- .

Based on record review and interview, the hospice failed to ensure: 1. Initial spiritual assessments were conducted by the Chaplain within the five-day timeframe required to complete the initial comprehensive assessment for 14 (Patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13 and #14) of 14 patients. 2. Initial psychosocial assessments were conducted by the MSW within the five-day timeframe required to complete the initial comprehensive assessment for 13 (Patients #1, 2, 3, 5, 6, 7, 8, 9, 10, 11, 12, 13 and #14) of 14 patients. The failed practice had the potential to effect the hospices ability to identify immediate patient needs and provide necessary care and services to meet those needs for all patients. --- Findings: Patient #1 A review of the clinical record showed an election of the hospice benefit/SOC on 07/12/24. Documentation showed no spiritual assessment, and no psychosocial assessment was conducted by 07/17/24 (five days from the date of election). Documentation showed no declined chaplain or MSW visits and no changes in orders. Patient #2 A review of the clinical record showed an election of the hospice benefit/SOC on 03/20/24. Documentation showed no spiritual assessment, and no psychosocial assessment was conducted by 03/25/24 (five days from the date of election). Documentation showed no declined chaplain or MSW visits and no changes in orders. Patient #3 A review of the clinical record showed an election of the hospice benefit/SOC on 08/22/24. Documentation showed no spiritual assessment, and no psychosocial assessment was conducted by 08/27/24 (five days from the date of election). Documentation showed no declined chaplain or MSW visits and no changes in orders. Patient #4 A review of the clinical record showed an election of the hospice benefit/SOC on 07/25/24. Documentation showed no spiritual assessment, and no psychosocial assessment was conducted by 07/30/24 (five days from the date of election). Documentation showed no declined chaplain or MSW visits and no changes in orders. Patient #5 A review of the clinical record showed an election of the hospice benefit/SOC on 03/22/24. Documentation showed no spiritual assessment, and no psychosocial assessment was conducted by 03/27/24 (five days from the date of election). Documentation showed no declined chaplain or MSW visits and no changes in orders. Patient #6 A review of the clinical record showed an election of the hospice benefit/SOC on 08/20/24. Documentation showed no spiritual assessment, and no psychosocial assessment was conducted by 08/25/24 (five days from the date of election). Documentation showed no declined chaplain or MSW visits and no changes in orders. Patient #7 A review of the clinical record showed an election of the hospice benefit/SOC on 02/23/23. Documentation showed no spiritual assessment, and no psychosocial assessment was conducted by 02/28/23 (five days from the date of election). Documentation showed no declined chaplain or MSW visits and no changes in orders. Patient #8 A review of the clinical record showed an election of the hospice benefit/SOC on 06/19/24. Documentation showed no spiritual assessment, and no psychosocial assessment was conducted by 06/24/24 (five days from the date of election). Documentation showed no declined chaplain or MSW visits and no changes in orders. Patient #9 A review of the clinical record showed an election of the hospice benefit/SOC on 05/22/23. Documentation showed no spiritual assessment, and no psychosocial assessment was conducted by 05/27/23 (five days from the date of election). Documentation showed no declined chaplain or MSW visits and no changes in orders. Patient #10 A review of the clinical record showed an election of the hospice benefit/SOC on 08/06/24. Documentation showed no spiritual assessment, and no psychosocial assessment was conducted by 08/11/24 (five days from the date of election). Documentation showed no declined chaplain or MSW visits and no changes in orders. Patient #11 A review of the clinical record showed an election of the hospice benefit/SOC on 07/25/22. Documentation showed no spiritual assessment, and no psychosocial assessment was conducted by 07/30/22 (five days from the date of election). Documentation showed no declined chaplain or MSW visits and no changes in orders. Patient #12 A review of the clinical record showed an election of the hospice benefit/SOC on 02/27/24. Documentation showed no spiritual assessment, and no psychosocial assessment was conducted by 03/03/23 (five days from the date of election). Documentation showed no declined chaplain or MSW visits and no changes in orders. Patient #13 A review of the clinical record showed an election of the hospice benefit/SOC on 02/19/24. Documentation showed no spiritual assessment, and no psychosocial assessment was conducted by 02/24/24 (five days from the date of election). Documentation showed no declined chaplain or MSW visits and no changes in orders. Patient #14 A review of the clinical record showed an election of the hospice benefit/SOC on 06/24/22. Documentation showed no spiritual assessment was conducted by 06/29/24 (five days from the date of election). Documentation showed no declined chaplain visits and no changes in orders. On 08/28/24 at 10:42 a.m. to 11:30, Staff B stated: 1. The Chaplain had not conducted the initial spiritual assessment for patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13 and #14 within the five-day timeframe required to complete the initial comprehensive assessment; 2. The MSW had not conducted the initial psychosocial assessment for patients #1, 2, 3, 5, 6, 7, 8, 9, 10, 11, 12, 13 and #14 within the five-day timeframe required to complete the initial comprehensive assessment; and The hospice didnt have a MSW of Chaplain and we (the Hospice) thought that if the hospice was looking for an MSW and Chaplain the nurse could complete the psychosocial and spiritual parts of the comprehensive assessments.

Based on record review and interview, the hospice failed to ensure development of a bereavement POC for 14 (Patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13 and #14) of 14 patients. The failed practice had the potential to effect the hospices ability to identify and address bereavement issues that would impact the patient, family or other caregivers' ability to cope with the patients death for all patients. --- Findings: Patient #1 A review of the clinical record showed an election of the hospice benefit/SOC on 07/12/24. Documentation showed no spiritual assessment, and no psychosocial assessment was conducted (initial bereavement assessment) and showed no bereavement POC. Documentation showed no patient or caregiver refusal of a bereavement POC and showed no change in orders. Patient #2 A review of the clinical record showed an election of the hospice benefit/SOC on 03/20/24. Documentation showed no spiritual assessment, and no psychosocial assessment was conducted (initial bereavement assessment) and showed no bereavement POC. Documentation showed no patient or caregiver refusal of a bereavement POC and showed no change in orders. Patient #3 A review of the clinical record showed an election of the hospice benefit/SOC on 08/22/24. Documentation showed no spiritual assessment, and no psychosocial assessment was conducted (initial bereavement assessment) and showed no bereavement POC. Documentation showed no patient or caregiver refusal of a bereavement POC and showed no change in orders. Patient #4 A review of the clinical record showed an election of the hospice benefit/SOC on 07/25/24. Documentation showed no spiritual assessment, and no psychosocial assessment was conducted (initial bereavement assessment) and showed no bereavement POC. Documentation showed no patient or caregiver refusal of a bereavement POC and showed no change in orders. Patient #5 A review of the clinical record showed an election of the hospice benefit/SOC on 03/22/24. Documentation showed no spiritual assessment, and no psychosocial assessment was conducted (initial bereavement assessment) and showed no bereavement POC. Documentation showed no patient or caregiver refusal of a bereavement POC and showed no change in orders. Patient #6 A review of the clinical record showed an election of the hospice benefit/SOC on 08/20/24. Documentation showed no spiritual assessment, and no psychosocial assessment was conducted (initial bereavement assessment) and showed no bereavement POC. Documentation showed no patient or caregiver refusal of a bereavement POC and showed no change in orders. Patient #7 A review of the clinical record showed an election of the hospice benefit/SOC on 02/23/23. Documentation showed no spiritual assessment, and no psychosocial assessment was conducted (initial bereavement assessment) and showed no bereavement POC. Documentation showed no patient or caregiver refusal of a bereavement POC and showed no change in orders. Patient #8 A review of the clinical record showed an election of the hospice benefit/SOC on 06/19/24. Documentation showed no spiritual assessment, and no psychosocial assessment was conducted (initial bereavement assessment) and showed no bereavement POC. Documentation showed no patient or caregiver refusal of a bereavement POC and showed no change in orders. Patient #9 A review of the clinical record showed an election of the hospice benefit/SOC on 05/22/23. Documentation showed no spiritual assessment, and no psychosocial assessment was conducted (initial bereavement assessment) and showed no bereavement POC. Documentation showed no patient or caregiver refusal of a bereavement POC and showed no change in orders. Patient #10 A review of the clinical record showed an election of the hospice benefit/SOC on 08/06/24. Documentation showed no spiritual assessment, and no psychosocial assessment was conducted (initial bereavement assessment) and showed no bereavement POC. Documentation showed no patient or caregiver refusal of a bereavement POC and showed no change in orders. Patient #11 A review of the clinical record showed an election of the hospice benefit/SOC on 07/25/22. Documentation showed no spiritual assessment, and no psychosocial assessment was conducted (initial bereavement assessment) and showed no bereavement POC. Documentation showed no patient or caregiver refusal of a bereavement POC and showed no change in orders. Patient #12 A review of the clinical record showed an election of the hospice benefit/SOC on 02/27/24. Documentation showed no spiritual assessment, and no psychosocial assessment was conducted (initial bereavement assessment) and showed no bereavement POC. Documentation showed no patient or caregiver refusal of a bereavement POC and showed no change in orders. Patient #13 A review of the clinical record showed an election of the hospice benefit/SOC on 02/19/24. Documentation showed no spiritual assessment, and no psychosocial assessment was conducted (initial bereavement assessment) and showed no bereavement POC. Documentation showed no patient or caregiver refusal of a bereavement POC and showed no change in orders. Patient #14 A review of the clinical record showed an election of the hospice benefit/SOC on 06/24/22. Documentation showed no spiritual assessment was conducted (initial bereavement assessment) and showed no bereavement POC. Documentation showed no patient or caregiver refusal of a bereavement POC and showed no change in orders. On 08/28/24 at 10:00 a.m., Staff C stated Bereavement POCs are developed and put into place after a patient passes away. On 08/28/24 at 10:42 a.m. to 11:30, Staff B stated patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13 and #14 had no bereavement POCs.

Based on record review and interview, the hospice failed to ensure the IDG developed and initiated a POC after the SOC for 14 (Patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13 and #14) of 14 patients. The failed practice had the potential to effect the hospices ability to evaluate the patient's response to the care, treatment and services provided to meet desired patient outcomes for all patients. --- Findings: Patient #1 A review of the clinical record showed no POC for the certification period of 07/12/24 to 09/11/24. IDG update meetings on 07/16/24, 07/23/24, 08/06/24 and 08/20/24 showed no documentation of a POC for the initial certification period starting on 07/12/24. Documentation showed no IDG communications (IDG meeting forms documented a date of the IDG team meeting and a check marked box for, Patient agrees with the POC). Documentation showed no patient detail, no IDG review of the patients care and services provided by the hospice and showed no physician notifications related to certification for hospice services. Patient #2 A review of the clinical record showed no POC for the certification period of 03/20/24 to 06/17/24. IDG update meetings on 03/26/24, 04/09/24, 04/23/24, 05/07/24, 05/21/24, 06/04/24, 06/18/24 showed no documentation of a POC for the initial certification period starting on 03/20/24. Documentation showed no IDG communications (IDG meeting forms documented a date of the IDG team meeting and a check marked box for, Patient agrees with the POC). Documentation showed no patient detail, no IDG review of the patients care and services provided by the hospice and showed no physician notifications related to certification for hospice services. Patient #3 A review of the clinical record showed no POC for the certification period of 08/22/24 to 11/20/24. No IDG update meetings showed no documentation of a POC for the initial certification period starting on 08/22/24. Documentation showed no IDG communications, no patient detail, no IDG review of the patients care and services provided by the hospice and showed no physician notifications related to certification for hospice services. Patient #4 A review of the clinical record showed no POC for the certification period of 07/25/24 to 09/22/24. IDG update meetings on 07/23/24, 08/06/24 and 08/20/24 showed no documentation of a POC for the initial certification period starting on 07/25/24. Documentation showed no IDG communications (IDG meeting forms documented a date of the IDG team meeting and a check marked box for, Patient agrees with the POC). Documentation showed no patient detail, no IDG review of the patients care and services provided by the hospice and showed no physician notifications related to certification for hospice services. Patient #5 A review of the clinical record showed no POC for the certification period of 03/22/24 to 06/19/24. IDG update meetings on 03/26/24, 04/09/24, 04/23/24, 05/07/24, 05/21/24, 06/04/24, 06/18/24 showed no documentation of a POC for the initial certification period starting on 03/22/24. Documentation showed no IDG communications (IDG meeting forms documented a date of the IDG team meeting and a check marked box for, Patient agrees with the POC). Documentation showed no patient detail, no IDG review of the patients care and services provided by the hospice and showed no physician notifications related to initial certification for hospice services. Patient #6 A review of the clinical record showed no POC for the certification period of 08/20/24 to 11/18/24. IDG update meeting on 08/20/24 showed no documentation of a POC for the initial certification period starting on 08/20/24. Documentation showed no IDG communications (IDG meeting form documented a date of the IDG team meeting and a check marked box for, Patient agrees with the POC). Documentation showed no IDG communications, no patient detail, no IDG review of the patients care and services provided by the hospice and showed no physician notifications related to certification for hospice services. Patient #7 A review of the clinical record showed no POC for the certification period of 08/16/24 to 10/14/24. IDG update meetings on 08/06/24 and on 08/20/24 showed no documentation of a POC for the recertification period starting on 08/16/24. Documentation showed no IDG communications (IDG meeting form documented a date of the IDG team meeting and a check marked box for, Patient agrees with the POC). Documentation showed no IDG communications, no patient detail, no IDG review of the patients care and services provided by the hospice and showed no physician notifications related to certification for hospice services. Patient #8 A review of the clinical record showed no POCs for the certification periods of 06/19/24 to 09/12/24. IDG update meetings on 07/02/24, 07/16/24, 07/23/24, 08/06/24 and 08/20/24 showed no documentation of a POC for the initial certification period starting on 06/19/24. Documentation showed no IDG communications (IDG meeting forms documented a date of the IDG team meeting and a check marked box for, Patient agrees with the POC). Documentation showed no patient detail, no IDG review of the patients care and services provided by the hospice and showed no physician notifications related to initial certification and continued recertification for hospice services. Patient #9 A review of the clinical record showed no POC for the certification period of 05/16/24 to 07/14/24. IDG update meetings on 05/07/24, 05/21/24, 06/04/24, 06/18/24, 07/02/24 showed no documentation of a POC for the certification periods starting on 05/16/24. Documentation showed no IDG communications (IDG meeting forms documented a date of the IDG team meeting and a check marked box for, Patient agrees with the POC). Documentation showed no patient detail, no IDG review of the patients care and services provided by the hospice and showed no physician notifications related to initial certification and continued recertification for hospice services. Patient #10 A review of the clinical record showed no POC for the certification period of 08/06/24 to 11/05/24. IDG update meeting on 08/20/24 showed no documentation of a POC for the initial certification period starting on 08/06/24. Documentation showed no IDG communications (IDG meeting form documented a date of the IDG team meeting and a check marked box for, Patient agrees with the POC). Documentation showed no IDG communications, no patient detail, no IDG review of the patients care and services provided by the hospice and showed no physician notifications related to certification for hospice services. Patient #11 A review of the clinical record showed no POC for the certification period of 07/14/24 to 09/11/24. IDG update meetings on 07/02/23, 07/16/23, 07/23/24 and 08/06/24 showed no documentation of a POC for the recertification period starting on 07/14/24. Documentation showed no IDG communications (IDG meeting forms documented a date of the IDG team meeting and a check marked box for, Patient agrees with the POC). Documentation showed no patient detail, no IDG review of the patients care and services provided by the hospice and showed no physician notifications related to certification for hospice services. Documentation showed a POC dated 08/01/24 with a discharge from hospice services on 08/14/24. Patient #12 A review of the clinical record showed no POC for the certification period of 02/27/24 to 05/27/24. Documentation showed no IDG update meetings and showed no documentation of a POC for the initial certification period starting on 02/27/24. Documentation showed no IDG communications, no patient detail, no IDG review of the patients care and services provided by the hospice and showed no physician notifications related to certification for hospice services. Patient #13 A review of the clinical record showed no POC for the certification period of 02/19/24 to 04/18/24. IDG update meeting on 02/27/24 showed no documentation of a POC for the recertification period starting on 02/19/24. Documentation showed no IDG communications, no patient detail, no IDG review of the patients care and services provided by the hospice and showed no physician notifications related to certification for hospice services. Patient #14 A review of the clinical record showed no POCs for the certification periods of 02/15/24 to 04/15/24. IDG update meetings on 02/03/24, 02/27/24, 03/12/24, 03/26/24 and 04/09/24 showed no documentation of a POC for the recertification period starting on 02/15/24. Documentation showed no IDG communications (IDG meeting forms documented a date of the IDG team meeting and a check marked box for, Patient agrees with the POC). Documentation showed no patient detail, no IDG review of the patients care and services provided by the hospice and showed no physician notifications related to certification for hospice services. On 08/28/24 at 10:42 a.m. to 11:30 a.m., Staff B stated initial plans of care for patients #2, 5, 7, 9, 11 and #14 were not developed and implemented by the IDG.

Based on record review and interview the hospice failed to ensure the IDG supervised the care and services received from the hospice for 14 (Patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13 and #14) of 14 patients. The failed practice had the potential to effect the hospice care teams ability to contribute to the care planning process and to provide comprehensive care to meet patient care needs for all patients. See tag L539. Based on record review and interview, the hospice failed to ensure physician (medical provider) orders for: 1. SN visits provided without a documented plan of care or POC update by the IDG for 14 (Patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13 and 14) of 14 patients and; 2. Aide visits provided without a documented plan of care or POC update by the IDG for eight (Patients #2, 4, 7, 8, 9, 11, 12 and #14) of 14 patients. The failed practice had the potential to impact the hospices ability to provide care and services based on each patients individualized care plan effecting patient outcomes for all patients. See tag L543. Based on record review and interview, the hospice failed to ensure the IDG updated the plans of care the recertification periods for five (Patients #2, 5, 7, 9, 11 and #14) of 14 patients. The failed practice had the potential to impact the hospices ability to prepare an effective plan of care for all patients. See tag L545. --- .

Based on record review and interview the hospice failed to ensure the IDG supervised the care and services received from the hospice for 14 (patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13 and #14) of 14 patients. The failed practice had the potential to effect the hospice care teams ability to contribute to the care planning process and to provide comprehensive care to meet patient care needs for all patients. --- Findings: Patient #1 A review of the clinical record showed no POC for the certification period of 07/12/24 to 09/11/24. IDG update meetings on 07/16/24, 07/23/24, 08/06/24 and 08/20/24 showed no documentation of a POC for the initial certification period starting on 07/12/24. Documentation showed no IDG communications (IDG meeting forms documented a date of the IDG team meeting and a check marked box for, Patient agrees with the POC). Documentation showed no patient detail, no IDG review of the patients care and services provided by the hospice and showed no physician notifications related to certification for hospice services. Patient #2 A review of the clinical record showed no POCs for the certification periods of 03/20/24 to 06/17/24 and 06/18/24 to 09/15/24. IDG update meetings on 03/26/24, 04/09/24, 04/23/24, 05/07/24, 05/21/24, 06/04/24, 06/18/24, 07/02/24, 07/16/24, 07/23/24, 08/06/24 and 08/20/24 showed no documentation of a POC for the initial certification period starting on 03/20/24 or for subsequent recertification period starting on 06/18/24. Documentation showed no IDG communications (IDG meeting forms documented a date of the IDG team meeting and a check marked box for, Patient agrees with the POC). Documentation showed no patient detail, no IDG review of the patients care and services provided by the hospice and showed no physician notifications related to certification for hospice services. Patient #3 A review of the clinical record showed no POC for the certification period of 08/22/24 to 11/20/24. No IDG update meetings showed no documentation of a POC for the initial certification period starting on 08/22/24. Documentation showed no IDG communications, no patient detail, no IDG review of the patients care and services provided by the hospice and showed no physician notifications related to certification for hospice services. Patient #4 A review of the clinical record showed no POC for the certification period of 07/25/24 to 09/22/24. IDG update meetings on 07/23/24, 08/06/24 and 08/20/24 showed no documentation of a POC for the initial certification period starting on 07/25/24. Documentation showed no IDG communications (IDG meeting forms documented a date of the IDG team meeting and a check marked box for, Patient agrees with the POC). Documentation showed no patient detail, no IDG review of the patients care and services provided by the hospice and showed no physician notifications related to certification for hospice services. Patient #5 A review of the clinical record showed no POCs for the certification periods of 03/22/24 to 06/19/24 and 06/20/24 to 09/17/24. IDG update meetings on 03/26/24, 04/09/24, 04/23/24, 05/07/24, 05/21/24, 06/04/24, 06/18/24, 07/02/24, 07/16/24, 07/23/24, 08/06/24 and 08/20/24 showed no documentation of a POC for the initial certification period starting on 03/22/24 or for subsequent recertification period starting on 06/20/24. Documentation showed no IDG communications (IDG meeting forms documented a date of the IDG team meeting and a check marked box for, Patient agrees with the POC). Documentation showed no patient detail, no IDG review of the patients care and services provided by the hospice and showed no physician notifications related to initial certification and continued recertification for hospice services. Patient #6 A review of the clinical record showed no POC for the certification period of 08/20/24 to 11/18/24. IDG update meeting on 08/20/24 showed no documentation of a POC for the initial certification period starting on 08/20/24. Documentation showed no IDG communications (IDG meeting form documented a date of the IDG team meeting and a check marked box for, Patient agrees with the POC). Documentation showed no IDG communications, no patient detail, no IDG review of the patients care and services provided by the hospice and showed no physician notifications related to certification for hospice services. Patient #7 A review of the clinical record showed no POC for the certification period of 08/16/24 to 10/14/24. IDG update meetings on 08/06/24 and on 08/20/24 showed no documentation of a POC for the recertification period starting on 08/16/24. Documentation showed no IDG communications (IDG meeting form documented a date of the IDG team meeting and a check marked box for, Patient agrees with the POC). Documentation showed no IDG communications, no patient detail, no IDG review of the patients care and services provided by the hospice and showed no physician notifications related to certification for hospice services. Patient #8 A review of the clinical record showed no POCs for the certification periods of 06/19/24 to 09/12/24. IDG update meetings on 07/02/24, 07/16/24, 07/23/24, 08/06/24 and 08/20/24 showed no documentation of a POC for the initial certification period starting on 06/19/24. Documentation showed no IDG communications (IDG meeting forms documented a date of the IDG team meeting and a check marked box for, Patient agrees with the POC). Documentation showed no patient detail, no IDG review of the patients care and services provided by the hospice and showed no physician notifications related to initial certification and continued recertification for hospice services. Patient #9 A review of the clinical record showed no POCs for the certification periods of 05/16/24 to 07/14/24 and 07/15/24 to 09/12/24. IDG update meetings on 05/07/24, 05/21/24, 06/04/24, 06/18/24, 07/02/24, 07/16/24, 07/23/24, 08/06/24 and 08/20/24 showed no documentation of a POC for the recertification periods starting on 05/16/24 and on 07/15/24. Documentation showed no IDG communications (IDG meeting forms documented a date of the IDG team meeting and a check marked box for, Patient agrees with the POC). Documentation showed no patient detail, no IDG review of the patients care and services provided by the hospice and showed no physician notifications related to initial certification and continued recertification for hospice services. Patient #10 A review of the clinical record showed no POC for the certification period of 08/06/24 to 11/05/24. IDG update meeting on 08/20/24 showed no documentation of a POC for the initial certification period starting on 08/06/24. Documentation showed no IDG communications (IDG meeting form documented a date of the IDG team meeting and a check marked box for, Patient agrees with the POC). Documentation showed no IDG communications, no patient detail, no IDG review of the patients care and services provided by the hospice and showed no physician notifications related to certification for hospice services. Patient #11 A review of the clinical record showed no POC for the certification period of 07/14/24 to 09/11/24. IDG update meetings on 07/02/23, 07/16/23, 07/23/24 and 08/06/24 showed no documentation of a POC for the recertification period starting on 07/14/24. Documentation showed no IDG communications (IDG meeting forms documented a date of the IDG team meeting and a check marked box for, Patient agrees with the POC). Documentation showed no patient detail, no IDG review of the patients care and services provided by the hospice and showed no physician notifications related to certification for hospice services. Documentation showed a POC dated 08/01/24 with a discharge from hospice services on 08/14/24. Patient #12 A review of the clinical record showed no POC for the certification period of 02/27/24 to 05/27/24. Documentation showed no IDG update meetings and showed no documentation of a POC for the initial certification period starting on 02/27/24. Documentation showed no IDG communications, no patient detail, no IDG review of the patients care and services provided by the hospice and showed no physician notifications related to certification for hospice services. Patient #13 A review of the clinical record showed no POC for the certification period of 02/19/24 to 04/18/24. IDG update meetings on 02/27/24 showed no documentation of a POC for the recertification period starting on 02/19/24. Documentation showed no IDG communications (IDG meeting forms documented a date of the IDG team meeting and a check marked box for, Patient agrees with the POC). Documentation showed no patient detail, no IDG review of the patients care and services provided by the hospice and showed no physician notifications related to certification for hospice services. Patient #14 A review of the clinical record showed no POCs for the certification periods of 02/15/24 to 04/15/24. IDG update meetings on 02/03/24, 02/27/24, 03/12/24, 03/26/24 and 04/09/24 showed no documentation of a POC for the recertification period starting on 02/15/24. Documentation showed no IDG communications (IDG meeting forms documented a date of the IDG team meeting and a check marked box for, Patient agrees with the POC). Documentation showed no patient detail, no IDG review of the patients care and services provided by the hospice and showed no physician notifications related to certification for hospice services. On 08/28/24 at 10:42 a.m. to 11:30 a.m., Staff B stated IDG documentation showed no supervision of the care and services received from the hospice for patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13 and #14.

Based on record review and interview, the hospice failed to ensure physician (medical provider) orders for: SN visits provided without a documented plan of care or POC update by the IDG for 14 (Patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13 and 14) of 14 patients and Aide visits provided without a documented plan of care or POC update by the IDG for eight (Patients #2, 4, 7, 8, 9, 11, 12 and #14) of 14 patients. The failed practice had the potential to impact the hospices ability to provide care and services based on each patients individualized care plan effecting patient outcomes for all patients. --- Findings: Patient #1 A review of the clinical record showed no POC for the certification period of 07/12/24 to 09/11/24. IDG update meetings on 07/16/24, 07/23/24, 08/06/24 and 08/20/24 showed no documentation of a SN visit frequency. Documentation showed SN visits were conducted on 07/14/24, 07/18/24, 07/25/24 x2 visits, 07/26/24, 08/01/24, 08/08/24, 08/13/24, 08/15/24, 08/23/24 and on 08/24/24 (11 visits conducted, no visits ordered). Documentation showed no communications between the IDG, no physician notifications and showed no ordered SN visit frequency. Patient #2 A review of the clinical record showed no POCs for the certification periods of 03/20/24 to 06/17/24 and 06/18/24 to 09/15/24 with IDG update meetings on 03/26/24, 04/09/24, 04/23/24, 05/07/24, 05/21/24, 06/04/24, 06/18/24, 07/02/24, 07/16/24, 07/23/24, 08/06/24 and 08/20/24. Documentation showed SN visits were conducted on 03/26/24, 03/27/24, 04/02/24, 04/03/24, 04/09/24, 04/16/24, 04/17/24, 04/20/24, 04/23/24, 04/30/24 (10 visits conducted, no visits ordered) and aide visits were conducted on 04/02/24, 04/04/24, 04/11/24, 04/15/24, 04/18/24, 04/22/24, 04/25/24, 04/29/24, and on 05/02/24 (nine visits conducted, no visits ordered). Documentation showed no communications between the IDG, no physician notifications and showed no ordered SN or aide visit frequency. Patient #3 A review of the clinical record showed no POC for the certification period of 08/22/24 to 11/20/24. No IDG update meetings were conducted. Documentation showed no SN visit frequency. Documentation showed SN visits were conducted on 08/23/24 and on 08/24/24 (two visits conducted, no visits ordered). Documentation showed no communications between the IDG, no physician notifications and showed no ordered SN visit frequency. Patient #4 A review of the clinical record showed no POC for the certification period of 07/25/24 to 09/22/24. IDG update meetings on 07/23/24, 08/06/24 and 08/20/24 showed no documentation of a SN or aide visit frequency. Documentation showed SN visits were conducted on 07/25/24 and on 08/01/24 (two visits conducted, no visits ordered) and aide visits were conducted on 07/25/24 and on 07/27/24 (two visits conducted, no visits ordered). Documentation showed no communications between the IDG, no physician notifications and showed no ordered SN visit frequency. Patient #5 A review of the clinical record showed no POCs for the certification periods of 03/22/24 to 06/19/24 and 06/20/24 to 09/17/24 with IDG update meetings on 03/26/24, 04/09/24, 04/23/24, 05/07/24, 05/21/24, 06/04/24, 06/18/24, 07/02/24, 07/16/24, 07/23/24, 08/06/24 and 08/20/24. Documentation showed SN visits were conducted on 05/02/24, 05/06/24, 05/08/24, 05/10/24, 05/11/24, 05/13/24, 05/15/24, 05/20/24, 05/22/24, 05/23/24, 05/24/24, 05/29/24, 05/31/24, 06/03/24, 06/06/24, 06/10/24, 06/13/24, 06/17/24, 06/20/24, 06/24/24, 06/27/24, 07/01/24, 07/03/24, 07/05/24, 07/10/24, 07/11/24, 07/15/24, 07/22/24, 07/25/24, 07/26/24, 07/29/24, 08/02/24, 08/05/24, 08/08/24, 08/12/24, 08/13/24, 08/15/24, 08/19/24, 08/22/24 and on 08/26/24 (40 visits conducted, no visits ordered). Documentation showed no communications between the IDG, no physician notifications and showed no ordered SN visit frequency. Patient #6 A review of the clinical record showed no POC for the certification period of 08/20/24 to 11/18/24. IDG update meeting on 08/20/24 was conducted. Documentation showed no SN visit frequency. Documentation showed SN visits were conducted on 08/22/24 and on 08/26/24 (two visits conducted, no visits ordered). Documentation showed no communications between the IDG, no physician notifications and showed no ordered SN visit frequency. Patient #7 A review of the clinical record showed no POC for the certification period of 08/16/24 to 10/14/24. IDG update meetings on 08/06/24 and on 08/20/24 were conducted. Documentation showed no SN visit frequency. Documentation showed SN visits were conducted on 08/16/24, 08/19/24, 08/20/24 and on 08/26/24 (four visits conducted, no visits ordered). Documentation showed no communications between the IDG, no physician notifications and showed no ordered SN visit frequency. Patient #8 A review of the clinical record showed no POCs for the certification periods of 06/19/24 to 09/12/24 with IDG update meetings on 07/02/24, 07/16/24, 07/23/24, 08/06/24 and 08/20/24. Documentation showed SN visits were conducted on 06/19/24, 06/20/24 x2, 06/29/24, 07/03/24, 07/05/24, 07/10/24, 07/10/24, 07/17/24, 07/26/24, 07/31/24, 08/07/24, 08/13/24, 08/14/24 and on 08/21/24 (14 visits conducted, no visits ordered) and aide visits on 06/20/24, 06/24/24, 06/27/24, 07/01/24, 07/08/24, 07/11/24, 07/15/24, 07/18/24, 07/22/24, 07/25/24, 07/29/24, 08/01/24, 08/05/24 and on 08/12/24 (14 visits conducted, no visits ordered). Documentation showed no communications between the IDG, no physician notifications and showed no ordered SN or aide visit frequency. Patient #9 A review of the clinical record showed no POCs for the certification periods of 05/16/24 to 07/14/24 and 07/15/24 to 09/12/24 with IDG update meetings on 05/07/24, 05/21/24, 06/04/24, 06/18/24, 07/02/24, 07/16/24, 07/23/24, 08/06/24 and 08/20/24. Documentation showed SN visits were conducted on 05/16/24, 05/23/24, 05/24/24, 05/30/24, 06/06/24, 06/07/24, 06/13/24, 06/20/24, 06/21/24, 07/03/24, 07/05/24, 07/11/24, 07/18/24, 08/02/24, 08/08/24, 08/15/24 and on 08/22/24 (17 visits conducted, no visits ordered) and aide visits on 05/16/24, 05/23/24, 05/24/24, 05/30/24, 06/01/24, 07/11/24 and on 08/01/24 (six visits conducted, no visits ordered). Documentation showed no communications between the IDG, no physician notifications and showed no ordered SN or aide visit frequency. Patient #10 A review of the clinical record showed no POC for the certification period of 08/06/24 to 11/05/24. IDG update meeting on 08/20/24 was conducted. Documentation showed no SN visit frequency. Documentation showed SN visits were conducted on 08/13/24 (one visit conducted; no visits ordered). Documentation showed no communications between the IDG, no physician notifications and showed no ordered SN visit frequency. Patient #11 A review of the clinical record showed no POC for the certification period of 07/14/24 to 09/11/24. IDG update meetings on 07/02/23, 07/16/23, 07/23/24 showed no documentation of a SN or aide visit frequency. Documentation showed SN visits and aide visits were conducted, no visits ordered. Documentation showed no communications between the IDG, no physician notifications and showed no ordered SN or aide visit frequencies from 07/14/24 to 07/31/24. Patient #12 A review of the clinical record showed no POC for the certification period of 02/27/24 to 05/27/24. Documentation showed no IDG update meetings were conducted. Documentation showed no SN or aide visit frequency. Documentation showed SN visits were conducted on 02/27/24, 02/28/24, 02/29/24, 03/02/24, 03/07/24, 03/09/24 and on 03/11/24 (seven visits conducted, no visits ordered) and an aide visit on 03/01/24. Documentation showed no communications between the IDG, no physician notifications and showed no ordered SN or aide visit frequencies. Patient #13 A review of the clinical record showed no POC for the certification period of 02/19/24 to 04/18/24. IDG update meetings on 02/27/24 showed no documentation of a POC for the recertification period starting on 02/19/24. Documentation showed no IDG communications (IDG meeting forms documented a date of the IDG team meeting and a check marked box for, Patient agrees with the POC). Documentation showed no patient detail, no IDG review of the patients care and services provided by the hospice and showed no physician notifications related to certification for hospice services. Documentation showed no SN frequency. Documentation showed SN visits were conducted on 02/20/24, 02/21/24, 02/26/24, 03/04/24, 03/08/24 and on 03/10/24 x2 visits (seven visits conducted, no visits ordered). Documentation showed no communications between the IDG, no physician notifications and showed no ordered SN visit frequency. Patient #14 A review of the clinical record showed no POC for the certification periods of 02/15/24 to 04/15/24 with IDG update meetings on 02/03/24, 02/27/24, 03/12/24, 03/26/24 and 04/09/24. Documentation showed SN visits were conducted on 02/20/24, 02/27/24, 03/05/24, 03/12/24, 03/14/24, 03/15/24, 03/19/24, 03/25/24, 03/28/24, 04/01/24, 04/05/24, 04/06/24 and on 04/10/24 (13 visits conducted, no visits ordered) and aide visits were conducted on 04/04/24 and on 04/08/24 (two visits conducted, no visits ordered). Documentation showed no communications between the IDG, no physician notifications and showed no ordered SN or aide visit frequencies. On 08/28/24 at 10:42 a.m. to 11:30 a.m., Staff B stated SN visits and aide visits were provided without an established POC by the IDG and without written orders from the physician and/or ordering medical provider for patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13 and 14.

Based on record review and interview, the hospice failed to ensure the IDG updated the plans of care the recertification periods for five (Patients #2, 5, 7, 9, 11 and #14) of 14 patients. The failed practice had the potential to impact the hospices ability to prepare an effective plan of care for the patients for all patients. --- Findings: Patient #2 A review of the clinical record showed no POC for the certification period of 06/18/24 to 09/15/24. IDG update meetings on 06/04/24, 06/18/24, 07/02/24, 07/16/24, 07/23/24, 08/06/24 and 08/20/24 showed no documentation of a POC for subsequent recertification period starting on 06/18/24. Documentation showed no IDG communications (IDG meeting forms documented a date of the IDG team meeting and a check marked box for, Patient agrees with the POC). Documentation showed no patient detail, no IDG review of the patients care and services provided by the hospice and showed no physician notifications related to certification for hospice services. Patient #5 A review of the clinical record showed no POC for the certification period of 06/20/24 to 09/17/24. IDG update meetings on 06/18/24, 07/02/24, 07/16/24, 07/23/24, 08/06/24 and 08/20/24 showed no documentation of a POC for subsequent recertification period starting on 06/20/24. Documentation showed no IDG communications (IDG meeting forms documented a date of the IDG team meeting and a check marked box for, Patient agrees with the POC). Documentation showed no patient detail, no IDG review of the patients care and services provided by the hospice and showed no physician notifications related to initial certification and continued recertification for hospice services. Patient #9 A review of the clinical record showed no POC for the certification period of 05/16/24 to 07/14/24 and 07/15/24 to 09/12/24. IDG update meetings on 05/07/24, 05/21/24, 06/04/24, 06/18/24, 07/02/24, 07/16/24, 07/23/24, 08/06/24 and 08/20/24 showed no documentation of a POC for the recertification periods starting on 05/16/24 and on 07/15/24. Documentation showed no IDG communications (IDG meeting forms documented a date of the IDG team meeting and a check marked box for, Patient agrees with the POC). Documentation showed no patient detail, no IDG review of the patients care and services provided by the hospice and showed no physician notifications related to initial certification and continued recertification for hospice services. Patient #11 A review of the clinical record showed no POC for the certification period of 07/14/24 to 09/11/24. IDG update meetings on 07/02/23, 07/16/23, 07/23/24 and 08/06/24 showed no documentation of a POC for the recertification period starting on 07/14/24. Documentation showed no IDG communications (IDG meeting forms documented a date of the IDG team meeting and a check marked box for, Patient agrees with the POC). Documentation showed no patient detail, no IDG review of the patients care and services provided by the hospice and showed no physician notifications related to certification for hospice services. Documentation showed a POC dated 08/01/24 with a discharge from hospice services on 08/14/24. Patient #14 A review of the clinical record showed no POCs for the certification periods of 02/15/24 to 04/15/24. IDG update meetings on 02/03/24, 02/27/24, 03/12/24, 03/26/24 and 04/09/24 showed no documentation of a POC for the recertification period starting on 02/15/24. Documentation showed no IDG communications (IDG meeting forms documented a date of the IDG team meeting and a check marked box for, Patient agrees with the POC). Documentation showed no patient detail, no IDG review of the patients care and services provided by the hospice and showed no physician notifications related to certification for hospice services. On 08/28/24 at 10:42 a.m. to 11:30 a.m., Staff B stated the recertification plans of care for patients #2, 5, 7, 9, 11 and #14 were not updated and implemented by the IDG prior to the beginning of the patients subsequent recertification periods.

Based on record review and interview, the hospice failed to ensure and its QAPI Program showed measurable improvement in indicators related to improved palliative outcomes and hospice services for all patients, employees and volunteers. The failed practice had the potential to effect the hospices' ability to achieve measurable improvement in the care and services it offers for all patients. See tag L561. Based on record review and interview, the hospice failed to ensure its QAPI Program showed utilization of quality indicator data related to improved palliative outcomes and hospice services for all patients, employees and volunteers. The failed practice had the potential to impact the hospices' ability to evaluate its quality assessment program to identify opportunities for improvement for all patients. See tag L563. Based on record review and interview, the hospice failed to ensure implementation and evaluation of PIPs from 10/01/22 to 08/26/24 for all patients, employees and volunteers. The failed practice had the potential to effect the hospices' ability to correct problems and monitor actions to improve patient care and organizational outcomes for all patients. See tag L573. Based on record review and interview, the hospice failed to ensure governing body oversite of the conduction of patient centered QAPI Program activities for all patients, volunteers, and employees. The failed practice had the potential to effect the hospices' ability to define, implement and maintain an ongoing quality improvement program and to ensure patient safety for all patients. See tag L574. --- .

Based on record review and interview, the hospice failed to ensure its QAPI Program showed measurable improvement in indicators related to improved palliative outcomes and hospice services for all patients, employees, and volunteers. The failed practice had the potential to effect the hospices' ability to achieve measurable improvement in the care and services it offers to its patients, for all patients. --- Findings: Administrative records related to the QAPI program for the hospice for 05/01/2022 to 08/26/24 were requested. Administrative records showed an audit form titled, patient tracking form for 2nd quarter April thru June 2022, 3rd quarter July thru September 2022, 4th quarter October thru December 2022; (no 1st quarter January through March 2023 or 2nd quarter April thru June 2023), 3rd quarter July thru September 2023, 4th quarter October thru December 2023; 1st quarter January thru March 2024 and 2nd quarter April thru June 2024. Documentation showed no QAPI meeting activities, and no measurable improvement in indicators related to improved palliative outcomes and hospice services. Additional request for administrative records yielded no results. On 08/28/24 at 9:30 a.m., Staff A stated the hospice had no administrative records related to QAPI program meeting activities which showed measurable improvement in indicators related to improved palliative outcomes and hospice services for the hospice for 05/01/2022 to 12/31/22, calendar years 2023 and 01/01/24 to 08/26/24.

Based on record review and interview, the hospice failed to ensure its QAPI Program showed utilization of quality indicator data related to improved palliative outcomes and hospice services for all patients, employees, and volunteers. The failed practice had the potential to impact the hospices' ability to evaluate its quality assessment program to identify opportunities for improvement for all patients. --- Findings: Administrative records related to the QAPI program for the hospice for 05/01/2022 to 08/26/24 were requested. Administrative records showed an audit form titled, patient tracking form for 2nd quarter April thru June 2022, 3rd quarter July thru September 2022, 4th quarter October thru December 2022; (no 1st quarter January through March 2023 or 2nd quarter April thru June 2023), 3rd quarter July thru September 2023, 4th quarter October thru December 2023; 1st quarter January thru March 2024 and 2nd quarter April thru June 2024. Documentation showed no QAPI meeting activities, and no utilization of quality indicator data related to improved palliative outcomes and hospice services. Additional request for administrative records yielded no results. On 08/28/24 at 9:30 a.m., Staff A stated the hospice had no administrative records related to QAPI program meeting activities which showed utilization of quality indicator data related to improved palliative outcomes and hospice services for the hospice for 05/01/2022 to 12/31/22, calendar years 2023 and 01/01/24 to 08/26/24.

Based on record review and interview, the hospice failed to ensure implementation and evaluation of PIPs from 10/01/22 to 08/26/24 for all patients, employees, and volunteers. The failed practice had the potential to effect the hospices' ability to correct problems and monitor actions to improve patient care and organizational outcomes for all patients. --- Findings: Administrative records related to the QAPI program PIPs for the hospice for 05/01/2022 to 12/31/22, calendar years 2023 and 01/01/24 to 08/26/24 were requested. No administrative records related to the implementation and evaluation of QAPI program PIPs from 10/01/22 to 08/26/24 were provided. Additional request for administrative QAPI program PIP records yielded no results. On 08/28/24 at 9:30 a.m., Staff A stated the hospice had no QAPI program PIP administrative records related to the implementation and evaluation of QAPI program PIPs for 10/01/22 to 08/26/24.

Based on record review and interview, the hospice failed to ensure governing body oversite of the conduction of patient centered QAPI Program activities for all patients, volunteers, and employees. The failed practice had the potential to effect the hospices' ability to define, implement and maintain an ongoing quality improvement program and to ensure patient safety, for all patients. --- Findings: A review of administrative records showed no governing body oversite of an ongoing QAPI program for the hospice for 05/01/22 to 12/31/22, calendar year 2023 and 01/01/24 to 08/26/24. Additional requests for administrative records yielded no results. On 08/28/24 at 9:30 a.m., Staff A stated the hospice had no documentation which showed governing body oversite of QAPI program activities that included review and approval of data collection, analysis, implementation and follow up of QAPI activities for 05/01/22 to 12/31/22, calendar year 2023 and 01/01/24 to 08/26/24.

Based on record review and interview, the hospice failed to ensure its infection control program included surveillance monitoring and reporting was included in QAPI program activities for all patients, employees and volunteers. --- Findings: Administrative records which showed documentation of the agencys infection control programs surveillance data reported in the QAPI program activities for the hospice was requested for 05/01/22 to 08/26/24. No infection control program surveillance data reported in QAPI documentation was provided. On 08/28/24 at 9:30 p.m., Staff A stated the hospice had no administrative records related to QAPI program meeting activities which showed infection control program and its surveillance data for 05/01/22 thru 12/31/22, calendar year 2023 and 01/01/24 to 08/26/24.

Based on a record review and interview, the hospice failed to ensure multi-disciplined skilled professional staff were available to participate and provide input into the agencys QAPI program for all patients, employees, and volunteers. --- Findings: A review of administrative records showed no multi-disciplined skilled professional staff participation in QAPI activities for 10/01/22 to 12/31/22, calendar year 2023 and 01/01/24 to 08/26/24. On 08/28/24 at 9:30 p.m., Staff A stated the hospice had no administrative records related to QAPI program meeting activities which showed evidence of multi-disciplined skilled professional staff participation in ongoing QAPI program activities for the hospice.

Based on record review and interview, the hospice failed to ensure continued review and update of the hospice aide care plan for six (Patients #2, 4, 7, 11, 12 and #14) of 14 patients. --- Findings: Patient #2 A review of the clinical record showed no POCs for the certification periods of 06/18/24 to 09/15/24 with IDG update meetings on 06/04/24, 06/18/24, 07/02/24, 07/16/24, 07/23/24, 08/06/24 and 08/20/24 documented no physician orders for hospice aide visits. Documentation showed a hospice aide care plan dated 04/25/24 and showed no review or update to the hospice aide care plan for the 06/18/24 to 09/15/24 certification period. Documentation showed no communications between the IDG, no physician notifications and showed no ordered aide visit frequency. Patient #4 A review of the clinical record showed no POC for the certification period of 07/25/24 to 09/22/24. IDG update meetings on 07/23/24, 08/06/24 and 08/20/24 documented no physician orders for hospice aide visits. Documentation showed a hospice aide care plan dated 09/25/23 and showed no review or update to the hospice aide care plan for the 06/18/24 to 09/15/24 certification period. Documentation showed aide visits were conducted on 07/25/24 and on 07/27/24 (two visits conducted, no visits ordered). Documentation showed no communications between the IDG, no physician notifications and showed no ordered aide visit frequency. Patient #7 A review of the clinical record showed no POC for the certification period of 08/16/24 to 10/14/24. IDG update meetings on 08/06/24 and on 08/20/24 documented no physician orders for hospice aide visits. Documentation showed a hospice aide care plan dated 09/25/23 and showed no review or update to the hospice aide care plan for the 08/16/24 to 10/14/24 certification period. Documentation showed aide visits were conducted on 08/16/24, (one visit conducted, no visits ordered). Documentation showed no communications between the IDG, no physician notifications and showed no ordered aide visit frequency. Patient #11 A review of the clinical record showed no POC for the certification period of 07/14/24 to 09/11/24. IDG update meetings on 07/02/23, 07/16/23, 07/23/24 documented no physician orders for hospice aide visits. Documentation showed a hospice aide care plan dated 09/25/23 and showed no review or update to the hospice aide care plan for the 07/14/24 to 09/11/24 certification period. Documentation showed aide visits were conducted, no visits ordered. Documentation showed no communications between the IDG, no physician notifications and showed no ordered aide visit frequencies from 07/14/24 to 07/31/24. Patient #12 A review of the clinical record showed no POC for the certification period of 02/27/24 to 05/27/24. Documentation showed no IDG update meetings were conducted. Documentation showed no physician orders for hospice aide visits. Documentation showed no hospice aide care plan for the 02/27/24 to 05/27/24 certification period. Documentation showed an aide visit on 03/01/24. Documentation showed no communications between the IDG, no physician notifications and showed no ordered aide visit frequencies. Patient #14 A review of the clinical record showed no POC for the certification periods of 02/15/24 to 04/15/24 with IDG update meetings on 02/03/24, 02/27/24, 03/12/24, 03/26/24 and 04/09/24 documented no physician orders for hospice aide visits. Documentation showed hospice aide care plan for the 02/15/24 to 04/15/24 certification period. Documentation showed aide visits were conducted on 04/04/24 and on 04/08/24 (two visits conducted, no visits ordered). Documentation showed no communications between the IDG, no physician notifications and showed no ordered aide visit frequency. On 08/28/24 at 10:42 a.m. to 11:30 a.m., Staff B stated the clinical record documentation for patients #2, 4, 7, 11, 12 and #14 showed no review or update to the hospice aide care plans.

Based on record review and interview, the hospice failed to ensure volunteer orientation and training related to hospice care and philosophy for one (Volunteer #1) of one volunteer. The failed practice had the potential to effect the hospices' ability to provide orientation and training to volunteer personnel that is consistent with hospice industry standards for all patients. See tag L643. Based on record review and interview, the hospice failed to ensure volunteer services were a part of the hospice program for 14 (Patients# 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13 and 14) of 14 patients), caregivers, and employees. The failed practice had the potential to effect core services provided to patients, for all patients. See tag L644. --- .

Based on record review and interview, the hospice failed to ensure volunteer orientation and training related to hospice care and philosophy for one (Volunteer #1) of one volunteer. The failed practice had the potential to effect the hospices' ability to provide orientation and training to volunteer personnel that is consistent with hospice industry standards for all patients. --- Findings: Volunteer #1 A review of volunteer personnel records showed no orientation or training related to hospice care and philosophy. Additional request for personnel records yielded no results. On 08/28/24 at 10:00 a.m., Staff A stated the hospice had no personnel record documentation that showed Volunteer #1 was provided orientation and training related to hospice care and philosophy.

Based on record review and interview, the hospice failed to ensure volunteer services were a part of the hospice program for 14 (Patients# 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13 and 14) of 14 patients), caregivers, and employees. The failed practice had the potential to effect core services provided to patients, for all patients. --- Findings: On 08/27/24 at 10:45 a.m., during the entrance conference the surveyor requested the name of the volunteer coordinator for the hospice. Staff A stated the hospice had no volunteer coordinator. A review of administrative records showed the hospice program had one volunteer since 07/08/21, showed no volunteer activities from 05/12/23 (end date of the pandemic waiver) to 08/27/24 and had no volunteer coordinator. On 08/28/24 at 10:35 a.m., Staff A stated: 1. The hospice had no administrative records which showed volunteer service activities from 05/12/23 to 08/20/24. 2. The hospice had no volunteer personnel other than Volunteer #1 (a chaplain). 3. The hospice has no Volunteer Coordinator.

Based on record review and interview, the hospice failed to ensure bereavement and counseling services (spiritual services) were provided in a manner consistent with acceptable standards of practice for 14 current (Patients# 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13 and 14) of 14 patients and any future patients admitted to hospice services. The failed practice had the potential to effect the hospices' ability to provide core services necessary to meet the patients care needs for all patients. See tag L652. Based on record review and interview, the hospice failed to ensure orientation and training related to hospice care and philosophy for five (Staff A, B, C, D and E) of five employees. The failed practice had the potential to effect the hospices' ability to ensure its services are provided by capable staff to meet the needs of its patients, for all patients. See tag L661. Based on record review and interview, the hospice failed to ensure personnel records were maintained with required volunteer acknowledged job descriptions for one (Volunteer #1) of one volunteer and three (Staff B, C and E) of five staff files reviewed. The failed practice had the potential to effect the hospices' ability to ensure each employee and volunteers specific job duties are addressed for all patients. See tag L662. Based on record review and interview, the hospice failed to ensure personnel records were maintained with required annual employee performance evaluations for one (Volunteer #1) of one volunteer and for five (Staff A, B, C, D and E) of five staff reviewed. The failed practice had the potential to effect the hospices' ability to ensure its employees and volunteers possessed the skills required to deliver effective patient care and services for all patients. See tag L663. --- .

Based on record review and interview, the hospice failed to ensure bereavement and counseling services (spiritual services) were provided in a manner consistent with acceptable standards of practice for 14 current (Patients# 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13 and 14) of 14 patients and any future patients admitted to hospice services. The failed practice had the potential to effect the hospices' ability to provide core services necessary to meet the patients care needs, for all patients. --- Findings: On 08/27/24 at 10:45 a.m., during the entrance conference the surveyor requested the names of the bereavement coordinator and chaplain. Staff A identified Staff E as the bereavement coordinator and Volunteer #1 as the Chaplain. Administrative records were reviewed. Documentation showed no bereavement coordinator, no social worker, and no chaplain for the hospice. On 08/28/24 at 9:35 a.m., a review of a personnel record for Staff C showed a job description as an administrative secretary and showed no documentation or job description as the bereavement coordinator for the hospice. On 08/28/24 at 10:00 a.m., Staff C stated: 1. The hospice did not have a bereavement coordinator. 2. She did the standard mailouts after a patients death; letters, booklets, etc.... On 08/28/24 at 10:30 a.m., Staff A stated: The hospice did not employ a Chaplain. The hospice has not had a social worker since 05/19/23 and is in the process to onboard a newly hired Social Worker.

Based on record review and interview, the hospice failed to ensure orientation and training related to hospice care and philosophy for five (Staff A, B, C, D and E) of five employees. The failed practice had the potential to effect the hospices ability to ensure its services are provided by capable staff to meet the needs of its patients, for all patients. --- Findings: Staff A A review of personnel records showed no orientation or training related to hospice care and philosophy. Staff B A review of personnel records showed no orientation or training related to hospice care and philosophy. Staff C A review of personnel records showed no orientation or training related to hospice care and philosophy. Staff D A review of personnel records showed no orientation or training related to hospice care and philosophy. Staff E A review of personnel records showed no orientation or training related to hospice care and philosophy. Additional request for personnel records yielded no results. On 08/28/24 at 10:00 a.m., Staff A stated the hospice had no personnel record documentation that showed Staff A, B, C, D and E was provided orientation and training related to hospice care and philosophy.

Based on record review and interview, the hospice failed to ensure personnel records were maintained with required volunteer acknowledged job descriptions for one (Volunteer #1) of one volunteer and three (Staff B, C and E) of five staff files reviewed. The failed practice had the potential to effect the hospices ability to ensure each employees and volunteers specific job duties are addressed for all patients. --- Findings: Volunteer 1 A review of personnel records showed no signed job description for hospice volunteer role, responsibilities, and limitations. Staff B A review of personnel records showed no signed job description for hospice role, responsibilities, and limitations. Staff C A review of personnel records showed no signed job description for hospice role, responsibilities, and limitations. Staff E A review of personnel records showed no signed job description for hospice role, responsibilities, and limitations. Additional request for information yielded no results. On 08/27/24 at 10:00 a.m., Staff A stated personnel records were provided in their entirety and did not contain all required information for Volunteer #1 and Staff B, C and E.

Based on record review and interview, the hospice failed to ensure personnel records were maintained with required annual employee performance evaluations for one (Volunteer #1) of one volunteer and for five (Staff A, B, C, D and E) of five staff reviewed. The failed practice had the potential to effect the hospices' ability to ensure its employees and volunteers possess the skills required to deliver effective patient care and services for all patients. --- Findings: Volunteer 1 A review of personnel records showed a date of hire of 07/08/21. Documentation showed no initial skills competency evaluation and no annual performance evaluation for a hospice volunteer for 2022, 2023 and 2024. Staff A A review of personnel records showed a date of hire of 09/00/13. Documentation showed no initial skills competency evaluation and no annual performance evaluation for 2022 and 2023. Staff B A review of personnel records showed the date of hire of 07/03/20. Documentation showed no initial skills competency evaluation and no annual performance evaluation 2022, 2023 and 2024. Staff C A review of personnel records showed the date of hire of 06/15/18. Documentation showed no initial skills competency evaluation and no annual performance evaluation for 2022, 2023 and 2024. Staff D A review of personnel records showed the date of hire of 07/17/23. Documentation showed no initial skills competency evaluation and no annual performance evaluation for 2024. Staff E A review of personnel records showed the date of hire of 07/17/23. Documentation showed no initial skills competency evaluation and no annual performance evaluation for 2024. Additional request for information yielded no results. On 08/28/24 at 10:00 a.m., Staff A stated personnel records were provided in their entirety and did not contain all required information for Volunteers #1 and Staff A, B, C, D and E.

Based on record review and interview, the hospice failed to ensure clinical record documentation contained a POC and/or physician (medical provider) orders for 14 (Patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13 and 14) of 14 patients. The failed practice had the potential to impact the hospices ability to provide care and services consistent with care needs identified and ordered by the physician for all patients. See tag L678. Based on record review and interview, the hospice failed to ensure completion and provision of a transfer with discharge summary of care for two (Patients #11 and #12) of 14 patients. The failed practice had the potential to effect the hospices' ability to coordinate care and services, and to impact care outcomes in the management of terminal illness for all individual patients. See tag L682. Based on observation, record review and interview, the hospice failed to ensure the IDG communicated and coordinated the patients care with the residential care facility for one (Patient #9) of 14 patients. The failed practice had the potential to effect the hospices' ability in the oversite and coordination of the provision of care for all patients. See tag L778. --- .

Based on record review and interview, the hospice failed to ensure clinical record documentation contained a POC and/or physician (medical provider) orders for 14 (Patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13 and 14) of 14 patients. The failed practice had the potential to impact the hospices ability to provide care and services consistent with care needs identified and ordered by the physician for all patients. --- Findings: Patient #1 A review of the clinical record showed no POC for the certification period of 07/12/24 to 09/11/24. IDG update meetings on 07/16/24, 07/23/24, 08/06/24 and 08/20/24 showed no documentation of a SN visit frequency. Documentation showed SN visits were conducted on 07/14/24, 07/18/24, 07/25/24 x2 visits, 07/26/24, 08/01/24, 08/08/24, 08/13/24, 08/15/24, 08/23/24 and on 08/24/24 (11 visits conducted, no visits ordered). Documentation showed no communications between the IDG, no physician notifications and showed no ordered SN visit frequency. Patient #2 A review of the clinical record showed no POCs for the certification periods of 03/20/24 to 06/17/24 and 06/18/24 to 09/15/24 with IDG update meetings on 03/26/24, 04/09/24, 04/23/24, 05/07/24, 05/21/24, 06/04/24, 06/18/24, 07/02/24, 07/16/24, 07/23/24, 08/06/24 and 08/20/24. Documentation showed SN visits were conducted on 03/26/24, 03/27/24, 04/02/24, 04/03/24, 04/09/24, 04/16/24, 04/17/24, 04/20/24, 04/23/24, 04/30/24 (10 visits conducted, no visits ordered) and aide visits were conducted on 04/02/24, 04/04/24, 04/11/24, 04/15/24, 04/18/24, 04/22/24, 04/25/24, 04/29/24, and on 05/02/24 (nine visits conducted, no visits ordered). Documentation showed no communications between the IDG, no physician notifications and showed no ordered SN or aide visit frequency. Patient #3 A review of the clinical record showed no POC for the certification period of 08/22/24 to 11/20/24. No IDG update meetings were conducted. Documentation showed no SN visit frequency. Documentation showed SN visits were conducted on 08/23/24 and on 08/24/24 (two visits conducted, no visits ordered). Documentation showed no communications between the IDG, no physician notifications and showed no ordered SN visit frequency. Patient #4 A review of the clinical record showed no POC for the certification period of 07/25/24 to 09/22/24. IDG update meetings on 07/23/24, 08/06/24 and 08/20/24 showed no documentation of a SN or aide visit frequency. Documentation showed SN visits were conducted on 07/25/24 and on 08/01/24 (two visits conducted, no visits ordered) and aide visits were conducted on 07/25/24 and on 07/27/24 (two visits conducted, no visits ordered). Documentation showed no communications between the IDG, no physician notifications and showed no ordered SN visit frequency. Patient #5 A review of the clinical record showed no POCs for the certification periods of 03/22/24 to 06/19/24 and 06/20/24 to 09/17/24 with IDG update meetings on 03/26/24, 04/09/24, 04/23/24, 05/07/24, 05/21/24, 06/04/24, 06/18/24, 07/02/24, 07/16/24, 07/23/24, 08/06/24 and 08/20/24. Documentation showed SN visits were conducted on 05/02/24, 05/06/24, 05/08/24, 05/10/24, 05/11/24, 05/13/24, 05/15/24, 05/20/24, 05/22/24, 05/23/24, 05/24/24, 05/29/24, 05/31/24, 06/03/24, 06/06/24, 06/10/24, 06/13/24, 06/17/24, 06/20/24, 06/24/24, 06/27/24, 07/01/24, 07/03/24, 07/05/24, 07/10/24, 07/11/24, 07/15/24, 07/22/24, 07/25/24, 07/26/24, 07/29/24, 08/02/24, 08/05/24, 08/08/24, 08/12/24, 08/13/24, 08/15/24, 08/19/24, 08/22/24 and on 08/26/24 (40 visits conducted, no visits ordered). Documentation showed no communications between the IDG, no physician notifications and showed no ordered SN visit frequency. Patient #6 A review of the clinical record showed no POC for the certification period of 08/20/24 to 11/18/24. IDG update meeting on 08/20/24 was conducted. Documentation showed no SN visit frequency. Documentation showed SN visits were conducted on 08/22/24 and on 08/26/24 (two visits conducted, no visits ordered). Documentation showed no communications between the IDG, no physician notifications and showed no ordered SN visit frequency. Patient #7 A review of the clinical record showed no POC for the certification period of 08/16/24 to 10/14/24. IDG update meetings on 08/06/24 and on 08/20/24 were conducted. Documentation showed no SN visit frequency. Documentation showed SN visits were conducted on 08/16/24, 08/19/24, 08/20/24 and on 08/26/24 (four visits conducted, no visits ordered). Documentation showed no communications between the IDG, no physician notifications and showed no ordered SN visit frequency. Patient #8 A review of the clinical record showed no POCs for the certification periods of 06/19/24 to 09/12/24 with IDG update meetings on 07/02/24, 07/16/24, 07/23/24, 08/06/24 and 08/20/24. Documentation showed SN visits were conducted on 06/19/24, 06/20/24 x2, 06/29/24, 07/03/24, 07/05/24, 07/10/24, 07/10/24, 07/17/24, 07/26/24, 07/31/24, 08/07/24, 08/13/24, 08/14/24 and on 08/21/24 (14 visits conducted, no visits ordered) and aide visits on 06/20/24, 06/24/24, 06/27/24, 07/01/24, 07/08/24, 07/11/24, 07/15/24, 07/18/24, 07/22/24, 07/25/24, 07/29/24, 08/01/24, 08/05/24 and on 08/12/24 (14 visits conducted, no visits ordered). Documentation showed no communications between the IDG, no physician notifications and showed no ordered SN or aide visit frequency. Patient #9 A review of the clinical record showed no POCs for the certification periods of 05/16/24 to 07/14/24 and 07/15/24 to 09/12/24 with IDG update meetings on 05/07/24, 05/21/24, 06/04/24, 06/18/24, 07/02/24, 07/16/24, 07/23/24, 08/06/24 and 08/20/24. Documentation showed SN visits were conducted on 05/16/24, 05/23/24, 05/24/24, 05/30/24, 06/06/24, 06/07/24, 06/13/24, 06/20/24, 06/21/24, 07/03/24, 07/05/24, 07/11/24, 07/18/24, 08/02/24, 08/08/24, 08/15/24 and on 08/22/24 (17 visits conducted, no visits ordered) and aide visits on 05/16/24, 05/23/24, 05/24/24, 05/30/24, 06/01/24, 07/11/24 and on 08/01/24 (six visits conducted, no visits ordered). Documentation showed no communications between the IDG, no physician notifications and showed no ordered SN or aide visit frequency. Patient #10 A review of the clinical record showed no POC for the certification period of 08/06/24 to 11/05/24. IDG update meeting on 08/20/24 was conducted. Documentation showed no SN visit frequency. Documentation showed SN visits were conducted on 08/13/24 (one visit conducted; no visits ordered). Documentation showed no communications between the IDG, no physician notifications and showed no ordered SN visit frequency. Patient #11 A review of the clinical record showed no POC for the certification period of 07/14/24 to 09/11/24. IDG update meetings on 07/02/23, 07/16/23, 07/23/24 showed no documentation of a SN or aide visit frequency. Documentation showed SN visits and aide visits were conducted, no visits ordered. Documentation showed no communications between the IDG, no physician notifications and showed no ordered SN or aide visit frequencies from 07/14/24 to 07/31/24. Patient #12 A review of the clinical record showed no POC for the certification period of 02/27/24 to 05/27/24. Documentation showed no IDG update meetings were conducted. Documentation showed no SN or aide visit frequency. Documentation showed SN visits were conducted on 02/27/24, 02/28/24, 02/29/24, 03/02/24, 03/07/24, 03/09/24 and on 03/11/24 (seven visits conducted, no visits ordered) and an aide visit on 03/01/24. Documentation showed no communications between the IDG, no physician notifications and showed no ordered SN or aide visit frequencies. Patient #13 A review of the clinical record showed no POC for the certification period of 02/19/24 to 04/18/24. IDG update meetings on 02/27/24 showed no documentation of a POC for the recertification period starting on 02/19/24. Documentation showed no IDG communications (IDG meeting forms documented a date of the IDG team meeting and a check marked box for, Patient agrees with the POC). Documentation showed no patient detail, no IDG review of the patients care and services provided by the hospice and showed no physician notifications related to certification for hospice services. Documentation showed no SN frequency. Documentation showed SN visits were conducted on 02/20/24, 02/21/24, 02/26/24, 03/04/24, 03/08/24 and on 03/10/24 x2 visits (seven visits conducted, no visits ordered). Documentation showed no communications between the IDG, no physician notifications and showed no ordered SN visit frequency. Patient #14 A review of the clinical record showed no POC for the certification periods of 02/15/24 to 04/15/24 with IDG update meetings on 02/03/24, 02/27/24, 03/12/24, 03/26/24 and 04/09/24. Documentation showed SN visits were conducted on 02/20/24, 02/27/24, 03/05/24, 03/12/24, 03/14/24, 03/15/24, 03/19/24, 03/25/24, 03/28/24, 04/01/24, 04/05/24, 04/06/24 and on 04/10/24 (13 visits conducted, no visits ordered) and aide visits were conducted on 04/04/24 and on 04/08/24 (two visits conducted, no visits ordered). Documentation showed no communications between the IDG, no physician notifications and showed no ordered SN or aide visit frequencies. On 08/28/24 at 10:42 a.m. to 11:30 a.m., Staff B stated: 1. SN visits and aide visits were provided without an established POC by the IDG and without written orders from the physician and/or ordering medical provider for patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13 and 14 and; 2. The clinical records for patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13 and 14 should contain POCs and/or physician (medical provider) orders.

Based on record review and interview, the hospice failed to ensure completion and provision of a transfer with discharge summary of care for two (Patients #11 and #12) of 14 patients. The failed practice had the potential to effect the hospices' ability to coordinate care and services, and to impact care outcomes in the management of terminal illness for all individual patients. --- Findings: Patient #11 A review of the clinical record showed the patient was transferred with discharged from the hospice on 08/14/24 to other hospice care services. Documentation showed no transfer with discharge summary of care was completed or provided to the other hospice service provider or the attending physician. Patient #12 A review of the clinical record showed the patient was transferred with discharged from the hospice on 03/11/24 to other hospice care services. Documentation showed no transfer with discharge summary of care was completed or provided to the other hospice service provider or the attending physician. On 08/28/24 at 11:30 a.m., Staff A stated documentation for patients #11 and #12 showed no transfer/discharge summary of care was provided to the other hospice service provider or the attending physician.

Based on observation, record review and interview, the hospice failed to ensure the IDG communicated and coordinated the patients care with the residential care facility for one (Patients #9) of 14 patients. The failed practice had the potential to effect the hospices' ability in the oversite and coordination of the provision of care for all patients. --- Findings: Patient #9 A review of the clinical record showed an election of the hospice benefit/SOC on 05/22/23. Documentation showed no POCs for the certification periods of 05/16/24 to 07/14/24 and 07/15/24 to 09/12/24 with IDG update meetings on 05/07/24, 05/21/24, 06/04/24, 06/18/24, 07/02/24, 07/16/24, 07/23/24, 08/06/24 and 08/20/24. Documentation showed SN visits were conducted on 05/16/24, 05/23/24, 05/24/24, 05/30/24, 06/06/24, 06/07/24, 06/13/24, 06/20/24, 06/21/24, 07/03/24, 07/05/24, 07/11/24, 07/18/24, 08/02/24, 08/08/24, 08/15/24 and on 08/22/24 (17 visits conducted, no visits ordered) and aide visits on 05/16/24, 05/23/24, 05/24/24, 05/30/24, 06/01/24, 07/11/24 and on 08/01/24 (six visits conducted, no visits ordered). Documentation showed no communications between the IDG, no physician notifications and showed no ordered SN or aide visit frequency and documentation showed no IDG communications or coordination of care with the residential care facility. On 08/28/24 at 8:15 a.m., patient #9 had no hospice binder (home chart) in the residential care facility and showed no hospice POC or written communication by the IDG as an update to a POC. At 8:30 a.m., Residential Care Facility Staff #1 stated: 1. The hospice should leave a written report of any changes in a patient during a visit; 2. The hospice has not provided a POC which documented care services provided to patient #9; and 3. Residential Care Facility Staff #1 did not know what disciplines of care or visit frequency and duration of each service discipline patient #9 received from the hospice. At 9:25a.m., Staff A stated each patient should have had an updated POC at each certification period and/or when the POC was changed by the IDG in their home chart (binder). At 11:15 a.m., Staff B stated documentation for patient #9 showed no IDG communications or coordination of care with the residential care facility.

Based on record review and interview, the hospice failed to ensure: 1. Completion of the initial spiritual assessment no later than 5 calendar days after the election of hospice care for six (Patient #1, 2, 3, 4, 6 and 7) of 11 patients; and 2. Completion of the initial psychosocial assessment no later than 5 calendar days after the election of hospice care for two (Patient #2 and 3) of 11 patients. Findings: Patient #1 A review of the clinical record showed an election of the hospice benefit on 03/08/22 with no completion of the initial spiritual assessment from 03/08/22 to 03/31/22 (22 days after election of the hospice benefit) with no documentation of attempts to contact the patient made by the Chaplain and no patient or caregiver refusal of Chaplain visits. Patient #2 A review of the clinical record showed an election of the hospice benefit on 03/09/22 with no completion of the initial spiritual assessment from 03/09/22 to 03/31/22 (20 days after the election of the hospice benefit) and no completion of the initial psychosocial assessment from 03/09/22 to 03/15/22 (6 days after election of the hospice benefit) with no documentation of attempts to contact the patient made by the Chaplain or the Medical Social Worker and no patient or caregiver refusal of Chaplain or Medical Social Worker visits. Patient #3 A review of the clinical record showed an election of the hospice benefit on 12/17/21 with no completion of the initial spiritual assessment from 12/17/21 to 03/16/22 (90 days after the election of the hospice benefit) and no completion of the initial psychosocial assessment from 12/17/21 to 12/29/22 (12 days after election of the hospice benefit) with no documentation of attempts to contact the patient made by the Chaplain or the Medical Social Worker and no patient or caregiver refusal of Chaplain or Medical Social Worker visits. Patient #4 A review of the clinical record showed an election of the hospice benefit on 02/09/22 with no completion of the initial spiritual assessment from 02/09/22 to 03/31/22 (50 days after election of the hospice benefit) with no documentation of attempts to contact the patient made by the Chaplain and no patient or caregiver refusal of Chaplain visits. Patient #6 A review of the clinical record showed an election of the hospice benefit on 02/17/22 with no completion of the initial spiritual assessment from 02/17/22 to 03/31/22 (42 days after election of the hospice benefit) with no documentation of attempts to contact the patient made by the Chaplain and no patient or caregiver refusal of Chaplain visits. Patient #7 A review of the clinical record showed an election of the hospice benefit on 03/08/22 with no completion of the initial spiritual assessment from 03/08/22 to 03/31/22 (22 days after election of the hospice benefit) with no documentation of attempts to contact the patient made by the Chaplain and no patient or caregiver refusal of Chaplain visits. On 03/31/22 at 3:40 pm, Staff B stated the initial spiritual assessments were not completed within the first five days after the election of the hospice benefit for Patients #1, 2, 3, 4, 6 and 7. Staff B stated the initial psychosocial assessments were not completed within the first five days after the election of the hospice benefit for Patients #2 and 3.

Based on record review and interview, the hospice failed to ensure the plan of care was fully developed to include all services necessary for the palliation and management of the terminal illness for five (Patients #2, 3, 4, 10 and 11) of eleven patients reviewed. Findings: Patient #2 A plan of care dated 03/09/22 to 06/06/22 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #3 A plan of care dated 12/17/21 to 03/16/22 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #4 A plan of care dated 02/09/22 to 05/09/22 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #10 A plan of care dated 01/26/22 to 03/26/22 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #11 A plan of care dated 12/25/21 to 02/22/22 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. On 03/24/22 at 12:20 pm, Staff A stated the plans of care for Patients #2, 3, 4, 10 and 11 failed to include services necessary for the palliation and management of the terminal illness.