Every finding on record at D' Alexandria Hospice Inc.

It is required that the hospice informs and distributes to the patient written information about its policies on advance directives, including a description of applicable state law. This standard was not met as evidenced by clinical record review and interview. In 3 of 4 (75%) clinical records reviewed revealed the interdisciplinary team did not ensure that the patient/family received written information about its policies on advance directives, including a description of applicable state law. Clinical Record 1: The patient’s benefit election was dated 8/2/2023. There was no evidence that the hospice provided written information about their advance directive policies or applicable state law. Clinical Record 2: The patient’s benefit election was dated 8/2/2023. There was no evidence that the hospice provided written information about their advance directive policies or applicable state law. Clinical Record 4: The patient’s benefit election was dated 8/4/2023. There was no evidence that the hospice provided written information about their advance directive policies or applicable state law. The RN who reviewed records with this site visitor on 10/31/2023 confirmed this finding. In 3 of 4 (75%) clinical records reviewed revealed the interdisciplinary team did not ensure that the patient/family received written information about its policies on advance directives, including a description of applicable state law.

It is required that the hospice Interdisciplinary Group, in consultation with the individual's attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care. This standard was not met as evidenced by clinical record review and interview. In 1 of 4 (25%) clinical records reviewed in which a comprehensive assessment was performed, revealed the hospice did not ensure that the interdisciplinary group completed the comprehensive assessment within 5 calendar days after the election of hospice care. Clinical Record 4: The patient’s benefit election was dated 8/4/2023. The need for a spiritual care (SC) and MSW evaluation was documented in the comprehensive assessment. The chaplain documented their initial visit on 8/20/2022 (16 days after the election of hospice care). The MSW documented their initial visit on 8/20/2022 (16 days after the election of hospice care). There was no documentation as to why the assessment was not completed within 5 calendar days after the election of hospice care. The RN who reviewed records with this site visitor on 10/31/2023 stated that she did not know why the comprehensive assessments were not completed within 5 calendar days after the election of hospice care. In 1 of 4 (25%) clinical records reviewed in which a comprehensive assessment was performed, revealed the hospice did not ensure that the interdisciplinary group completed the comprehensive assessment within 5 calendar days after the election of hospice care.

It is required that the hospice medical director or physician designee reviews the clinical information for each patient being evaluated for admission and provides written certification that it is anticipated that the patient's life expectancy is six months or less if the illness runs its normal course. The physician considers the primary terminal condition, related diagnosis(es), if any, current subjective and objective medical findings, current medication and treatment orders, and information about the medical management of any of the patient's conditions unrelated to the terminal illness when making this determination. This standard was not met as evidenced by clinical record review and interview. In 2 of 4 (50%) clinical records reviewed in which the hospice medical director wrote and signed the certification of terminal illness revealed the hospice did not ensure the physician's review of the patient's clinical information. Clinical Record 1: The physician's certification for hospice benefit dated 8/2/2023-10/30/2023 did not contain evidence that the certifying physician composed a narrative explaining the clinical findings to support the patient's terminal illness. The certifying physician's written summary contains the verbatim narrative assessment written by the RN at the time of admission. Clinical Record 4: The physician's certification for hospice benefit dated 8/4/2023-11/1/2023 did not contain evidence that the certifying physician composed a narrative explaining the clinical findings to support the patient's terminal illness. The certifying physician's written summary contains the verbatim narrative assessment written by the RN at the time of admission. An interview with the DPCS on 11/1/2023 confirmed this finding. She stated, "I know she's been doing that." She stated she told the medical director that she needed to write her own assessment. In 2 of 4 (50%) clinical records reviewed in which the hospice medical director wrote and signed the certification of terminal illness revealed the hospice did not ensure the physician's review of the patient's clinical information.

It is required that when controlled medications are first ordered, a copy of the hospice’s written policies and procedures for the management and disposal of controlled medications is provided to the patient or family or patient’s legal representative(s). The Interdisciplinary Group documents in the patient record that the policies and procedures for managing and disposing of controlled medications is provided and discussed. This standard was not met as evidenced by clinical record review and interview. In 1 of 4 (25%) clinical records reviewed revealed the hospice did not ensure that a copy of the hospice’s written policies and procedures for the management and disposal of controlled medications was provided to the patient/family. Clinical Record 4: The patient’s benefit election was dated 8/4/2023. There was no evidence that the hospice provided a copy of their written policies and procedures for managing and disposing of controlled substances to the patient/family. The RN who reviewed records with this site visitor on 10/31/2023 confirmed this finding. In 1 of 4 (25%) clinical records reviewed revealed the hospice did not ensure that a copy of the hospice’s written policies and procedures for the management and disposal of controlled medications was provided to the patient/family.