Every finding on record at Divine Hospice and Palliative Care LLC

It is required that the hospice Interdisciplinary Group, in consultation with the individual's attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by document review, clinical record review, and interview. In 1 of 14 (7%) clinical records reviewed, the agency did not ensure the initial comprehensive assessment was completed no later than five days after the election of hospice services. Agency policy Initial Assessment/Comprehensive Assessment, required in part, "the Hospice IDG, in consultation with the patient's attending physician (if any), must complete the comprehensive assessment no later than 5 calendar days after the patient's election of Hospice care." Clinical Record 8: The patient elected the Hospice benefit on 03/29/2024. The RN documented on the initial assessment dated 03/29/2024 that the patient is Catholic and was open to Chaplain visits. Review of the clinical record revealed an admission order for the Spiritual Counselor prn (as needed) for spiritual needs. There was no documented evidence in the clinical record that the Spiritual Counselor completed the initial assessment of the patient’s spiritual needs, as part of the initial comprehensive assessment, and there was no documentation in the record that the patient had declined the Spiritual Counselor. During an interview and joint review of the clinical record on 01/23/2025, the Administrator stated that she was unable to find evidence in the clinical record that the family declined the Spiritual Counselor.

It is required that counseling services include an organized program for providing bereavement services delivered by or under the supervision of a qualified professional with experience or education in grief or loss counseling. The bereavement services reflect the needs of the bereaved per a bereavement plan of care that includes: The types of bereavement services to be offered and the frequency of service delivery. This standard was not met as evidenced by document review, clinical record review, and interview. In 1 of 2 (50%) clinical records reviewed, the agency did not ensure documentation of a bereavement plan of care that included the types of bereavement services to be offered. Agency policy Bereavement Services, required in part, "After a patient death has occurred, the case will be discussed at the next IDG [interdisciplinary group] meeting. Recommendations for bereavement will be made based on the severity of grief and determined by the family member's consent for further services. Bereavement services must reflect the needs of the bereaved. Unless Bereavement Services have been refused, a Bereavement Counselor, Chaplain or Social Worker will call designated bereaved to continue bereavement supportive or counseling services. A bereavement plan of care will be initiated... The plan of care will note the kind of bereavement services to be offered and frequency of service delivery." Clinical Record 12: The patient elected the hospice benefit on 01/17/2024 and the patient’s date of death was 03/18/2024. Clinical record review revealed no documented evidence that bereavement services were initiated or that a bereavement plan of care was developed. During an interview on 01/22/2025, the Bereavement Coordinator stated that she could not locate documentation in the clinical record that reflected the bereavement plan of care, or any activities planned or completed. She stated that she remembered that the family refused bereavement, but there was no documentation in the clinical record.

It is required that hospice aides are supervised by a registered nurse who makes 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; Ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. The hospice aide does not need to be present. This standard was not met as evidenced by document review, clinical record review, and interview. In 4 of 12 (33%) clinical records reviewed, the agency did not ensure the Hospice Aide was supervised by a Registered Nurse who makes an on-site visit no less frequently than every 14 days. Agency policy Hospice Aides, required in part, "Hospice Aides are closely supervised to ensure their competence in providing care. At lease every 14 days the registered nurse (RN) makes an onsite home supervisory visit to assess relationships and determine whether goals are being met. This is done with or without the aide's presence." Clinical Record 1: The patient elected the hospice benefit on 10/02/2022. The plan of care dated 07/23/2024 to 09/20/2024 included an order for hospice aide services three times a week starting on 07/22/2024. Clinical record review revealed hospice aide services were provided as ordered on the plan of care. The RN documented an aide supervisory visit on 08/14/2024 and the next aide supervisory visit was dated 09/10/2024, a total of 27 days and 13 days outstanding. Clinical Record 2: The patient elected the hospice benefit on 07/19/2024. The plan of care dated 10/17/2024 to 01/14/2025 included an order for hospice aide services three times a week starting on 10/16/2024. Clinical record review revealed hospice aide services were provided as ordered on the plan of care. The RN documented an aide supervisory visit on 11/04/2024 and the next aide supervisory visit was dated 11/21/2024, a total of 17 days and 3 days outstanding. The RN documented an aide supervisory visit on 12/18/2024 and the next aide supervisory visit was dated 01/03/2025, a total of 16 days and 2 days outstanding. Clinical Record 3: The patient elected the hospice benefit on 06/05/2024. The plan of care dated 09/03/2024 to 12/01/2024 included an order for hospice aide services three times a week starting on 09/04/2024. Clinical record review revealed hospice aide services were provided as ordered on the plan of care. The RN documented an aide supervisory visit on 12/20/2024 and the next aide supervisory visit was dated 01/07/2025, a total of 18 days and 4 days outstanding. Clinical Record 9: The patient elected the hospice benefit on 06/25/2024. The plan of care dated 09/23/2024 to 12/21/2024 included an order for hospice aide services two times a week starting on 09/23/2024. Clinical record review revealed hospice aide services were provided as ordered on the plan of care. The RN documented an aide supervisory visit on 11/14/2024 and the next aide supervisory visit was dated 12/12/2024, a total of 28 days and 14 days outstanding. During an interview on 01/21/2025, the Administrator stated that they have had a lot of staff changes, but they would do some additional education on the requirements of aide supervision visits.

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 document review, personnel record review, and interview. In 1 of 10 (10%) personnel records reviewed, the agency did not ensure documentation of the assessment of the skills and competencies for individuals providing care, as required by agency policy. Agency policy Staff Competency Program, required in part, "Patient care staff will be competency assessed at defined intervals: for each new employee (including contract employees) during orientation." Personnel Record 8: Certified Nurse Assistant date of hire 07/20/2022. Personnel record review revealed no documented evidence of an initial competency assessment during orientation. During an interview and joint review of the personnel record on 01/21/2025, the Administrator and the Office Manager stated that an initial competency assessment could not be found in the record. They were unsure how it was missed, but they would review their process.

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 is a CONTINUING required action. This standard was not met as evidenced by clinical record review and interview. 1 of 5 (20%) 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 1: The patient’s benefit election was dated 11/8/22. The need for a spiritual care evaluation was documented in the comprehensive assessment. On 11/16/22, the chaplain documented that the patient refused chaplain services (8 days after the election of hospice care). There was no documentation as to why the assessment was delayed beyond the 5 calendar days after the election of hospice care. The administrator/LPN who reviewed records with this site visitor on 7/27/23 stated that she did not know why the chaplain did not contact the patient/family within 5 calendar days after the election of hospice care. This is a continuing required action. In 1 of 5 (20%) 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 during the initial assessment visit and in advance of providing care the hospice provides the patient—or his or her representative—with verbal and written notice of the patient’s rights and responsibilities. The hospice obtains the patient’s or representative’s signature confirming that he or she received a copy of the Bill of Rights and Responsibilities statement. This standard was not met as evidenced by clinical record review and interviews. 2 of 11 (18%) clinical records revealed the hospice agency did not ensure patients’ acknowledgement confirming receipt of the notice of rights and responsibilities. Record 38070: the election of benefit was dated 6/27/2021. The patient information packet on page 6 contained a section for the patient to acknowledge and agree to the terms and conditions described in the following documents including, the informed consent and treatment, Medicare /state hospice benefit election, privacy notice, financial agreement, advance directives, photography release, grievances and complaint procedure, infection control/handwashing instructions and control substance disposal. There was no acknowledgement by the patient and or representative confirming receipt of the notice of rights and responsibilities. Record 80158: the election of benefit was dated 11/6/2021. The patient information packet on page 6 contained a section for the patient to acknowledge and agree to the terms and conditions described in the following documents including the informed consent and treatment, Medicare/state hospice benefit election, privacy notice, financial agreement, advance directives, photography release, grievances and complaint procedure, infection control/handwashing instructions and control substance disposal. There was no acknowledgement by the patient and or representative confirming receipt of the notice of rights and responsibilities. An interview was conducted on 3/29/2022 with the Alternate Administrator (Staff ID 91669) who agreed that the records lacked documentation by the patient and or representative, acknowledging receipt of the hospice terms and conditions.

It is required that the hospice Interdisciplinary Group, in consultation with the individual's attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review and staff interview. 2 of 11 (18%) clinical records revealed the agency social worker failed to complete the initial comprehensive assessment no later than five (5) days. Record 34343 (election of benefit 12/14/2021): social worker completed comprehensive assessment on 12/20/2021. Record 29108 (election of benefit 1/17/2022): social worker completed comprehensive assessment on 1/28/2022. An interview was conducted on 3/29/2022 with the Alternate Administrator (Staff ID 91669) who stated after review that the assessments was not completed timely.

It is required that the hospice designates an Interdisciplinary Group or groups who, in consultation with the patient's attending physician, prepare a written plan of care (POC) for each patient. This standard was not met as evidenced by clinical record review. 2 of 11 (18%) of clinical records revealed the hospice agency did not ensure plans of care were developed to meet identified, patient-specific needs. Record 58130 (election of benefit 1/25/2022), IDG identified patient was started on antibiotics for diminished lung sounds and difficulty swallowing. The IDG also identified a wound on the right elbow. No documented care plan dysphagia/impaired swallowing or impaired skin integrity was found in the clinical record. Record 31572 (election of benefit 11/30/2020), IDG identified during four consecutive meetings the patient was noted to have dysphagia. No documented care plan for dysphagia/impaired swallowing was found in the clinical record.

It is required that a hospice aide provides services ordered by the Interdisciplinary Group. This standard was not met as evidenced by clinical record review and staff interview. 1 of 11 (9%) clinical records revealed the hospice agency did not ensure that hospice aides provided services as ordered by the Interdisciplinary Group Record 34343 (election of benefit 12/14/2021), aide services to begin on 12/15/2021 for 2 times per week. Week of 12/19/2021, 12/26/2021, 1/9/2022, 1/16/2022, 1/25/2022 only one aide visit is documented in the clinical record. The Alternate Administrator (Staff ID 91669) was interviewed on 3/30/2022 and confirmed hospice aide services were ordered at a frequency of 2 times a week, but 1 aide visit was provided weekly.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum a signed copy of the notice of patient rights and the hospice election statement. This standard was not met as evidenced by clinical record review. 7 of 11 (63%) of clinical records revealed the hospice agency did not ensure completed hospice election statements. Record 38707: the election of benefit was dated 6.27.2021. The informed consent and treatment authorization states patient’s physician is the primary caregiver (page 1), page 2 is missing designated attending physician address and phone number. Page 6 is missing a check verifying acknowledgement and agreement to the terms and conditions described in the following documents and the release of patient records. The addendum on page 2 was missing the physician's NPI and office address. Record 58130: the election of benefit was dated 1/25/2022. The hospice addendum was missing the hospice agency representative's signature and date on page 2. Record 80158: the election of benefit was dated 11/6/2021. The acknowledgement on EOB dated 11/17/2021 was missing documentation of acknowledgment and agreement to the terms and conditions described in the following documents including the informed consent, Medicare hospice election benefit, privacy notice, financial agreement, advanced directives, photo release, grievances and complaints, infection control, controlled substance disposal. Record 54012: the election of benefit was 5/19/2021. The hospice addendum on page 2 was missing the effective date of election. Record 38049: the election of benefit was 2/9/2022. Page 2 of the hospice election statement addendum, under the right to choose an attending physician was not checked and the patient did not sign or date this form. Record 34343: the election of benefit was dated 12/14/2021. The hospice benefit effective date was left blank; the right to choose an attending physician on the hospice election statement addendum was not checked. Record 31572: the election of benefit was 11/30/2020. The informed consent and treatment authorization form on page 2 was missing the hospice care effective date.

It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid/MediCal-certified facility, the hospice forwards to the receiving facility a copy the hospice discharge summary. This standard was not met as evidence by clinical record review, and document review. 1 of 1 (100%) applicable discharge records revealed the hospice agency did not ensure a hospice discharge summary was sent when the patient was transferred to another hospice facility. Record #38707: patient EOB dated 6/27/21. The patient was transferred to another hospice on 8/18/2021 and no evidence of a discharge summary was noted in the clinical record. An interview was conducted on 3/29/2022 with the Alternate Administrator (Staff ID 91669) who confirmed that the discharge summary was not completed and sent to the receiving facility at the time of patient transfer.