Every finding on record at Empress Care Hospice Inc

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 it was revealed that the agency did not ensure that the hospice Interdisciplinary Group, in consultation with the individual's attending physician (if any), completed an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care. Clinical Record 3: The patient was admitted on 10/04/2024. The Social Worker was ordered on admission. The record lacked a social worker assessment within 5-days and there was not documentation as to why the visit was not completed. During an interview conducted on 10/30/2024, the Alternate Administrator stated that she was unsure why the assessment was not completed. Clinical Record 4: The patient was admitted on 05/16/2024. The Chaplain was ordered on admission. The Spiritual assessment dated 05/20/2024 was blank. In an interview with the Alternate Administrator on 10/30/2024, the Alternate Administrator stated that she was unsure why the assessment was not completed and stated it should not have been blank.

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, other alternative treatments that could affect drug therapy. This standard was not met as evidenced by clinical record review and interview. In 3 of 14 (21%) clinical records reviewed revealed that the agency did not ensure that the comprehensive assessments included a drug profile that contained the patient's current prescription and over-the-counter drugs. Clinical Record 1: This patient was admitted on 07/06/2024 with a diagnosis of Chronic Obstructive Pulmonary Disease and was on Oxygen therapy. Oxygen was included in the plan of care as a treatment but was not included in the drug profile as a medication. Clinical Record 3: The patient was transferred from another hospice and was admitted on 10/04/2024 with diagnoses that included Cerebral Infarction and Senile Degeneration of the Brain. The Plan of Care (POC) for episode 10/04/2024 to 12/02/2024 included Oxygen. Oxygen was not included in the drug profile. Clinical Record 4: The patient was admitted on 05/16/2024 with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD) and was oxygen dependent. Oxygen was not included in the drug profile. The Alternate Administrator in an interview on 10/30/2024, stated that she was unaware that oxygen was not being included on the medication lists and said that the current patient charts would be audited.

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. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed revealed that the agency did not ensure that the patient's individualized plan of care included planned interventions based on problems identified on the initial and updated comprehensive assessments. Clinical Record 3: The patient elected hospice on 10/4/2024 with diagnoses that included Cerebral Infarction and Senile Degeneration of the Brain. The comprehensive assessment included documentation of aspiration pneumonia before admission to hospice. The Plan of Care (POC) for episode 10/04/2024 to 12/02/2024 did not include aspiration precautions. The Alternate Administrator stated in an interview on 10/29/2024 that she was unaware that this item was missing.

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, document review, and interview. In 1 of 1 (100%) clinical record reviewed, the agency did not ensure the hospice interdisciplinary group (IDG), completed an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care. Agency policy #2-036 Spiritual Assessment (Dated: 1/2023), stated in part, "An in-depth spiritual assessment will be completed as part of the comprehensive assessment within the 5-day period after the election of hospice care by the Chaplain. If the patient and family/caregiver refuse these services, the refusal will be documented." Clinical Record 1: The patient elected the hospice benefit on 9/20/23, with a terminal diagnosis of unspecified systolic congestive heart failure. Clinical record review revealed no documented evidence that an initial spiritual assessment was completed by the Chaplain as part of the comprehensive assessment. The clinical record contained no evidence that the patient and family/caregiver had refused the Chaplain or spiritual services during the five (5) day period after the election of hospice care. During an interview on 10/2/23, the Director of Patient Care Services/Alternate Administrator reviewed the finding and agreed the agency did not ensure that the Chaplain had completed an initial spiritual assessment as part of the comprehensive assessment nor was there supportive documentation that Chaplain services were refused during the 5-day window.

It is required that the comprehensive assessment includes an initial bereavement assessment of the needs of the patient's family and other individuals, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and considered in the bereavement plan of care. This standard was not met as evidenced by clinical record review, document review, and interview. In 1 of 1 (100%) clinical record reviewed, the agency failed to ensure an initial bereavement assessment was completed as part of the comprehensive assessment. Agency policy #2-037 Bereavement Assessment (Dated: 1/2023), stated in part, "On admission, the social worker or hospice registered nurse will complete a bereavement risk assessment that will be given to the Bereavement Coordinator." Clinical Record 1: The patient elected the hospice benefit on 9/20/23, with a terminal diagnosis of unspecified systolic congestive heart failure. The clinical record contained no documented evidence that an initial bereavement assessment was completed as part of the comprehensive assessment. During an interview on 10/2/23, the Director of Patient Care Services/Alternate Administrator reviewed the finding and agreed the agency did not ensure that an initial bereavement assessment was completed as part of the comprehensive assessment.

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, interview, and personnel record review. In 1 of 6 (17%) personnel records reviewed, the agency did not ensure all staff that provided care to the agency’s patients had completed the initial skills competencies as required per agency policy. Agency policy #1-002 Qualifications of Hospice Personnel (Dated: 1/2023), stated in part, "Competency: Professional Hospice Staff - Individuals must demonstrate their competency, within their orientation and probationary period, according to the orientation checklists developed for each position." Personnel Record 2: Bachelor of Social Work (BSW) with date of hire 3/15/23. As of the date of personnel record review on 10/2/23, the personnel record contained no documented evidence that an initial skills competency had been completed for the BSW. Personnel Record 5: Chaplain/Bereavement Coordinator with date of hire 3/15/23. As of the date of personnel record review on 10/2/23, the personnel record contained no documented evidence that an initial skills competency had been completed for the Chaplain/Bereavement Coordinator. During an interview on 10/2/23, the Director of Patient Care Services/Alternate Administrator reviewed the findings and agreed the agency did not ensure that staff that provided care to agency patients had completed the initial skills competencies as per the agency policy.

It is required that the hospice medical director or physician designee reviews the clinical information for each patient being evaluated for admission and provides written certification that it is anticipated that the patient's life expectancy is six months or less if the illness runs its normal course. The physician considers the following when making this determination, the primary terminal condition, related diagnosis(es), if any, 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. This standard was not met as evidenced by clinical record review, document review, and interview. In 1 of 1 (100%) clinical record reviewed, the agency did not ensure that the physician narrative on the certificate of terminal illness (CTI) included the consideration of the patient's primary terminal condition or diagnosis(es). Agency policy #2-025 Certification of Terminal Illness (Dated: 1/2023), stated in part, "When certifying the patient as terminally ill, the hospice medical direct must consider at least the diagnosis of the terminal condition of the patient, other health conditions, whether related or not to the terminal condition, and current relevant information supporting the diagnosis." Clinical Record 1: The patient elected the hospice benefit on 9/20/23, with a terminal diagnosis of unspecified systolic congestive heart failure. Review of the physician’s narrative on the CTI dated 9/20/23 revealed no documented evidence of the patient's primary terminal condition or diagnosis. During an interview on 10/2/23, the Director of Patient Care Services/Alternate Administrator reviewed the finding and agreed the agency did not ensure that the physician’s narrative on the CTI included the patient's primary terminal condition or diagnosis.

It is required that a social worker who holds a bachelor’s degree [BSW] is supervised by a CMS-qualified MSW [Social Worker with a master's degree in social work] who has a degree from a school of social work accredited by the Council on Social Work Education and has one (1) year of experience in a health care setting. This standard was not met as evidenced by document review, interview, and personnel record review. In 1 of 1 (25%) personnel record reviewed for a social worker, the agency did not ensure the BSW was supervised by an MSW. Agency policy #1-002 Qualifications of Hospice Personnel (Dated: 1/2023), stated in part, "Minimum Qualifications: Social Worker: Hold's at least a bachelor's degree from a school of social work accredited by the Council on Social Work Education and is supervised by a MSW [Masters Social Worker]." Review of the "Social Worker/Social Work Assistant Job Description (Signed/Dated by the BSW on 2/22/23)," stated in part, "Qualifications: Educational/Degree and Training/Licensure: A Hospice Social Worker must at least meet one of the following options: Have a baccalaureate degree in social work (BSW) from a school of social work accredited by the CSWE [Council on Social Work Education], and one year of experience in a health care setting and be supervised by a MSW from a school of social work accredited by the CSWE and who has one year experience in a health care setting." Personnel Record 2: Bachelor of Social Work (BSW) with date of hire 3/15/23. The personnel record included evidence that the employee was a BSW and received the degree on 5/8/2017. During an interview on 10/2/23, the Social Worker stated, "I am not an MSW; I am a BSW. I do not have a master's degree." The BSW was asked if an MSW provides supervision. The BSW replied "No". During an interview on 10/2/23, the Administrator reviewed the finding and agreed that the Social Worker on staff was a BSW. The Administrator stated we have an MSW that is supposed to start by Friday 10/6/2023 and will provide prn [as needed] visits and supervision for the BSW.