Every finding on record at Cura-Hpc Edmond, LLC

It is required that the hospice implements emergency preparedness (EP) policies and procedures, based on the emergency plan, the risk assessment, and the communication plan. The policies and procedures address the development and inclusion of a plan for each hospice patient during a natural or man-made disaster as part of a patient/family comprehensive assessment and the documented discussion of the plan provided to the patient/family and maintained by the hospice. This standard was not met as evidenced by clinical record review, document review and interview. In 14 of 14 (100%) clinical records reviewed revealed that the agency did not ensure that an individualized emergency plan was developed and discussed with the patient/family for all hospice patients. Document 1: Policy Individualized Emergency Plan for Home Health Patients Effective Date: 2023 stated in part "The agency will have an individualized emergency plan for each home health patient." Clinical Record 1: The patient elected hospice on 08/08/2024. The patient was assigned a triage code at the time of the initial assessment. The clinical record lacked evidence that an individualized emergency plan was developed and discussed with the patient/family for a natural or man-made disaster as part of a patient/family comprehensive assessment. Clinical Record 2: The patient elected hospice on 07/17/2024. The patient was assigned a triage code at the time of the initial assessment. The clinical record lacked evidence that an individualized emergency plan was developed and discussed with the patient/family for a natural or man-made disaster as part of a patient/family comprehensive assessment. Clinical Record 3: The patient elected hospice on 08/16/2024. The patient was assigned a triage code at the time of the initial assessment. The clinical record lacked evidence that an individualized emergency plan was developed and discussed with the patient/family for a natural or man-made disaster as part of a patient/family comprehensive assessment. Clinical Record 4: The patient elected hospice on 07/09/2024. The patient was assigned a triage code at the time of the initial assessment. The clinical record lacked evidence that an individualized emergency plan was developed and discussed with the patient/family for a natural or man-made disaster as part of a patient/family comprehensive assessment. Clinical Record 5: The patient elected hospice on 09/26/2023. The patient was assigned a triage code at the time of the initial assessment. The clinical record lacked evidence that an individualized emergency plan was developed and discussed with the patient/family for a natural or man-made disaster as part of a patient/family comprehensive assessment. Clinical Record 6: The patient elected hospice on 02/14/2024. The patient was assigned a triage code at the time of the initial assessment. The clinical record lacked evidence that an individualized emergency plan was developed and discussed with the patient/family for a natural or man-made disaster as part of a patient/family comprehensive assessment. Clinical Record 7: The patient elected hospice on 01/27/2023. The patient was assigned a triage code at the time of the initial assessment. The clinical record lacked evidence that an individualized emergency plan was developed and discussed with the patient/family for a natural or man-made disaster as part of a patient/family comprehensive assessment. Clinical Record 8: The patient elected hospice on 06/14/2024. The patient was assigned a triage code at the time of the initial assessment. The clinical record lacked evidence that an individualized emergency plan was developed and discussed with the patient/family for a natural or man-made disaster as part of a patient/family comprehensive assessment. Clinical Record 9: The patient elected hospice on 12/20/2023. The patient was assigned a triage code at the time of the initial assessment. The clinical record lacked evidence that an individualized emergency plan was developed and discussed with the patient/family for a natural or man-made disaster as part of a patient/family comprehensive assessment. Clinical Record 10: The patient elected hospice on 08/23/2024. The patient was assigned a triage code at the time of the initial assessment. The clinical record lacked evidence that an individualized emergency plan was developed and discussed with the patient/family for a natural or man-made disaster as part of a patient/family comprehensive assessment. Clinical Record 11: The patient elected hospice on 04/29/2024. The patient was assigned a triage code at the time of the initial assessment. The clinical record lacked evidence that an individualized emergency plan was developed and discussed with the patient/family for a natural or man-made disaster as part of a patient/family comprehensive assessment. Clinical Record 12: The patient elected hospice on 04/09/2024. The patient was assigned a triage code at the time of the initial assessment. The clinical record lacked evidence that an individualized emergency plan was developed and discussed with the patient/family for a natural or man-made disaster as part of a patient/family comprehensive assessment. Clinical Record 13: The patient elected hospice on 08/11/2023. The patient was assigned a triage code at the time of the initial assessment. The clinical record lacked evidence that an individualized emergency plan was developed and discussed with the patient/family for a natural or man-made disaster as part of a patient/family comprehensive assessment. Clinical Record 14: The patient elected hospice on 12/26/2023. The patient was assigned a triage code at the time of the initial assessment. The clinical record lacked evidence that an individualized emergency plan was developed and discussed with the patient/family for a natural or man-made disaster as part of a patient/family comprehensive assessment. The Clinical Director confirmed findings in a joint clinical record review and interview on 09/12/2024

It is required that the hospice maintains an emergency preparedness training program that is based on the emergency preparedness plan, risk assessment, policies and procedures, and the communication plan. The training program is reviewed and updated at least every two (2) years. The hospice EP training program includes the following: for all new hospice employees and those providing services under arrangement, initial training in EP policies and procedures consistent with their expected roles; Demonstration of staff knowledge of emergency procedures; EP training of all hospice employees and individuals providing services under arrangement at least every two (2) years; More frequent training occurs if there is a significant update of EP policies and procedures; A periodic review and rehearsal of the hospice’s EP plan with hospice employees (including non-employee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others; and documentation of each training including the date(s), participants, and content. This standard was not met as evidenced by document review, interview and personnel record review. In 5 of 12 (42%) personnel records reviewed revealed that the agency did not ensure that all hospice employees and those providing services under arrangement received initial emergency training upon hire and every two years thereafter. Document 1: Policy Emergency Preparedness for Hospices Effective Date: 2023 stated in part "A. The hospice training program must document all of the following: I. Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, individuals providing services under arrangement, and hospice volunteers which is consistent with their expected roles and the communication plan. iii. Provide emergency preparedness at least every two (2) years." Personnel Record 2: Regional Clinical Director/Supervising Nurse/Alternate Administrator. Date of hire 04/16/2022. The personnel record lacked evidence that emergency preparedness education was provided upon hire and every two years thereafter. Personnel Record 3: Quality/Alternate Clinical Director. Date of hire 03/19/2022. The personnel record lacked evidence that emergency preparedness education was provided upon hire and every two years thereafter. Personnel Record 4: Volunteer Coordinator/Bereavement Coordinator. Date of hire 04/18/2022. The personnel record lacked evidence that emergency preparedness education was provided upon hire and every two years thereafter. Personnel Record 5: Registered Nurse. Date of hire 04/22/2024. The personnel record lacked evidence that emergency preparedness education was provided upon hire and every two years thereafter. Personnel Record 7: Social Worker. Date of hire 05/31/2023. The personnel record lacked evidence that emergency preparedness education was provided upon hire and every two years thereafter. The Regional Director/Administrator confirmed the findings in a joint personnel record review and interview on 09/13/2024.

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current prescription and over-the-counter (OTC) drugs, supplements, herbal remedies, and other alternative treatments that could affect drug therapy. The medication review process includes the identification of the effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy, and drug therapy associated with laboratory monitoring. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by clinical record review, document review, interview and observation. In 3 of 14 (21%) clinical records reviewed revealed that the agency did not ensure that the drug profile included the patient's current medications. Document 1: Policy Drug Regimen Review Effective Date 2022 stated in part "Upon initial and comprehensive assessment, a Registered Nurse creates and maintains a current medication profile and reviews all patient medications, both prescription and nonprescription, on an ongoing basis in collaboration with the other interdisciplinary group (IDG) members, including but not limited to, all prescription drugs, over-the-counter medications, herbal remedies, and other alternative treatments which could affect their drug therapy." Home Visit 1: The patient elected hospice on 05/10/2024 with a diagnosis of Alzheimer’s disease. During the home visit observation with the social worker (Personnel Record 7) on 09/12/2024 for Clinical Record 1, the patient's medications were reviewed with the patient's daughter. The medicines in the home did not match the hospice medication profile and plan of care effective 09/11/2024. The hospice medication profile included Amlodipine, Metoprolol, Aspirin, Insulin, MiraLAX, Vitamin D, and Synthroid. The patient's daughter stated in part "She is only taking these (referring to Amlodipine, Metoprolol, and Aspirin) and her Insulin." The daughter stated in part that "She hasn't taken those medications (MiraLAX, Vitamin D, and Synthroid) since at least the beginning of the month and that the patient has the opposite problem (has loose stools at times)." The clinical record revealed the medications were being reviewed however, lacked evidence that the hospice medication profile reflected the current medications the daughter was administering to the patient. Home Visit 2: The patient elected hospice on 07/17/2024 with a diagnosis of Parkinson’s disease. The patient resided in a skilled nursing facility (SNF). The SNF medication profile was reviewed during the home visit observation with the registered nurse (Personnel Record 5) for Clinical Record 2 on 09/12/2024. The SNF medication profile printed on 09/12/2024 included Midodrine HCl tablet 2.5 mg twice daily with an order date of 08/16/2024. The hospice medication profile printed on 09/11/2024 did not include Midodrine HCl. The clinical record revealed the medications were being reviewed however, lacked evidence that the hospice medication profile reflected the current medications the patient was receiving at the facility. Home Visit 3: The patient elected hospice on 08/16/2024 with a diagnosis of Huntington’s disease. The patient resided in a skilled nursing facility (SNF). The SNF medication profile was reviewed during the home visit observation with the hospice aide (Personnel Record 9) for Clinical Record 3 on 09/12/2024. The hospice medication profile printed on 09/11/2024 included Docusate Sodium 100 mg daily, Trazadone 25 mg at bedtime, and Tizanidine HCl 1 mg twice daily. The facility medication profile printed on 09/12/2024 did not include Docusate Sodium, Trazadone, or Tizanidine. The clinical record revealed the medications were being reviewed however, lacked evidence that the hospice medication profile reflected the current medications the patient was receiving at the SNF. The Alternate Clinical Director was present for the duration of the home visit observations on 09/12/2024 and confirmed the medication profiles for home visits 1, 2, and 3 were not updated to reflect the current medications.

It is required that the hospice designates a registered nurse member of the IDG to provide coordination of care; ensure continuous assessment of each patient’s and family’s needs; and ensure the implementation of the interdisciplinary plan of care. This standard was not met as evidenced by clinical record review and interview. In 5 of 14 records reviewed revealed the agency did not ensure that the registered nurse (RN) provided coordination of care, ensured continuous assessment of patient’s and family’s needs and ensured that the interdisciplinary plans of care met the patient’s needs. Clinical Record 1: The patient elected hospice on 05/10/2024 with a diagnosis of Alzheimer’s disease. The review of the clinical record revealed a lack of evidence that the RN ensured the comprehensive assessments included accurate drug profiles. Clinical Record 2: The patient elected hospice care on 07/17/2024 with a diagnosis of Parkinson’s disease. The patient resided in a skilled nursing facility (SNF). The review of the clinical record revealed a lack of evidence that the RN ensured the comprehensive assessments included accurate drug profiles; documented coordination of care between the hospice agency and the SNF; ensured the interdisciplinary plans of care included all treatments; and interventions required to meet the patient needs. Clinical Record 3: The patient elected hospice care on 08/16/2024. The patient resided in a SNF. The review of the clinical record revealed a lack of evidence that the RN ensured the comprehensive assessments included accurate drug profiles; documented coordination of care between the hospice agency and the SNF; ensured the interdisciplinary plans of care included all treatments; and interventions required to meet the patient needs. Clinical Record 13: The patient elected hospice care on 08/11/2023. The patient received respite care, at a SNF, beginning on 10/16/2023 and ending on 10/20/2023. The review of the clinical record revealed a lack of evidence that the RN documented coordination of care between the hospice agency and the SNF. Clinical Record 14: The patient elected hospice care on 12/26/2023. The RN initial assessment was completed on 12/26/2023. The patient resided at a SNF. The review of the clinical record revealed a lack of evidence that the RN documented coordination of care between the hospice agency and the SNF; and ensured the interdisciplinary plans of care included all treatments. The Alternate Clinical Director confirmed the findings in a joint record review and interview on 09/12/2024.

It is required that each patient’s individualized written plan of care reflects patient and family goals and identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review, document review and interview. In 2 of 14 (14%) clinical records reviewed revealed that that agency did not ensure the patient's individualized written plan of care reflected patient and family goals and identified planned interventions based on problems identified in the initial and comprehensive assessments. Document 1: Policy Patient/Family Plan of Care Effective: 2022 stated in part "The plan of care must reflect patient and family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments." Clinical Record 2: The patient elected hospice care on 07/17/2024. The skilled nursing visit on 08/01/2024 included documentation identifying a new wound and stated in part "Patient has a new wound to the right elbow that has a depth of 0.2cm and 0.5cm round." The plan of care order and Interdisciplinary (IDG) meeting effective 08/07/2024 included goals and planned interventions for a previously identified sacral wound however did not include any goals or interventions related to the new right elbow wound identified on 08/01/2024. Clinical Record 3: The patient elected hospice care on 08/16/2024. A skilled nursing visit was completed on 09/04/2024. The wound care documentation noted six wounds (left lateral toe, right posterior heel, right plantar foot, right dorsal foot, right lateral foot, and left lateral hip). The documentation stated in part "Wound care performed by facility nurse prior to writer arriving." The plan of care order and IDG Meeting effective 09/11/2024 included goals and interventions for altered nutrition, neurological decline, fall risk, pain, constipation, coping, coordination of care, spiritual support, infection, and lack of companionship, however did not include any goals or interventions related to the new wounds identified on 09/04/2024. During the joint record review and interview on 09/12/2024, the Alternate Clinical Director confirmed that the plans of care were not updated to include goals and interventions when new wounds were identified.

It is required that each patient’s individualized written plan of care include the drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review, document review and interview. In 3 of 14 (21%) clinical records reviewed revealed that the agency did not ensure that the patient's individualized written plan of care included the treatment necessary to meet the patient's needs. Document 1: Policy Patient/Family Plan of Care Effective Date: 2022 stated in part "The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including the following: D. Drugs and treatment necessary to meet the needs of the patient." Clinical Record 2: The patient elected hospice care on 07/17/2024 with a diagnosis of Parkinson’s disease. The patient resided in a skilled nursing facility (SNF). The Registered Nurse (RN) initial comprehensive assessment included documentation related to a sacral wound. The documentation stated in part "sacral wound pressure stage 3 length 11.4cm width 5.14 cm depth 01.4cm. Treatment: Wound doctor debrided wound yesterday. Orders for cleaning with Dakins on day shift Tues, Thurs, and Sun apply nickel size amount Santyl ointment, cover with alginate and bordered foam dressing." The clinical record lacked evidence that the treatment necessary to meet the wound care needs of the patient was included in the patient's individualized plan of care that was effective on 07/17/2024. Clinical Record 3: The patient, who resided in a SNF, elected hospice care on 08/16/2024 with a diagnosis of Huntington’s disease and documented in the initial comprehensive assessment that the patient had six wounds (left lateral toe, right posterior heel, right plantar foot, right dorsal foot, right lateral foot, and left lateral hip). A skilled nursing visit was completed on 09/04/2024, in which the registered nurse documented the six wounds and stated, "Wound care performed by facility nurse prior to writer arriving." The clinical record lacked evidence that the treatment necessary to meet the wound care needs of the patient was included in the patient's individualized plan of care that was effective as of 08/16/2024. Clinical Record 14: The patient elected hospice care on 12/26/2023 with a diagnosis of congestive heart failure. The patient resided in a skilled nursing facility (SNF). The RN initial assessment was completed on 12/26/2023. The wound care documentation noted three wounds (sacrum, lower back, and left shoulder). The documentation stated in part "Wound care managed and performed by facility nurse." The clinical records lacked evidence that the treatment necessary to meet the wound care needs of the patient was included in the patient's individualized plan of care effective on 12/26/2023. During the joint record review and interview on 09/12/2024, the Alternate Clinical Director confirmed the plans of care did not include the medications and treatments specific to meet the patient’s needs.

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as hand hygiene and use of gloves, mask, eye protection, or face shield depending on anticipated exposure. This standard was not met as evidenced by document review, interview and observation. In 1 of 3 (33%) home visit observations, the agency did not ensure that the hospice followed accepted standard of practice and agency policy to prevent the transmission of infection and communicable diseases including the use of standard precautions such as hand washing and use of gloves. Document 1: Policy Gloves Effective Date: 2022 stated in part "Discard and replace disposable gloves as soon as feasible when contaminated or the function as a barrier has been compromised." Home Visit 3: The patient elected hospice care on 08/16/2024. During the home visit on 09/12/2024 with the hospice aide (personnel record 9), the aide was observed washing her hands and setting up the work area to perform a bed bath. The hospice aide began the bed bath by washing the patient's face and upper body, she then proceeded to look around the room for a bag to dispose of the washcloth. The hospice aide, with her gloves donned, opened drawers containing clean supplies looking for a bag. The Alternate Clinical Director (personnel record 3) who was present for the site visit, stepped out of the room to retrieve a bag. The hospice aide resumed care including providing peri care. Once the bed bath was completed, the hospice aide applied lotion with the contaminated gloves still donned. During joint observation and interview on 09/12/2024, the Alternate Clinical Director confirmed the findings and stated in part "I saw that too" and agreed the aide did not adhere to the policy.

It is required that hospice aide provides services ordered by the Interdisciplinary Group. This standard was not met as evidenced by clinical record review and interview. In 2 of 14 (14%) clinical records reviewed, in which aide services were accepted, revealed the agency did not ensure the hospice aides completed the visits as ordered by the interdisciplinary group (IDG). Clinical Record 4: The patient elected hospice care on 07/09/2024. The IDG plan of care effective 08/21/2024 included orders for hospice aide visit frequency of three times per week. The record revealed the patient received hospice aide visits on 08/26/2024, 08/27/2024, 08/28/2024, 08/29/2024, and 08/30/2024 which was two additional hospice aide visits for the week of 08/26/2024. The record did not include orders for the two additional aide visits. Clinical Record 9: The patient elected hospice care on 12/20/2023. The IDG plan of care effective 08/21/2024 included orders for hospice aide visit frequency of three times per week. The patient received hospice aide visits on 08/26/2024, 08/27/2024, 08/28/2024, 08/29/2024, and 08/30/2024 which was two additional hospice aide visits for the week of 08/26/2024. The record did not include orders for the two additional aide visits. The Alternate Clinical Director confirmed the findings in a joint record review and interview on 09/12/2024.

It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services, and, as necessary, provides in-service training and education programs where required. This standard was not met as evidenced by document review, interview and personnel record review. In 2 of 12 (17%) personnel records reviewed revealed that the agency did not ensure that all individuals providing service completed a self-assessment of competency upon hire. Document 1: Policy Competency and Training Effective Date: 2021 stated in part "All direct patient care personnel shall complete a self-assessment of competency upon hire." Personnel Record 8: Chaplain/Clergy. Date of hire 10/03/2022. The personnel record lacked evidence that a self-assessment of competency upon hire was completed by the employee, per agency policy. Personnel Record 9: Hospice Aide. Date of hire 08/25/2022. The personnel record lacked evidence that a self-assessment of competency upon hire was completed by the employee, per agency policy. The Regional Director/Administrator confirmed the findings in a joint personnel record review and interview on 09/13/2024.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: the initial plan of care, updated plans of care, initial assessment, comprehensive assessment, updated comprehensive assessments, and clinical notes including the care and services provided. This standard was not met as evidenced by clinical record review, document review and interview. In 2 of 14 (14%) clinical records reviewed revealed that the agency did not ensure that documentation was completed on the same day as consistent with agency policy. Document 1: Policy Documentation Requirements reviewed 2022 stated in part "All documentation is to be completed on the day of the patient contact." Clinical Record 4: The patient elected hospice care on 07/09/2024. The hospice aide visited the patient on 08/01/2024. A patient communication note was completed on 08/06/2024 that documented the visit activities. The patient communication note was signed and submitted on 08/06/2024, five (5) days after the services were provided. The clinical record lacked evidence that the documentation submitted for the visit on 08/01/2024 complied with agency policy. Clinical Record 9: The patient elected hospice care on 12/20/2023. The hospice aide visited the patient on 08/21/2024. A patient communication note was completed on 08/23/2024 that documented the visit activities. The patient communication note was signed and submitted on 08/23/2024, two (2) days after the services were provided. The clinical record lacked evidence that the documentation submitted for the visit on 08/21/2024 complied with agency policy. The Alternate Clinical Director confirmed the findings during a joint record review and interview on 09/11/2024 and stated in part "The notes were not submitted timely."

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record contains at a minimum: physician orders. This standard was not met as evidenced by clinical record review, document review and interview. In 6 of 14 (43%) clinical records reviewed revealed that the agency did not ensure that physician orders were obtained for wound care provided, hospice aide visits provided outside ordered frequency, and level of care changes. Document 1: Policy Client Records Effective Date: 2022 stated in part "A clinical record containing past and current findings is maintained for each hospice patient. Each record will contain: I. Physician/allowed practitioner orders." Clinical Record 2: The patient elected hospice care on 07/17/2024. A skilled nursing visit dated 09/04/2024 included documentation which stated in part "He has a wound to the right elbow and stage 4 ulcer to his coccyx. Wound care is provided by the nursing facility staff." The clinical record lacked evidence of the physician orders for the wound care being provided by the facility. Clinical Record 3: The patient elected hospice care on 08/16/2024. A skilled nursing visit dated 09/04/2024 included documentation that the patient had six wounds (left lateral toe, right posterior heel, right plantar foot, right dorsal foot, right lateral foot, and left lateral hip). The documentation stated in part "Wound care performed by facility nurse prior to writer arriving." The clinical record lacked evidence that the record included physician orders for the wound care being provided. Clinical Record 4: The patient elected hospice care on 07/09/2024. The plan of care effective 08/21/2024 included orders for hospice aide frequency three times per week. The patient received hospice aide visits on 08/26/2024, 08/27/2024, 08/28/2024, 08/29/2024, and 08/30/2024 (two additional hospice aide visits were provided the week of 08/26/2024). The clinical record lacked evidence that physician orders were obtained for the additional hospice aide visits that were provided. Clinical Record 9: The patient elected hospice care on 12/20/2023. The plan of care effective 08/21/2024 included orders for hospice aide frequency three times per week. The patient received hospice aide visits on 08/26/2024, 08/27/2024, 08/28/2024, 08/29/2024, and 08/30/2024 (two additional hospice aide visits were provided the week of 08/26/2024). The clinical record lacked evidence that physician orders were obtained for the additional hospice aide visits that were provided. Clinical Record 13: The patient elected hospice care on 08/11/2023. The patient was transferred to a facility for respite care on 10/16/2023. A physician order was obtained on 10/16/2023 to change the level of care to respite. The clinical record lacked evidence that the record included physician orders to change the level of care to routine on 10/20/2023. Clinical Record 14: The patient elected hospice care on 12/26/2023. The RN initial assessment was completed on 12/26/2023. The wound care documentation noted three wounds (sacrum, lower back, and left shoulder). The documentation stated in part "Wound care managed and performed by facility nurse." The clinical record lacked evidence that the record included physician orders for the wound care being provided. The Alternate Clinical Director confirmed the findings in a joint record review and interview on 09/12/2024.

It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid certified facility, the hospice forwards to the receiving facility a copy of the hospice discharge summary described in HCDT 40.I; and the patient’s record, if requested. This standard was not met as evidenced by clinical record review, document review and interview. In 2 of 2 (100%) clinical records reviewed, for patient’s transferred to another hospice, revealed that the agency did not ensure a hospice discharge summary was sent to the receiving facility. Document 1: Policy Transfer and Discharge Criteria Effective Date: 2022 stated in part "When care is transferred to another Medicare or Medicaid-certified hospice, the hospice will forward a copy of the hospice discharge summary and, if requested, the patient's clinical record." Clinical Record 11: The patient elected hospice care on 03/14/2024. The patient chose to transfer to another hospice and was discharged from the hospice on 04/29/2024. The clinical record lacked evidence that the agency sent the discharge summary to the receiving hospice agency. Clinical Record 12: The patient elected hospice care on 04/09/2024. The patient chose to transfer to another hospice and was discharged from the hospice on 05/24/2024. The clinical record lacked evidence that the agency sent the discharge summary to the receiving hospice agency. The Clinical Director confirmed in a joint record review and interview on 09/12/2024 that the discharge summary was not sent to the receiving hospice.

It is required that the hospice discharge summary provided to a facility receiving a hospice patient for care—or to the patient’s community attending physician upon hospice discharge—includes at least the following: a summary of the patient’s hospice stay, including treatments, symptoms, and pain management; the patient’s current plan of care; the patient’s latest physician orders; and any other documentation that will assist in the post-discharge continuity of care or that is requested by the receiving facility or the attending physician. This standard was not met as evidenced by clinical record review, document review and interview. In 2 of 2 (100%) discharged clinical records reviewed, that were transferred to another hospice, revealed that the agency did not ensure that the discharge summary included a summary of the patient’s hospice stay, including treatments, symptoms, and pain management, the patient's current plan of care, the patient's latest physician orders, and any other documentation to assist in the post-discharge continuity of care. Document 1: Policy Transfer and Discharge Criteria Effective Date: 2022 stated in part "The discharge summary shall include: A. A summation of the patient's stay including treatments, symptoms, and pain management; B. The patient's current plan of care; C. The patient's current physician orders; and D. Any other documentation that will assist in post-discharge continuity of care or that is requested by the attending physician or receiving hospice." Clinical Record 11: The patient elected hospice care on 04/09/2024. The patient chose to transfer to another hospice and was discharged from the hospice on 05/24/2024. The discharge note dated 05/24/2024 included the date of discharge and the reason for discharge. The clinical record lacked evidence that the discharge summary including the summary of the patient’s hospice stay, including treatments, symptoms, and pain management, the patient's current plan of care, the patient's latest physician orders, and any other documentation to assist in the post-discharge continuity of care was provided to the receiving hospice. Clinical Record 12: The patient elected hospice care on 03/14/2024. The patient chose to transfer to another hospice and was discharged from the hospice on 04/29/2024. The discharge note dated 04/29/2024 included the date of discharge and the reason for discharge. The clinical record lacked evidence that the discharge summary including the summary of the patient’s hospice stay, including treatments, symptoms, and pain management, the patient's current plan of care, the patient's latest physician orders, and any other documentation to assist in the post-discharge continuity of care was provided to the receiving hospice. During a joint record review and interview on 09/12/2024, the Clinical Director confirmed that the clinical records did not include documentation that a discharge summary was provided to the receiving hospice.

It is required that the hospice plan of care identifies the care and services that are needed and specifies which provider is responsible for performing the functions that are agreed upon and included in the plan of care. This standard was not met as evidenced by clinical record review, document review and interview. In 4 of 9 (44%) clinical record reviews, for patients that resided in a skilled nursing facility (SNF) revealed that the agency did not ensure that the hospice plan of care identified the care and services that were needed and specified which provider was responsible for performing the functions. Document 1: Policy Professional Management and Delineation of Care Effective: 2022 stated in part "If the hospice provides hospice care to residents of a Medicare or Medicaid certified SNF/NF or ICF/IID, the hospice will assume responsibility for professional management of the resident's hospice services according to the plan of care and conditions of participation. B. The written agreement must include the following at minimum: 6. A delineation of the hospice's responsibilities." Clinical Record 2: The patient elected hospice care on 07/17/2024. The patient resided in a SNF. A skilled nursing visit was completed on 09/04/2024. The documentation stated in part "He has a wound to the right elbow and stage 4 ulcer to his coccyx. Wound care is provided by the nursing facility staff." The clinical record lacked evidence that the hospice plan of care identified the care and services needed for wound care and specified which provider would be responsible for performing the functions that are agreed upon and included in the plan of care. Clinical Record 3: The patient elected hospice care on 08/16/2024. The patient resided in a SNF. A skilled nursing visit was completed on 09/04/2024. The wound care documentation noted six wounds (left lateral toe, right posterior heel, right plantar foot, right dorsal foot, right lateral foot, and left lateral hip). The documentation stated in part "Wound care performed by facility nurse prior to writer arriving." The clinical record lacked evidence that the hospice plan of care identified the care and services needed for wound care and specified which provider would be responsible for performing the functions that are agreed upon and included in the plan of care. Clinical Record 13: The patient elected hospice care on 08/11/2023. The patient received respite care beginning on 10/16/2023 and ending on 10/20/2023 due to spouse having surgery. The clinical record lacked evidence that the hospice plan of care identified the care and services needed and specified which provider would be responsible for performing the functions that are agreed upon and included in the plan of care during respite care. Clinical Record 14: The patient elected hospice care on 12/26/2023. The RN initial assessment was completed on 12/26/2023. The patient resided at a SNF. The wound care documentation noted three wounds (sacrum, lower back, and left shoulder). The documentation stated in part "Wound care managed and performed by facility nurse." The clinical record lacked evidence that the hospice plan of care identified the care and services needed for wound care and specified which provider would be responsible for performing the functions that are agreed upon and included in the plan of care. The Alternate Clinical Director confirmed the findings in a joint record review and interview on 09/12/2024.

It is required that the hospice obtains a criminal background check on all hospice employees who have direct patient contact or access to patient records. Hospice contracts require that all contracted employees who have direct patient contact or access to patient records obtain criminal background checks. This standard was not met as evidenced by document review and interview. In 1 of 9 (11%) contracts reviewed that include contracted direct patient care providers revealed that the agency did not ensure that the contract included language requiring criminal background checks. Document 1: Policy Criminal History Checks Effective Date: 2024 stated in part "The hospice must obtain a criminal background check on all hospice employees who have direct patient contact or access to patient records. Hospice contracts must require that all contract entities obtain criminal background checks on contracted employees who have direct patient contact or access to patient records." Contract 8: The Therapy, Social Work, Psych Nursing & Dietician Services Agreement was signed on 11/02/2021. The contract lacked evidence that criminal background checks would be completed for therapists, psychological nurses, and dieticians who provide direct care. The Regional Director/Administrator confirmed findings in a joint interview and contract review on 09/11/2024 and stated in part "I know what you are looking for and I don't see it in there."

It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services and, as necessary, provides in-service training and education programs where required. The hospice has written policies and procedures describing the method(s) of assessing competency and maintains a written description of the in-service training provided during the previous 12 months. This standard was not met as evidenced by personnel record review and interview. 3 of 10 (30%) personnel records reviewed revealed the hospice did not ensure that a competency assessment was completed on hire. Record #66937 was reviewed and did not contain documentation of a competency assessment. Record #26003 was reviewed and did not contain documentation of a competency assessment. Record #86682 was reviewed and did not contain documentation of a competency assessment. The executive director was interviewed on 12/1/2021 and stated, there were no competency assessments completed within the records identified.

It is required that the designated IDG member provides the SNF/NF or ICF/IDF with the following information for each patient/resident: hospice election form, physician certification and recertification of the terminal illness. This standard was not met as evidenced by clinical record review and interview which revealed 2 of 2 (100%) applicable records of patients in a SNF did not include evidence that the hospice election form, physician certification and recertification of the terminal illness were provided to the SNF by the designated IDG member. Record #24427: During a joint visit with the social worker on 11/30/2021, a review of the facility records revealed there was no evidence that the hospice election form, physician certification and recertification of the terminal illness were provided to the SNF. Record #36471: During a joint visit with the registered nurse on 11/30/2021, a review of the facility records revealed there was no evidence that the hospice election form, physician certification and recertification of the terminal illness were provided to the SNF. The clinical director was interviewed on 11/30/2021 and confirmed this finding.

It is required that the hospice obtains a criminal background check on all hospice employees who have direct patient contact or access to patient records. This standard was not met as evidenced by personnel record review and interview. 1 of 10 (10%) personnel records reviewed revealed the hospice did not ensure a criminal background check was completed on hospice employees. Record #86682 was reviewed and did not contain evidence that a background check was obtained upon hire. The executive director was interviewed on 12/1/2021 and stated, there were no background checks within the record identified.