Every finding on record at Eh of West Texas, LP

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 interview. In 2 of 14 (14%) clinical records reviewed, the agency did not ensure that the comprehensive assessment was completed no later than five (5) calendar days after the election of hospice care. Clinical Record 7: The patient elected the hospice benefit on 3/27/2023 with a diagnosis of malignant neoplasm of rectosigmoid junction. The initial plan of care dated 3/27/2023 ordered a Chaplain assessment. The Chaplain's initial assessment was completed on 4/3/2023, eight (8) days after the patient's election of the hospice benefit. The Director of Operations note dated 4/17/2023 documented the visit occurred after the actual in-home visit because the Chaplain was sick and was delayed in making the visit. During an interview and a joint review of the clinical record on 1/3/2024, the Director of Operations and Clinical Team Lead confirmed no coordination notes were found to explain the delay in the Chaplain assessment. Clinical Record 8: The patient elected the hospice benefit on 9/27/2023 with a diagnosis of hypertensive heart disease with heart failure. The initial plan of care dated 9/27/2023 ordered a Chaplain assessment. The Chaplain's initial assessment was completed on 10/9/2023, twelve (12) days after the patient's election of the hospice benefit. During an interview and a joint review of the clinical record on 1/3/2024, the Director of Operations confirmed no documentation was found to explain the delay of services.

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. Each patient’s record includes, at a minimum, physician certification and recertification of terminal illness as required. This standard was not met as evidenced by clinical record review, document review, and interview. In 1 of 14 (7%) clinical records reviewed, the agency did not ensure there was correct information on the certificate of terminal illness. Clinical Record 7: The patient elected the hospice benefit on 3/27/2023 with a diagnosis of Atherosclerotic Heart Disease. On 6/16/2023, the diagnosis was changed to Malignant Neoplasm of Rectosigmoid Junction. The initial Certification of Terminal Illness dated and signed 4/6/2023 stated, "year old male on Hospice services with a diagnosis of chronic obstructive pulmonary disease (COPD), respiratory failure. Comorbidities include pulmonary fibrosis, sleep apnea, DMII, Diabetic neuropathy, macular edema, and morbid obesity. SPO2 less than 88% on room air. It is noted that SPO2 less than 88% at times with O2 in place. Patient had foley catheter in place and is incontinent of bowel. Patient has had infection requiring antibiotic during this cert period. He has had multiple falls during this certification period, as well. PPS 40% and his is requiring increased assistance for all ADL's Patient is dependent upon caregivers for all needs." During an interview and a joint review of the clinical record and certification of terminal illness on 1/3/2024, the Clinical Team Lead (CTL), also the case manager for this patient, confirmed that the incorrect information was documented in the patient's initial certification of terminal illness. The CTL stated that the patient was admitted with Atherosclerotic Heart Disease, not COPD, and the patient did not have respiratory failure. The CTL stated that the patient's correct comorbidities are Rectal Cancer, Congestive Heart Failure, Deep Vein Thrombosis, presence of a pacemaker, diverticulitis, and neuropathy. The CTL confirmed that the patient does not have a Foley catheter in place, has had no infections treated with antibiotics, and has had one (1) fall. The agency has an active performance improvement plan for improving eligibility documentation and certificates of terminal illness.