Every finding on record at Definitive Hospice Care

Upon patient record review, 2 of 14 (Patient #2,9) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient 2 has documentation of skin breakdown / wounds, 11/07/24, with new wound care orders and ongoing documentation of wound care and ongoing assessments, this was also discussed in IDG, however; the plan of care "issues and problems" were not updated or added to the plan of care. Patient 9 has documentation of skin breakdown / wounds, 12/18/24, with new wound care orders and ongoing documentation of wound care and ongoing assessments, this was also discussed in IDG, however; the plan of care "issues and problems" were not updated or added to the plan of care.

Upon patient record review, 2 of 14 (Patient #11,12) did not have evidence the hospice offers bereavement counseling that includes: • Ensuring that bereavement services reflect the needs of the bereaved Patients 11, 12 had evidence of a Bereavement Plan of Care. However there is no evidence of actual contact with the bereaved other than mailings. Agency policy stated that two phone call would be made to the bereaved.

Upon patient record review, 1 of 14 (Patient #11) did not have evidence that the discharge summary includes all required information. Patient 11 does not have evidence of a discharge summary in the Electronic record.

Based on clinical record review and interview, the hospice failed to ensure the individualized POC was followed as ordered for one of two sampled patients (Patient 2), creating the risk of not providing necessary care and services to meet the care needs for this patient. --- The hospices' P&P titled The Plan of Care (undated) showed a written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The care provided to the patient must be in accordance with the pan of care. Review of Patient 2's clinical record was initiated on 7/30/24. The clinical record showed the SOC was 4/12/24. The patient was certified for hospice services during the certification period from 6/5/24 to 8/3/24. Review of the POC/IDG Review dated 7/5 and 7/19/24, showed the patient was identified to have episode of SOB on mild exertion. The interventions included SN to check oxygen saturation levels PRN during the SN visits and identify SOB in relation to activity and observed for signs and symptoms of respiratory infection. Review of the Visit Note RN dated 7/3 and 7/16/24, showed the SN had performed body system assessment. The respiratory assessment included dyspnea (SOB) showing the patient had light difficulty. In addition, review of the Visit Note RN dated 7/3 and 7/16/24, showed the SN had performed vital signs assessments and measurement. However, the section for the oxygen saturation level was left blank. On 7/29/24 at 1548 hours, an interview and concurrent clinical record review was conducted with the Administrator/CEO and DPCS Designee. They were asked as to when they needed to check the patient's oxygen saturation level. The DPCS Designee replied, if there was a mild to moderate dyspnea. They were asked if the POC was followed. The DPCS Designee reviewed the clinical record and stated the oxygen saturation level should have been checked and the POC was not followed. They were informed and acknowledged the findings.

Based on clinical record review and interview, the hospice failed to ensure the POC included the indication for the spiritual counselor PRN visits for Patient 2, creating the risk of not providing necessary care and services to this patient. --- The hospice's P&P titled The Plan of Care (undated) showed the plan of care will identify the patients needs and services to meet those needs. It must state in detail the scope the scope and frequency of services needed to meet the patients, family/caregivers needs, goals and outcome achievement. Review of Patient 2's clinical record was initiated on 7/30/24. The clinical record showed the SOC was 4/12/23. The patient was certified for hospice services during the certification period from 6/5/24 to 8/3/24. Review of the POC/IDG dated 7/5 and 7/19/24, showed spiritual counselor visit one time then PRN. However, the POC did not include the indication for the PRN visit or when the spiritual counselor should conduct the PRN visits. On 7/30/24 at 1558 hours, an interview and concurrent clinical record review was conducted with the Administrator/CEO and DPCS Designee. When asked for the reason of the PRN visit, the DPCS Designee replied during family request. The DPCS Designee was also asked if the PRN visit for the spiritual counselor needed to be documented. The DPCS Designee reviewed the POC/IDG and replied it should have been documented. They were informed and acknowledged the finding.

Based on clinical record review and interview, the hospice failed to ensure the POC included the measurable outcomes specific for the the patient's care needs identified in the assessment for two of the two sampled patients (Patients 1 and 2), creating the risk of not providing necessary care and services to these patients. --- Review of Patient 1's clinical record was initiated on 7/30/24. The clinical record showed the SOC was 4/10/24. The patient was certified for hospice services during the certification periods from 4/10/24 to 7/824 and 7/9/24 to 10/6/24. The POC/IDG Review dated 7/5/24 and 7/19/24, showed the patient's identified problems with the established goal and interventions. However, the POC failed to include measurable outcomes for the patient's identified problems. For example, one the goals for at risk for alteration in cardiac status related to advancing disease and aging process was to maintain optimum peripheral circulation. However, there was no documented evidence to specify as to what maintain optimum peripheral circulation was. The goal for alteration in bowel elimination related to advancing disease and aging process was to reestablish normal bowel pattern throughout the period. However, there was no documented evidence to specify as to what patients normal bowel pattern was. On 7/30/24 at 1545 hours, an interview was conducted with the Administrator/CEO and DPCS Designee. They were informed of the findings. Findings: The hospices' P&P titled The Plan of Care undated, showed the written plan of care will contain measurable outcomes anticipated from implementing and coordinating the plan of care. Review of Patient 2's clinical record was initiated on 7/30/24. The clinical record showed the SOC was 4/12/23. The patient was certified for hospice services during the certification period from 6/5/24 to 8/3/24. The POC/IDG for the certification period from 6/5/24 to 8/3/24 dated 7/5/24 and 7/19/24, showed the lists of the patient's care needs. The care needs includes the goals and interventions. For example, the documentation showed the following: The goal for gastrointestinal was to reduced discomfort with improved bowel elimination. The goal for muskuloskeletal was to increase strength and energy for optimal functional activities. The goal for nutrition was to have adequate food and fluids as tolerated or desired. However, the POC/IDG failed to include the measurable outcomes of the identified care needs for the patient to achieved these goals. On 7/30/24 at 1548 hours, an interview and concurrent medical record review was conducted with the Administrator/CEO and The DPCS Designee. They were asked if the identified goals were measurable. The DPCS Designee replied. reviewed the records and replied, no its not measurable. They were informed and acknowledged the findings.

Based on interview and record review, the hospice failed to provide nursing care and services under the supervisions of qualified DPCS as per the hospice's P&P. This failure had the potential to negatively impact the hospice's nursing care. --- Review of the hospices job description titled Clinical Director/Director of Patient Care Services dated 10/2019 showed the Clinical Director/Director of Patient Care Services is responsible for the overall direction of hospice clinical services. Coordinated and oversees all direct and indirect patient services provided by clinical organization personnel. Provides guidance and counseling to coordinators and clinical supervisors to assist them in continually improving all aspect of hospice care services, provided through organization personnel. Position qualifications the clinical director or Director of Patient Care Services shall qualify for the position by fulfilling the requirements under one of the following categories, unless the individual had been previously approved for such employment by a program flexibility issued for the individuals current position at the hospice agency prior to April 1, 1995, or A. Three years management experience within the last five years in a hospice or related health care organization, at least one year of which was a supervisory or administrative capacity. B. A registered nurse with four years experience within the last five years in a hospice agency, primary care clinic, or health facility, at least one year of which was in supervisory or administrative capacity. Review of the hospices personnel administration titled Personnel Record Contents dated 10/19 showed upon request, the organization will provide personnel with a copy of confidential information being placed in the file. Personnel record will be retained in a manner that allows each to be easily retrievable and in keeping with timeframes of applicable local, state, and federal law. New hire documents: signed job description. Review of the employee file for the DPCS showed the date of hire was 6/28/24. However, there was no documented evidence of the signed job description of DPCS completed upon hiring. In addition, the file showed the DPCS's last date of employment with another employer was 5/21. There was no documented evidence the DPCS had been working for the last three years. On 7/31/24 at 1520 hours, an interview and concurrent record review was conducted with the Administrator and Intake support. The Administrator and Intake support were informed and acknowledged the findings.

Upon patient record review, 5 of 5 (Patient #1,2,3,4,5) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #1,2,3,4,5, Oxygen @2lpm via nasal cannula PRN shortness of breath, may titrate to 5l as needed. Oxygen documented under treatment. No evidence oxygen was documented on Medication sheet.

Upon patient record review, 1 of 5 (Patient #4) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual's attending physician, if any) • Changes that have taken place since the initial assessment • Information on the patient's progress toward desired outcomes • Reassessment of the patient's response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days Patient #4, Patient seen by RN 4/12/24, 5/3/24, 5/14/24, 6/1/24. No evidence comprehensive assessment every 15days.

Condition of Participation: Interdisciplinary Group, Care Planning, and Coordination of Services. L536

Upon patient record review, 2 of 5 (Patient #1,3) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #1, No evidence MSW addressed patient full code status on psychosocial care plan. Patient #3, No evidence of problems/interventions/goals to address wound care for right elbow and left hip in care plan.

Upon patient record review, 4 of 5 (Patient #2,3,4,5) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient #2,3,4,5, Frequency MSW initial and PRN, SC initial and PRN, neither contain detailed statement of scope and frequency to meet patient needs.

Upon client record review, 2 of 5 (Patient #1, 5) did not have evidence that the IDG in collaboration with the attending physician reviewed, revised and documents the individualized plan as frequently as the patient's condition requires but no less frequently then every 15 calendar days. Patient #1, No evidence of IDG completed every 15 days, IDG completed on 4/23/24 then on 5/10/24. Patient #5, Patient was admitted to hospice on 4/12/24. No evidence of IDG completed until 5/10/24.

Upon client record review, 5 of 5 (Patient #1,2,3,4,5) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1, MSW frequency every recertification. Patient seen 4/25/24 and 5/4/24. No evidence of order for visit in May. Patient #2, Frequency LVN 1x/week and RN every 14 days. All weekly visits completed by RN. 5/28/24, 6/3/24, 6/10/24. Patient #3, Frequency LVN 1x/week and RN every 14 days. All weekly visits completed by RN. 5/21/24, 5/29/24, 6/3/24, 6/12/24. Patient #4, Frequency written RN every 14 days. Patient seen by RN 4/12/24, 5/3/24, 5/14/24, 6/1/24. No evidence patient was seen every 14 days to meet frequency order.

Upon observation, there was no evidence the board of directors/governing body approves the frequency and detail of the data collection. There was no evidence the governing body had met to review and/or approve any items since 10/2020.

Upon observation, there was no evidence of involvement of the governing body and organizational leaders in the Quality Assessment/Performance Improvement (QAPI) program. There was no evidence the governing body had met since 10/2020 to show involvement in the QAPI program.

Upon observation, there was no evidence the hospice's governing body is responsible for ensuring that the hospice-wide Quality Assessment and Performance Improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness. There was no evidence the governing body had met to review and/or approve any items since 10/2020.

Upon observation, there was no evidence all licensed professional services provided directly or under arrangement are authorized, delivered and supervised only by health care professionals who meet the appropriate qualifications specified in CFR 418.114 and who practice under the hospice's policies and procedures. Multiple attempts to reach DPS and Alt DPS without any answer to calls. No evidence of clinical supervision of personnel in all care/service areas provided 24 hours per day, 7 days a week.

Upon patient record review 4 of 5 (Patient #1,3,4,5) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #1, Aide frequency 2x/week, no evidence of visits made in the month of June. Last visit 5/30/24. Patient #3, Aide frequency 2x/week, only 1 visit week of 5/15/24, next 2 weeks 3 visits completed each week. Patient #4, No initial orders for Aide, visits were made 3x/week starting 5/13/24. Patient #5, Aide frequency 3x/week ordered on 4/12/24. No visits completed till 4/29/24. No evidence that frequency was followed the first 2 week.

Upon patient record review 1 of 5 (Patient #4) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs. Patient #4, No evidence of Aide supervisory visit completed every 14 days. Patient seen by RN 4/12/24, 5/3/24, 5/14/24, 6/1/24.

Upon observation, there was no evidence the hospice is directed by a Board of Directors/governing body which assumes full legal authority and responsibility for the operation of the hospice. No evidence of governing body minutes since 10/18/2020.

Upon patient record review, 3 of 5 (Patient #1,2,4) did not have evidence that the medical director or physician designee provides written certification that it is anticipated that the patient's life expectancy is 6 months or less if the illness runs its normal course. The physician must consider the following when making this determination: • The primary terminal condition • Related diagnosis • Current subjective and objective medical findings • Current medication and treatment orders • Information about the medical management of any of the patient's conditions unrelated to the terminal illness Patient #1,2,4, No evidence of narrative on CTI or signature of Medical Director on form.

Upon patient client record review, 2 of 5 (Patient #1,5) did not have evidence that each patient record contains Physician certification and recertification of terminal illness. Patient#1,5, No evidence of attending physician signature on initial CTI.

Upon patient client record review, 5 of 5 (Patient #1,2,3,4,5) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient #1, IDG note on 4/23/24, 5/10/24, 5/24/24, 6/7/24, no evidence of MD signature, missing SC signature on 6/7/24 IDG note. Patient #2, IDG note on 5/20/24, 5/24/24, 6/7/24, no evidence of MD signature, missing SC signature on 6/7/24 IDG note. Patient #3, IDG note on 5/15/24, no signature by MD, RN ,SC, MSW and no SC update. 5/24/24 only RN signed. 6/7/24 only RN signed and no SC update. Patient #4,5, IDG note on 5/10/24, 5/24/24, 6/7/24, no evidence of MD signature, missing SC signature on 6/7/24 IDG note. In addition, the admission forms contained an area on the form to mark for advanced directives however, this area was not completed.

Upon patient record review, 2 of 5 records (Patients #2,#3) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient 2: Upon observation during the home visit, the patient had equipment including a geri-chair and hoyer lift. There was no evidence of the chair and lift included on supplies in the plan of care. Patient 3: Upon observation during the home visit, the patient had equipment including a overbed table. There was no evidence of the table included on supplies in the plan of care.

Upon patient record review, 1 of 5 records (Patient #4) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Patient 4: The medical record contained initial psychosocial, spiritual and bereavement assessments completed by the social worker and chaplain. There was no evidence of the date visits were completed on the documents in section provided to identify date of service. Patient was only on service 4 days so it is clear comprehensive assessment was completed timely.