Every finding on record at Emerald Care Hospice, LLC

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 following: the effectiveness of drug therapy; drug side effects; actual or potential drug interactions; duplicate drug therapy; [and] drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and, as appropriate, preventive measurements are implemented to manage the side effects. 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, and interview. In 5 of 5 (100%) clinical records reviewed, the agency did not ensure the patient's medication profile included the patient's current medications. Agency Policy # PC. MSS "Medication Profile" read in part, "The medication profile must include... All current patient's medications...The patient's medication profile is reviewed by the IDG whenever there is a significant change and at a minimum, every 15 days."` Clinical Record 1: The patient elected hospice care on 06/07/2023. On 06/07/2023, the physician ordered, "Oxygen at 2-5 liters per minute (lpm) via nasal cannula as needed for dyspnea/respiratory distress." The interdisciplinary team meeting documentation dated 06/07/2023, 06/16/2023, 06/30/2023, 07/14/2023, 07/28/2023, 08/11/2023, 08/25/2023, 09/08/2023, 09/22/2023, 10/06/2023, 10/20/2023, 11/03/2023, 11/17/2023, 12/01/2023 and 12/15/2023 included medication profile review. A clinical record review on 12/28/2023 revealed oxygen was not documented in the patient's medication profile. Clinical Record 2: The patient elected hospice care on 06/13/2023. On 06/13/2023, the physician ordered, "Oxygen at 2-5 lpm via nasal cannula as needed for dyspnea/respiratory distress." The interdisciplinary team meeting documentation dated 06/13/2023, 06/16/2023, 06/30/2023, 07/14/2023, 07/28/2023, 08/11/2023, 08/25/2023, 09/08/2023, 09/22/2023, 10/06/2023, 10/20/2023, 11/03/2023, 11/17/2023, 12/01/2023 and 12/15/2023 included medication profile review. A clinical record review on 12/28/2023 revealed oxygen was not documented in the patient's medication profile. Clinical Record 3: The patient elected hospice care on 06/07/2023. On 06/07/2023, the physician ordered, "Oxygen at 2-5 lpm via nasal cannula as needed for dyspnea/respiratory distress." The interdisciplinary team meeting documentation dated 06/07/2023, 06/16/2023, 06/30/2023, 07/14/2023, 07/28/2023, 08/11/2023, 08/25/2023, 09/08/2023, 09/22/2023, 10/06/2023, 10/20/2023, 11/03/2023, 11/17/2023, 12/01/2023 and 12/15/2023 included medication profile review. A clinical record review on 12/28/2023 revealed oxygen was not documented in the patient's medication profile. Clinical Record 4: The patient elected hospice care on 06/08/2023. On 06/08/2023, the physician ordered, "Oxygen at 2-5 liters per minute (lpm) via nasal cannula as needed for dyspnea/respiratory distress." The interdisciplinary team meeting documentation dated 06/07/2023, 06/16/2023, 06/30/2023, 07/14/2023, 07/28/2023, 08/11/2023, 08/25/2023, 09/08/2023, 09/22/2023, 10/06/2023, 10/20/2023, 11/03/2023, 11/17/2023, 12/01/2023 and 12/15/2023 included medication profile review. A clinical record review on 12/28/2023 revealed oxygen was not documented in the patient's medication profile. Clinical Record 5: The patient elected hospice care on 08/14/2023. On 08/14/2023, the physician ordered, "Oxygen at 2-5 liters per minute (lpm) via nasal cannula as needed for dyspnea/respiratory distress." The interdisciplinary team meeting documentation dated 08/15/2023, 08/25/2023, 09/08/2023, 09/22/2023, 10/06/2023, 10/20/2023 and 11/03/2023 included medication profile review. A clinical record review on 12/28/2023 revealed oxygen was not documented in the patient's medication profile. During an interview and a joint review of the records on 12/29/2023, the Alternate Administrator confirmed the findings and stated that oxygen had since been added to the patient medication profiles.

It is required that each patient’s individualized written plan of care: identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. CONTINUING PRIOR REQUIRED ACTION This standard was not met as evidenced by clinical record review, document review, and interview. In 3 of 5 (60%) clinical records reviewed, the agency did not ensure the hospice plan of care (POC) included interventions and goals based on problems identified in the initial and updated comprehensive assessments. Agency policy #PC.P55 "Plan of Care" read in part, "The IDT must develop an individualized plan of care for each client.The plan of care must reflect client and family goals and interventions based on the problems identified in the initial comprehensive and updated comprehensive assessments." Clinical Record 1: The patient elected hospice care on 06/07/2023. The POC dated 12/04/2023 ordered hospice aide services three times a week. The hospice aide documented visits and care provided from 12/04/2023 through 12/26/2023. A review of the clinical record on 12/28/2023 revealed the POC did not include documentation of interventions and goals for hospice aide services based on the patient's inability to perform activities of daily living (ADL) independently as documented in the comprehensive assessments dated 12/01/2023 and the 12/25/2023. Clinical Record 2: The patient elected hospice care on 06/13/2023. The POC dated 12/10/2023 ordered hospice aide services once a week. The hospice aide documented visits and care provided from 12/12/2023 through 12/26/2023. A review of the clinical record on 12/28/2023 revealed the POC did not include documentation of interventions and goals for hospice aide services based on the patient's inability to perform activities of daily living independently as documented in the comprehensive assessments dated 12/01/2023 and the 12/25/2023. Clinical Record 5: The patient elected hospice care on 08/14/2023. The POC dated 08/14/2023 ordered hospice aide services three times a week. The hospice aide documented visits and care provided from 08/14/2023 through 10/24/2023. A review of the clinical record on 12/28/2023 revealed the POC did not include documentation of interventions and goals for hospice aide services based on the patient's inability to perform activities of daily living (ADL) independently as documented in the comprehensive assessments dated 08/14/2023, 08/25/2023, 09/08/2023, 09/22/2023, 10/06/2023, and 10/20/2023. During an interview and joint review of the records on 12/29/2023, the Alternate Administrator stated that the interventions and goals had been included on the hospice aide task assignment sheet but had been inadvertently omitted from the POC and had since been corrected.

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 and 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 clinical record review, document review, and interview. In 1 of 3 (33%) clinical records reviewed of patients that received hospice aide services, the agency did not ensure hospice aide supervision was completed no less frequently than every 14 days. Agency policy #PC. H40 "Hospice Aide Supervision" read in part, "A registered nurse makes an on-site visit to the patient's home no less frequently than every 14 days to ensure the services ordered by the IDG and provided by the hospice aide are meeting the patient's need." Clinical Record 2: The patient elected hospice care on 06/13/2023. The plans of care dated 09/11/2023 and 12/10/2023 ordered hospice aide services one time a week. The hospice aide documented hospice aide services provided as ordered from 09/11/2023 through 12/26/2023. A clinical record review revealed that as of 12/28/2023, there was no documented evidence of hospice aide supervisory visits conducted by the registered nurse (RN) for 11/20/2023 through 12/11/2023 and 12/11/2023 through 12/28/2023. There was no evidence the RN made an on-site visit to the patient's home any less frequently than every 14 days, 11/20/2023 through 12/11/2023. During an interview and a joint record review on 12/29/2023, the Alternate Administrator identified that the aide supervision was not completed timely and plans to have nursing staff complete every visit moving forward.

It is required that all entries in the patient record are legible, complete, and appropriately authenticated and dated by the person performing the care/service in accordance with hospice policy and with currently acceptable standards of practice. This standard was not met as evidenced by clinical record review, document review, and interview. In 5 of 5 (100%) clinical records reviewed, the agency did not ensure that all entries in the patient record were appropriately authenticated. Agency policy #PC. D25 "Documentation Requirements" read in part, "All documentation is signed using complete first and last name, credentials and title." Clinical Record 1: The patient elected hospice care on 06/07/2023. The spiritual assessment dated 06/12/2023 and the bereavement risk assessments dated 06/12/2023 and 12/27/2023 did not include documentation of credentials with the associated signatures and dates. Clinical Record 2: The patient elected hospice care on 06/13/2023. The spiritual assessment dated 06/15/2023 and the bereavement risk assessments dated 06/15/2023 and 12/22/2023 did not include documentation of credentials with the associated signatures and dates. Clinical Record 3: The patient elected hospice care on 06/07/2023. The spiritual assessment dated 06/10/2023 and the bereavement risk assessments dated 06/10/2023 and 12/17/2023 did not include documentation of credentials with the associated signatures and dates. Clinical Record 4: The patient elected hospice care on 06/08/2023. The spiritual assessments dated 06/10/2023 and 07/10/2023 did not include documentation of credentials with the associated signatures and dates. Clinical Record 5: The patient elected hospice care on 08/14/2023. The spiritual assessments dated 08/15/2023, 08/17/2023, 09/20/2023, and 10/20/2023, and the bereavement risk assessment dated 08/15/2023 did not contain credentials with the associated signatures and dates. During an interview on 12/29/2023, the Alternate Administrator reviewed the associated records and stated that the missing credentials had since been added.

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 minimum information provided to facilitate patient evacuation and transportation, including if the patient is mobile or not, if the patient has life-dependent equipment, and if so, is it able to be transported (e.g. battery operated, size, condition, etc.); and any patient special needs including cognitive disorders, intellectual disabilities, or communication issues (e.g. deaf, non-English speaking, etc.). This standard was not met as evidenced by clinical record review and interview. In 5 of 5 (100%) clinical records reviewed, the agency did not ensure pertinent information about the patient's level of mobility, their need for any life-dependent equipment and its portability, or any special needs such as language barriers, cognitive or sensory issues were included on the patients’ individualized Emergency Assessment/Plan for facilitating evacuation in the event of a disaster. Clinical Record 1: The patient elected the hospice benefit on 06/07/2023, with a terminal diagnosis of senile degeneration of the brain. The Patient Emergency/Disaster Plan form did not include the patient’s mobility status, need for life-dependent equipment, or any other special needs, and the section "How services will continue in the event of an emergency" was left blank. Clinical Record 2: The patient elected the hospice benefit on 06/13/2023, with a terminal diagnosis of stage IV kidney disease. The Patient Emergency/Disaster Plan form did not include the patient’s mobility status, need for life-dependent equipment, or any other special needs, and the section "How services will continue in the event of an emergency" was left blank. Clinical Record 3: The patient elected the hospice benefit on 06/07/2023, with terminal diagnosis of senile degeneration of the brain. The Patient Emergency/Disaster Plan form did not include the patient’s mobility status, need for life-dependent equipment, or any other special needs, and the section "How services will continue in the event of an emergency" was left blank. Clinical Record 4: The patient elected the hospice benefit on 06/08/2023, with a terminal diagnosis of chronic obstructive pulmonary disease. Clinical record review revealed no documented evidence of an individualized patient emergency assessment/ plan that included the patient’s mobility status, need for life-dependent equipment, or any other special needs. Clinical Record 5: The patient elected the hospice benefit on 08/14/2023, with a terminal diagnosis of congestive heart failure. Clinical record review revealed no documented evidence of an individualized patient emergency assessment/ plan that included the patient’s mobility status, need for life-dependent equipment, or any other special needs. During joint review of the agency's Patient Emergency/Disaster Plan form and interview on 10/31/2023, the Alternate Director of Clinical Services confirmed the forms were not complete and did not include information on mobility, equipment, or special needs to assist emergency officials in the event assistance is needed to evacuate a patient.

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 1 of 5 (20%) clinical records reviewed, the agency did not ensure the Interdisciplinary Group (IDG) completed the initial comprehensive assessment no later than five calendar days after the election of hospice care. Clinical Record 1: The patient elected the hospice benefit on 06/07/2023, with a terminal diagnosis of senile degeneration of the brain. Clinical record review revealed the psychosocial assessment was dated 06/20/2023, 13 days after the election of benefit and 8 days outstanding. During joint record review and interview on 10/31/2023, the Alternate Director of Clinical Services confirmed the psychosocial assessment was not completed within 5 calendar days and could not find documentation from the social worker to explain why the initial visit was completed outside the 5-day timeframe.

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. The plan of care specifies the hospice care and services necessary to meet the specific needs of the patient and family identified in the comprehensive assessment, relative to the terminal illness and associated conditions. THIS IS A CMS CONDITION LEVEL DEFICENCY. This condition of participation was not met as evidenced by review of clinical records, agency policy review, and interview with the Director of Clinical Services and Alternate Director of Clinical Services which revealed the following issues with the development and implementation of patients’ interdisciplinary plans of care: Failure to ensure the individualized plan of care reflected patient and family goals and identified planned interventions based on problems identified in the initial and updated comprehensive assessments [HCPC.21.I/L545]; Failure to ensure the individualized plan of care included a detailed statement of the scope and frequency of services necessary to meet specific patient and family needs [HCPC.21.I/L547]; Failure to ensure the patient's written plan of care included individualized measurable outcomes [HCPC.21.I/L548]; Failure to ensure revised plan of care included information from the patient’s updated comprehensive assessment and recorded the patient’s progress toward the outcomes and goals specified in the plan of care [HCPC.22.I/L553]; and Failure to ensure volunteer services were included in the patient's plan of care [HCDT.21.I/L644]. The cumulative effect of these deficiencies has resulted in the hospice organization's inability to ensure the provision of quality of care for the Condition of Participation CFR 418.56: Interdisciplinary Group, Care Planning, and Coordination of Services. The collective deficient practice illustrated systemic process failures that had the potential to affect all patients receiving hospice care service from the agency.

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 document review, clinical record review, and interview. In 5 of 5 (100%) clinical records reviewed, the agency did not ensure the individualized plan of care reflected patient and family goals and identified planned interventions based on problems identified in the initial and updated comprehensive assessments. Agency policy PC. P55 Plan of Care reviewed 06/15/2023 stated in part, The interdisciplinary written plan of care is developed with measurable goals and outcomes for planned interventions. The care and services provided/delivered to patients and their families are in accordance with an individualized, written plan of care." Clinical Record 1: The patient elected the hospice benefit on 06/07/2023, with a terminal diagnosis of senile degeneration of the brain. Review of the recertification plan of care dated 09/05/2023 through 12/03/2023 revealed standardized goals and interventions for each discipline that were not individualized to the patient’s condition and assessment findings. The plan of care included a visit frequency order for the Social Worker and the Chaplain but did not include goals and interventions for the Social Worker and Chaplain. Clinical Record 2: The patient elected the hospice benefit on 06/13/2023, with a terminal diagnosis of stage IV kidney disease. Review of the recertification plan of care dated 09/11/2023 through 12/09/2023 revealed standardized goals and interventions for each discipline that were not individualized to the patient’s condition and assessment findings. The plan of care included a visit frequency order for the Social Worker and the Chaplain but did not include goals and interventions for the Social Worker and Chaplain. Clinical Record 3: The patient elected the hospice benefit on 06/07/2023, with terminal diagnosis of senile degeneration of the brain. Review of the recertification plan of care dated 09/05/2023 through 12/03/2024 revealed standardized goals and interventions for each discipline that were not individualized to the patient’s condition and assessment findings. The plan of care included a visit frequency order for the Social Worker and the Chaplain but did not include goals and interventions for the Social Worker and Chaplain. Clinical Record 4: The patient elected the hospice benefit on 06/08/2023, with a terminal diagnosis of chronic obstructive pulmonary disease. Review of the plan of care dated 06/08/2023 through 09/05/2024 revealed standardized goals and interventions for each discipline that were not individualized to the patient’s condition and assessment findings. The plan of care included a visit frequency order for the Social Worker and the Chaplain but did not include goals and interventions for the Social Worker and Chaplain. Clinical Record 5: The patient elected the hospice benefit on 08/14/2023, with a terminal diagnosis of congestive heart failure. Review of the plan of care dated 08/14/2023 through 01/10/2024 revealed standardized goals and interventions for each discipline that were not individualized to the patient’s condition and assessment findings. The plan of care included a visit frequency order for the Social Worker and the Chaplain but did not include goals and interventions for the Social Worker and Chaplain. During a joint interview on 11/02/2023, the Director of Clinical Services and the Alternate Director of Clinical Services both confirmed that the plans of care were not individualized and if the name of the patient and the medications were covered, it would be impossible to determine one plan of care from the next.

It is required that each patient’s individualized written plan of care includes a detailed statement of the scope and frequency of services necessary to meet specific patient and family needs. This standard was not met as evidenced by document review, clinical record review, and interview. In 3 of 5 (60%) clinical records reviewed, the agency did not ensure the individualized plan of care included a detailed statement of the scope and frequency of services necessary to meet specific patient and family needs. Clinical Record 1: The patient elected the hospice benefit on 06/07/2023, with a terminal diagnosis of senile degeneration of the brain. The plan of care dated 06/07/2023 through 09/04/2023 ordered, "Therapy Visits - Frequency: Evaluate and call report to hospice case manager." The recertification plan of care dated 09/05/2023 through 12/03/2023 did not include an order for therapy visits. Clinical record review revealed the Physical Therapist provided therapy visits to the patient weekly from 06/24/2023 through the date of record review on 11/01/2023, except for the week of 09/24/2023. The plans of care did not include the scope and frequency of therapy services that were provided to the patient and there was no documented evidence of an updated physician order for the scope and frequency of therapy visits. Clinical Record 2: The patient elected the hospice benefit on 06/13/2023, with a terminal diagnosis of stage IV kidney disease. The plan of care dated 06/13/2023 through 09/10/2023 and the recertification plan of care dated 09/11/2023 through 12/09/2023 ordered "Volunteer visits when needed." The plans of care did not include frequency of visits for the volunteer and did not include volunteer interventions or goals. The Interdisciplinary Group Meeting Updates /IDG Plan of Care Updates dated 08/11/2023, 08/25/2023, 09/08/2023, 09/22/2023, 10/06/2023 and 10/20/2023 did not include volunteer frequency of visits, interventions, or goals. Clinical record review revealed volunteer visits were provided on 08/22/2023, 08/29/2023, 09/05/2023, 09/12/2023, 09/19/2023, 09/26/2023, 10/03/2023, 10/10/2023, 10/17/2023, 10/23/2023, and 10/30/2023. The volunteer documented that caregiver relief/support and light housekeeping/home organization was provided during volunteer visits. Clinical Record 5: The patient elected the hospice benefit on 08/14/2023, with a terminal diagnosis of congestive heart failure. The plan of care dated 08/14/2023 through 10/10/2023 ordered "Volunteer visits when needed." The plan of care did not include frequency of visits for the volunteer and did not include volunteer interventions or goals. The Interdisciplinary Group Meeting Updates /IDG Plan of Care Updates dated 08/25/2023, 09/08/2023, 09/22/2023, 10/06/2023 and 10/20/2023 did not include volunteer frequency of visits, interventions, or goals. Clinical record review revealed volunteer visits were provided on 08/28/2023, 08/29/2023, 09/12/2023, 09/15/2023, 09/18/2023, 09/19/2023, and 10/22/2023. The volunteer documented that caregiver relief/support and light housekeeping/home organization was provided during volunteer visits. During an interview on 11/01/2023, the Alternate Director of Clinical Services confirmed frequency orders were included in these patients' plans of care for volunteer and therapy visits.

It is required that each patient’s individualized written plan of care includes measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by document review, clinical record review, and interview. In 5 of 5 (100%) clinical records reviewed, the agency did not ensure the patient's written plan of care included individualized measurable outcomes. Agency policy PC. P55 Plan of Care reviewed 06/15/2023 stated in part, The interdisciplinary written plan of care is based on initial and updated patient-specific comprehensive assessments by members of the IDG (interdisciplinary group) and is developed with measurable goals and outcomes for planned interventions. The plan of care is revised as needed and includes the patient's progress toward outcomes and goals. Agency policy PC. D25 Documentation Requirements reviewed 06/15/2023 stated in part, "Members of the interdisciplinary group document the interventions provided to the patient/caregiver, their responses to care, services provided, and the goals or outcomes achieved. The patient record documentation provides patient information specific to care and services/products provided, current patient status, and progress toward goals and outcomes of care." Clinical Record 1: The patient elected the hospice benefit on 06/07/2023, with a terminal diagnosis of senile degeneration of the brain. Review of the plan of care dated 06/07/2023 through 09/04/2023 and the recertification plan of care dated 09/05/2023 through 12/03/2023 revealed the listed expected outcomes of care were not measurable. The outcomes listed on the plans of care included, symptoms of the disease process will be managed, the patient/caregiver will proceed through the grief process with the support of IDT, the patient/caregiver will find comfort through psychosocial/spiritual support, and the patient will experience a comfortable death. Clinical Record 2: The patient elected the hospice benefit on 06/13/2023, with a terminal diagnosis of stage IV kidney disease. Review of the plan of care dated 06/13/2023 through 09/10/2023 and the recertification plan of care dated 09/11/2023 through 12/09/2023 revealed the listed expected outcomes of care were not measurable. The outcomes listed on the plans of care included, symptoms of the disease process will be managed, the patient/caregiver will proceed through the grief process with the support of IDT, the patient/caregiver will find comfort through psychosocial/spiritual support, and the patient will experience a comfortable death. Clinical Record 3: The patient elected the hospice benefit on 06/07/2023, with terminal diagnosis of senile degeneration of the brain. Review of the plan of care dated 06/07/2023 through 09/04/2023 revealed the listed expected outcomes of care were not measurable. The outcomes listed on the plan of care included, symptoms of the disease process will be managed, the patient/caregiver will proceed through the grief process with the support of IDT, the patient/caregiver will find comfort through psychosocial/spiritual support, and the patient will experience a comfortable death. Clinical Record 4: The patient elected the hospice benefit on 06/08/2023, with a terminal diagnosis of chronic obstructive pulmonary disease. Review of the plan of care dated 06/08/2023 through 09/05/2023 revealed the listed expected outcomes of care were not measurable. The outcomes listed on the plan of care included, symptoms of the disease process will be managed, the patient/caregiver will proceed through the grief process with the support of IDT, the patient/caregiver will find comfort through psychosocial/spiritual support, and the patient will experience a comfortable death. Clinical Record 5: The patient elected the hospice benefit on 08/14/2023, with a terminal diagnosis of congestive heart failure. Review of the plan of care dated 08/14/2023 through 01/10/2024 revealed the listed expected outcomes of care were not measurable. The outcomes listed on the plan of care included, symptoms of the disease process will be managed, the patient/caregiver will proceed through the grief process with the support of IDT, the patient/caregiver will find comfort through psychosocial/spiritual support, and the patient will experience a comfortable death. During an interview on 11/01/2023, the Alternate Director of Clinical Services agreed each plan of care included the same outcomes and the outcomes were not measurable.

It is required that a revised plan of care includes information from the patient’s updated comprehensive assessment and record of the patient’s progress toward the outcomes and goals specified in the plan of care. This standard was not met as evidenced by document review, clinical record review, and interview. In 5 of 5 (100%) clinical records reviewed, the agency did not ensure the revised plan of care included information from the patient’s updated comprehensive assessment and record the patient’s progress toward the outcomes and goals specified in the plan of care. Agency policy PC. P55 Plan of Care reviewed 06/15/2023 stated in part, The interdisciplinary written plan of care is based on initial and updated patient-specific comprehensive assessments by members of the IDG and is developed with measurable goals and outcomes for planned interventions. The plan of care is revised as needed and includes the patient's progress toward outcomes and goals. Agency policy PC. D25 Documentation Requirements reviewed 06/15/2023 stated in part, "Members of the interdisciplinary group (IDG) document the interventions provided to the patient/caregiver, their responses to care, services provided, and the goals or outcomes achieved. The patient record documentation provides patient information specific to care and services/products provided, current patient status, and progress toward goals and outcomes of care." Clinical Record 1: The patient elected the hospice benefit on 06/07/2023, with a terminal diagnosis of senile degeneration of the brain. Review of the IDG meetings / updates to the plan of care dated 06/16/2023, 06/30/2023, 07/14/2023, 07/28/2023, 08/11/2023, 08/25/2023, 09/08/2023, 09/22/2023, 10/06/2023, and 10/20/2023 revealed no documented evidence that the IDG had assessed, discussed, or evaluated the patient’s progress towards outcomes and goals specified on the plan of care. Clinical Record 2: The patient elected the hospice benefit on 06/13/2023, with a terminal diagnosis of stage IV kidney disease. Review of the IDG meetings / updates to the plan of care dated 06/16/2023, 06/30/2023, 07/14/2023, 07/28/2023, 08/11/2023, 08/25/2023, 09/08/2023, 09/22/2023, 10/06/2023, and 10/20/2023 revealed no documented evidence that the IDG had assessed, discussed, or evaluated the patient’s progress towards outcomes and goals specified on the plan of care. Clinical Record 3: The patient elected the hospice benefit on 06/07/2023, with terminal diagnosis of senile degeneration of the brain. Review of the IDG meetings / updates to the plan of care dated 06/16/2023, 06/30/2023, 07/14/2023, 07/28/2023, 08/11/2023, 08/25/2023, 09/08/2023, 09/22/2023, 10/06/2023, and 10/20/2023 revealed no documented evidence that the IDG had assessed, discussed, or evaluated the patient’s progress towards outcomes and goals specified on the plan of care. Clinical Record 4: The patient elected the hospice benefit on 06/08/2023, with a terminal diagnosis of chronic obstructive pulmonary disease. Review of the IDG meetings / updates to the plan of care dated 06/16/2023, 06/30/2023, 07/14/2023, and 07/28/2023 revealed no documented evidence that the IDG had assessed, discussed, or evaluated the patient’s progress towards outcomes and goals specified on the plan of care. Clinical Record 5: The patient elected the hospice benefit on 08/14/2023, with a terminal diagnosis of congestive heart failure. Review of the IDG meetings / updates to the plan of care dated 08/25/2023, 09/08/2023, 09/22/2023, 10/06/2023, and 10/20/2023 revealed no documented evidence that the IDG had assessed, discussed, or evaluated the patient’s progress towards outcomes and goals specified on the plan of care. During an interview on 11/01/2023, the Alternate Director of Clinical Services agreed the IDG plan of care reviews/updates did not include documentation of the patient’s progress towards outcomes and goals.

It is required that bereavement services are supervised by a qualified professional with experience or education in grief or loss counseling. This standard was not met as evidenced by document review, personnel record review, and interview. In 1 of 1 (100%) personnel record reviewed for staff who provide bereavement services /Bereavement Coordinator, the agency did not ensure the Bereavement Coordinator had education, training, or work experience in grief or loss counseling prior to March 2023. Agency policy PC. B30 Bereavement Services stated in part, "The hospice has an organized program for the provision of bereavement services furnished under the supervision of a Bereavement Coordinator, who is a qualified professional with experience or education in grief or loss counseling in accordance with applicable laws, regulations, and recognized professional practice standards.” Personnel Record 4: Chaplain / Bereavement Coordinator (BC) date of hire 06/08/2023. Review of the job description for Bereavement Coordinator signed by the BC stated in part, A qualified professional with experience or education in grief or loss counseling, bachelor’s degree or equivalent theological degree from college or university. Experience with families/caregivers and patients through death/dying issues - or - master’s degree in social work with qualification of experienced clinical grief counseling. Two years of experience is preferred. Experience with counseling individuals and/or groups. A qualified professional with experience or education in grief or loss counseling. The ability to communicate well both verbally and in writing. Review of the personnel record revealed a Certificate of Ordination dated June 2023 and recent work experience as the hospice chaplain beginning in March of 2023. The personnel record contained no evidence that the BC had obtained a degree. Previous work history listed in the resume included Insurance Agent, School Admissions Director, Food Server, Travel Agent, and Home Sales. At the time of personnel record review on 11/01/2023, there was no documented evidence in the personnel record of any other education or training in grief or loss counseling or working with patients and families through the dying process before March of 2023. During an interview on 11/01/2023, the Chaplain/Bereavement Coordinator provided no further experience or qualifications for the role of BC beyond the role of a hospice chaplain started in March of 2023 and personal experience with mother and another family member's death in hospice care. During an interview on 11/02/2023, the Alternate Director of Clinical Services confirmed the agency had not sent the Chaplain/BC for any additional training or education and did not have any additional evidence or documentation to provide to support the qualifications of the Bereavement Coordinator.

It is required that volunteers are used in day-to-day administrative and/or direct patient care roles. Volunteer services are noted in the plan of care. This standard was not met as evidenced by document review, clinical record review, and interview. In 2 of 5 (40%) clinical records reviewed, the agency did not ensure volunteer services were included in the patient's plan of care. Agency policy PC. V20 Volunteers – Services reviewed 06/15/2023 stated in part, "Volunteer services are provided to patients/families as part of the hospice IDG (interdisciplinary group) oversight responsibilities. Defined volunteer activities are provided under the supervision of the Volunteer Coordinator and in accordance with the plan of care." Clinical Record 2: The patient elected the hospice benefit on 06/13/2023, with a terminal diagnosis of stage IV kidney disease. The plan of care dated 06/13/2023 through 09/10/2023 and the recertification plan of care dated 09/11/2023 through 12/09/2023 ordered "Volunteer visits when needed." The plans of care did not include frequency of visits for the volunteer and did not include volunteer interventions or goals. The Interdisciplinary Group Meeting Updates /IDG Plan of Care Updates dated 08/11/2023, 08/25/2023, 09/08/2023, 09/22/2023, 10/06/2023 and 10/20/2023 did not include volunteer frequency of visits, interventions, or goals. Review of the volunteer binder provided by the Alternate Director of Clinical Services revealed volunteer visits were provided on 08/22/2023, 08/29/2023, 09/05/2023, 09/12/2023, 09/19/2023, 09/26/2023, 10/03/2023, 10/10/2023, 10/17/2023, 10/23/2023, and 10/30/2023. The volunteer documented that caregiver relief/support and light housekeeping/home organization was provided during volunteer visits. Clinical Record 5: The patient elected the hospice benefit on 08/14/2023, with a terminal diagnosis of congestive heart failure. The plan of care dated 08/14/2023 through 10/10/2023 ordered "Volunteer visits when needed." The plan of care did not include frequency of visits for the volunteer and did not include volunteer interventions or goals. The Interdisciplinary Group Meeting Updates /IDG Plan of Care Updates dated 08/25/2023, 09/08/2023, 09/22/2023, 10/06/2023 and 10/20/2023 did not include volunteer frequency of visits, interventions, or goals. Review of the volunteer binder provided by the Alternate Director of Clinical Services revealed volunteer visits were provided on 08/28/2023, 08/29/2023, 09/12/2023, 09/15/2023, 09/18/2023, 09/19/2023, and 10/22/2023. The volunteer documented that caregiver relief/support and light housekeeping/home organization was provided during volunteer visits. During an interview on 11/01/2023, the Alternate Director of Clinical Services confirmed the agency's current practice did not include a volunteer plan of care or Interdisciplinary/Physician orders for the frequency of the volunteer visits and volunteer interventions/goals were not included in the patients’ plans of care.

It is required that volunteer services are documented in the patient record, including the time spent. This standard was not met as evidenced by document review, clinical record review, and interview. In 2 of 5 (40%) clinical records reviewed, the hospice did not ensure volunteer visit notes were included in the patient's clinical record. Agency policy PC. C30 Clinical Records reviewed 06/15/2023 stated in part, the agency must maintain a patient record system to ensure that the care and services provided to each patient are completely and accurately documented. The record is complete, promptly, and accurately documented, includes clinical and progress notes, and is incorporated into the client's record within 14 working days. Agency policy PC. D25 Documentation Requirements reviewed 06/15/2023 stated in part, "Documentation is completed by all hospice staff and volunteers whenever patient/caregiver visits occur." Clinical Record 2: The patient elected the hospice benefit on 06/13/2023, with a terminal diagnosis of stage IV kidney disease. The plan of care dated 06/13/2023 through 09/10/2023 and the recertification plan of care dated 09/11/2023 through 12/09/2023 ordered "Volunteer visits when needed." Clinical record review revealed no documented evidence of volunteer visit notes for the patient. Review of the volunteer binder provided by the Alternate Director of Clinical Services revealed volunteer visit notes for the patient dated 08/22/2023, 08/29/2023, 09/05/2023, 09/12/2023, 09/19/2023, 09/26/2023, 10/03/2023, 10/10/2023, 10/17/2023, 10/23/2023, and 10/30/2023. The volunteer visit notes were not included in the patient’s clinical record. Clinical Record 5: The patient elected the hospice benefit on 08/14/2023, with a terminal diagnosis of congestive heart failure. The plan of care dated 08/14/2023 through 10/10/2023 ordered "Volunteer visits when needed." Review of the volunteer binder provided by the Alternate Director of Clinical Services revealed volunteer visit notes for the patient dated 08/28/2023, 08/29/2023, 09/12/2023, 09/15/2023, 09/18/2023, 09/19/2023, and 10/22/2023. The volunteer visit notes were not included in the patient’s clinical record. During record review and interview on 11/01/2023, the Alternate Director of Clinical Services confirmed the current process was not to scan the volunteer notes into the clinical record.

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 6 (17%) personnel records reviewed which required competency evaluation, the agency did not ensure the staff competency was assessed per policy and regulation prior to being assigned patients. Agency policy HR. C10 Competency Assessment reviewed 06/15/2023 stated in part, "The hospice must assess the skills and competence of all individuals furnishing care." Agency policy PC. H35 Hospice Aide Services and Qualifications reviewed 06/15/2023 stated in part, "An individual may furnish hospice aide services...only after that individual has successfully completed a competency evaluation program. Hospice Aide skills are assessed prior to the delivery of services. The RN [registered nurse] must observe and evaluate the hospice aide's performance of tasks with a client in the following areas: communication skills...reading and recording temperature, pulse, and respiration; appropriate and safe techniques for performing personal hygiene and grooming tasks, including bed bath, sponge/tub/shower bath, hair shampoo in sink/tub/bed, nail and skin care, oral hygiene, toileting and elimination, safe transfer techniques and ambulation and normal range of motion and positioning. The following must be evaluated by observing an aide's performance of the task with a patient bed bath, sponge/tub/shower bath, hair shampoo in sink/tub/bed, nail and skin care, oral hygiene, toileting, and elimination, safe transfer techniques and ambulation and normal range of motion and positioning." Personnel Record 5: Hospice Aide date of hire 06/08/2023. Review of the Hospice Aide Competency Skills Checklist completed and signed on 06/08/2023 by the Hospice Aide and the Director of Clinical Services (DCS), revealed the section for hands-on care listing bed baths, sponge baths, tub baths, shower, shampoo, skin and nail care, oral hygiene, toileting, and catheter care were marked as performed by a verbal method and not observation. During an interview on 11/02/2023, the Alternate Director of Clinical Services confirmed the Hospice Aide's competency for the required observed skills were assessed verbally and not by observation.

A patient clinical record containing past and current findings is maintained for each hospice patient. Each patient’s record includes, at a minimum signed copies of the notice of patient rights and the hospice election statement. This standard was not met as evidenced by document review, clinical record review, and interview. In 5 of 5 (100%) clinical records reviewed, the agency did not ensure the hospice election statement included the effective date of election of hospice benefit. Agency policy PC. E10 Election of the Medicare Hospice Benefit reviewed 06/15/2023 stated in part, "During the admission process, the patient or his or her legal representative signs the hospice's election form. The election form includes the effective date of the election." Clinical Record 1: The patient elected the hospice benefit on 06/07/2023, with a terminal diagnosis of senile degeneration of the brain. The Hospice Election, Informed Consent, and Acknowledgment form included the statement, "hospice provides for my care under the Medicare Hospice Benefit, effective." The form was signed and dated at the bottom of the second page by the patient and hospice representative on 06/07/2023. The form did not include the effective date of the hospice election when the date was left blank. Clinical Record 2: The patient elected the hospice benefit on 06/13/2023, with a terminal diagnosis of stage IV kidney disease. The Hospice Election, Informed Consent, and Acknowledgment form included the statement, "hospice provides for my care under the Medicare Hospice Benefit, effective." The form was signed and dated at the bottom of the second page by the patient and hospice representative on 06/13/2023. The form did not include the effective date of the hospice election when the date was left blank. Clinical Record 3: The patient elected the hospice benefit on 06/07/2023, with terminal diagnosis of senile degeneration of the brain. The Hospice Election, Informed Consent, and Acknowledgment form included the statement, "hospice provides for my care under the Medicare Hospice Benefit, effective." The form was signed and dated at the bottom of the second page by the patient and hospice representative on 06/07/2023. The form did not include the effective date of the hospice election when the date was left blank. Clinical Record 4: The patient elected the hospice benefit on 06/08/2023, with a terminal diagnosis of chronic obstructive pulmonary disease. The Hospice Election, Informed Consent, and Acknowledgment form included the statement, "hospice provides for my care under the Medicare Hospice Benefit, effective." The form was signed and dated at the bottom of the second page by the patient and hospice representative on 06/08/2023. The form did not include the effective date of the hospice election when the date was left blank. Clinical Record 5: The patient elected the hospice benefit on 08/14/2023, with a terminal diagnosis of congestive heart failure. The Hospice Election, Informed Consent, and Acknowledgment form included the statement, "hospice provides for my care under the Medicare Hospice Benefit, effective." The form was signed and dated at the bottom of the second page by the patient and hospice representative on 08/14/2023. The form did not include the effective date of the hospice election when the date was left blank. During record review and interview on 10/31/2023, the Alternate Director of Clinical Services confirmed the effective date on the hospice election forms was not completed because she did not believe that was required since the agency was not yet billing for services.

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary. This standard was not met as evidenced by document review, clinical record review, and interview. In 1 of 1 (100%) clinical record reviewed where the patient was discharged from hospice, the agency did not ensure a discharge summary was sent to the patient's attending physician. Clinical Record 4: The patient elected the hospice benefit on 06/08/2023, with a terminal diagnosis of chronic obstructive pulmonary disease. There was no documented evidence in the clinical record that the discharge summary was sent to the patient’s attending physician. During an interview on 11/02/2023, the Alternate Director of Clinical Services confirmed that there was no documentation showing the discharge summary sent to a receiving physician.

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, and the patient’s latest physician orders, 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 and interview. In 1 of 1 (100%) clinical record reviewed with a live discharge, the agency did not ensure the discharge summary included a summary of the patient's care while on hospice, the plan of care, and the latest physician orders. Clinical Record 4: The patient elected the hospice benefit on 06/08/2023, with a terminal diagnosis of chronic obstructive pulmonary disease. The “Services Provided” section of the discharge summary included boxes checked for Nursing, Social Worker, Spiritual Counselor, and Hospice Physician, the “Summary of Care" section included documentation that stated "Patient revoked hospice benefits. They seek further treatment." The discharge summary did not include a summary of the patient's hospice care, the patient's current plan of care, or the latest physician orders. During record review and interview on 11/02/2023, the Alternate Director of Clinical Services agreed the discharge summary did not include the required elements of the standard.