Every finding on record at Epic Care Health LLC

It is required that testing: The hospice providing care in the patient’s home conducts exercises to test the emergency preparedness plan annually, including Participation in a full-scale exercise that is community-based every two (2) years. When a community-based exercise is not accessible, testing includes participation in an individual, facility-based functional exercise every two (2) years. If the organization experiences a natural or man-made emergency that requires activation of the emergency plan, the organization is exempt from engaging in its next required full-scale community-based exercise or individual, facility-based functional exercise following the onset of the emergency event. Conducting an additional exercise every two (2) years – opposite the year that a full-scale exercise or functional exercise is conducted. This exercise may include, but is not limited to, a second full-scale exercise that is community-based or a facility-based functional exercise, a mock disaster drill, or a tabletop exercise or workshop that is led by a facilitator that includes a group discussion using a narrated, clinically relevant emergency scenario and a set of problem statements, directed messages, or prepared questions designed to challenge the emergency plan. This standard was not met as evidenced by document review and interview. The agency did not ensure testing of the agency's Emergency Preparedness Plan was completed. Review of the agency's Emergency Preparedness program and binder revealed no documented evidence that the agency had tested its Emergency Preparedness Plan by evaluation of an actual emergency, a community-based exercise, or documentation of a tabletop exercise in the last three years. During an interview and review of the agency’s Emergency Preparedness program on 02/05/2025, the Administrator stated, "We do not have any documentation that the Emergency Plan was activated or evaluated after any actual emergency or that any tabletop activity was done." The agency did not ensure that the required testing of the agency's Emergency Preparedness Plan was completed.

It is required that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the patient’s terminal illness that are addressed to promote the patient’s well-being, comfort, and dignity throughout the dying process. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed, the agency did not ensure the comprehensive assessment included an assessment of the patient’s physical, psychosocial, emotional, and spiritual needs related to the patient’s terminal illness. Clinical Record 6: The patient elected the hospice benefit on 02/14/2024 with diagnosis of malnutrition and sarcopenia. The Registered Nurse documented on the comprehensive assessment dated 02/14/2024 that a spiritual assessment was not completed. The clinical record included documentation that the patient declined Spiritual Counselor services. The clinical record contained no documented evidence that the patient’s spiritual needs were assessed as part of the comprehensive assessment. During an interview and record review on 02/04/2025, the Director of Nursing stated, "Since the patient declined Spiritual Counselor services, the nurse should have assessed and documented a spiritual assessment."

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 document review, clinical record review, observation, and interview. In 1 of 14 (7%) clinical records reviewed, the agency did not ensure the comprehensive assessment included a medication review that identified duplicative drug therapy. Agency policy No. 2-019 Medication Monitoring, dated 04/2021, required in part, "1 The case manager will assess the effect of medications on the patient. The assessment will identify drug interactions, duplicative drug therapy, and noncompliance with drug therapy. 2 The clinical effects of medications will be obtained through direct observation during assessments performed during home visits, review of assessment information, as well as clinical results of diagnostic studies. 3 Review of information gathered from the above activities will be included in the comprehensive assessment and updates will be made if needed If there are questions, problems, or issues with the patient's medications, the hospice drug management consultant will be contacted to provide input to the interdisciplinary group." Clinical Record 1: During the home visit observation on 02/04/2025 with the Registered Nurse (RN) (Personnel Record 4), a medication review was completed by comparing the hospice medication profile to the patient’s home medications. The hospice plan of care and medication profile dated 01/30/2025 included orders for "Morphine Concentrate 100mg/5ml oral solution, 2.5ml every 2 hours as needed (PRN) orally for shortness of breath (SOB) or pain" with a start date of 12/22/2024 and "Morphine Concentrate 100mg/5ml oral solution, 0.25ml every 4-6 hours as needed for shortness of breath" with the start date of 12/27/2024. The RN stated the morphine was accidentally entered twice on the medication profile. Clinical record review revealed the most recent comprehensive assessment dated 01/13/2025 did not identify the potential duplicative drug therapy, when Morphine concentrate was listed twice on the patient’s medication list. The RN stated a medication reconciliation was last completed on Friday, 01/30/2025. However, there was no documented evidence in the nursing visit note dated 01/30/2025 that a medication reconciliation was completed.

It is required that hospice care and services provided to patients and families follow the individualized plan of care established by the hospice IDG [interdisciplinary group] in collaboration with the attending physician (if any), the patient or patient representative if any of them so desire, and the primary caregiver in accordance with the patient’s needs if any of them so desire. This standard was not met as evidenced by clinical record review and interview. In 5 of 14 (36%) clinical records reviewed, the agency did not ensure hospice care and services provided to patients and families follow the individualized plan of care. Clinical Record 2: The patient elected the hospice benefit on 12/24/2024 with a diagnosis of neurocognitive disorder with Lewy bodies. The plan of care dated 12/24/2024 to 03/23/2025 included an order for Skilled Nursing (SN) frequency of visits 3wk1 (three times a week for one week), 1wk12 (once a week for 12 weeks). An interim physician order updated the SN visit frequency to one visit weekly, effective 12/24/2024. The SN documented weekly visits from 12/24/2024 through 01/31/2024, except for the week of 01/05/2025. There was no documented SN visit for the week of 01/05/2025, and there was no documentation in the clinical record that the physician was notified of the missed visit. The SN did not provide visits as ordered on the plan of care. Clinical Record 4: The patient elected the hospice benefit on 09/06/2024 with a diagnosis of malnutrition. The plan of care dated 12/05/2024 to 03/04/2025 included orders for Social Work (SW) frequency of visits 1w1 (once a week for one week), then 1Q4WK4 (once every four weeks for 4 weeks) and Spiritual Counselor (SC) frequency of visits 1M3 (once a month for three months). The SW documented a visit was provided on 12/05/2024 and the SC documented a visit was provided on 12/19/2024. There was no documented evidence of SW or SC visits after the initial visits and the clinical record did not include documentation of missed visits or physician notification of missed visits, as of the date of record review on 02/05/2025. The SW and SC did not provide visits as ordered on the plan of care. Clinical Record 5: The patient elected the hospice benefit on 12/01/2024 with a diagnosis of ovarian cancer. The plan of care dated 12/01/2024 to 02/21/2025 included an order for SN frequency of visits 3w1 (three times a week for one week), 2w11 (twice a week for 11 weeks). The SN documented two visits per week for the first two weeks, then weekly visits were documented from 12/18/2024 through 01/28/2025. The clinical record did not include documentation of SN missed visits, interim orders to change the visit frequency, or physician notification of missed visits. The plan of care included an order for Social Work 1w1 (once a week for one week), then 1Q5WK5 (once visit every five weeks for five weeks), then 1Q4WK4 (once every four weeks for four weeks). An interim order dated 01/02/2025 changed the SW visit frequency to weekly. There was no SW visits documented for the weeks of 01/19/2025 and 01/26/2025. The plan of care included an order for Spiritual Counselor 5M1 (five visits each month for one month), then 4M1 (four visits each month for one month), then 3M1 (three visits per month for one month). Clinical record review revealed the SC documented 3 SC visits in December 2024. The clinical record did not include documentation of SN, SW, and SC missed visits, interim orders to change the visit frequencies, or physician notification of missed visits. Clinical Record 7: The patient elected the hospice benefit on 11/16/2024 with a diagnosis of malnutrition. The plan of care dated 11/16/2024 to 02/13/2025 included an order for SW 1w1 (once a week for one week). An interim order dated 12/06/2024 changed the SW frequency effective 12/15/2024 to 1w1 (once a week for one week), 1Q4WK4 (once every four weeks for four weeks). The SW documented a SW visit on 12/19/2024 and no further SW visits were documented in the clinical record, as of the date of record review on 02/05/2025. The clinical record did not include documentation of missed visits or physician notification of missed visits. Clinical Record 8: The patient elected the hospice benefit on 04/07/2023 with a diagnosis of neurocognitive disorder with Lewy bodies. The plan of care dated 01/26/2025 to 03/26/2025 included an order for SW 1w1 (once a week for one week), then 1Q4WK4 (once every four weeks for four weeks). There was no documented evidence in the clinical record of SW visits from 01/26/2025 through the date of record review on 02/05/2025 and no documented evidence of physician notification of missed visits. During an interview on 02/05/2025, the Director of Nursing stated, "There is a problem with how we are entering visit frequencies in [the Electronic Medical Record]. We need to get education on how frequencies should be entered."

It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including the following, measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review and interview. In 10 of 14 (71%) clinical records reviewed, the agency did not ensure the individualized plan of care include measurable outcomes anticipated from implementing and coordinating the plan of care. Clinical Record 1: The patient elected the hospice benefit on 08/09/2023 with a diagnosis of degenerative disease of the nervous system. The plan of care dated 01/30/2025 to 03/30/2025 included the following goals "A nursing plan of care will be established. Pain will be managed at a level acceptable to the patient. Facility staff is knowledgeable and involved in hospice plan of care for patient. Patient will receive assistance with personal care and hygiene and other activities of daily living as needed." The goals on the plan of care were not measurable when they did not include a timeframe for completion and/or identify patient specific outcomes expected. Clinical Record 2: The patient elected the hospice benefit on 12/24/2024 with a diagnosis of neurocognitive disorder with Lewy bodies. The plan of care dated 12/24/2024 to 03/23/2025 included the following goals "A nursing plan of care will be established. Changes in neurologic status will be addressed appropriately. Patient's anxiety and agitation is minimized/controlled, and caregiver verbalizes understanding of its effects/origin/treatment. Pain will be managed at a level acceptable to the patient. Patient and caregiver will verbalize understanding of effects of urinary incontinence." The goals on the plan of care were not measurable when they did not include a timeframe for completion and/or identify patient specific outcomes expected. Clinical Record 3: The patient elected the hospice benefit on 08/09/2024 with a diagnosis of chronic obstructive pulmonary disease. The plan of care dated 01/20/2025 to 03/20/2025 included the following goals "A nursing plan of care will be established. Patient/Caregiver will verbalize/demonstrate an understanding of how to use oxygen safely and effectively. Changes in neurologic status will be addressed appropriately. Patient and caregiver will demonstrate independence in administration of inhalation therapy and care for equipment. Caregiver will verbalize/demonstrate measures to prevent/manage skin breakdown. Medications will be managed appropriately as evidenced by steady symptom control. Patient and caregiver will verbalize and demonstrate compliance with medication regimen. Patient/caregiver will verbalize/demonstrate understanding of management of meds, symptoms, treatment. Patient/caregiver will verbalize knowledge of preventative measures and response in the event of hemorrhage. Bleeding/hemorrhage will be recognized early for management. Patient will receive assistance with personal care and hygiene and other activities of daily living as needed." The goals on the plan of care were not measurable when they did not include a timeframe for completion and/or identify patient specific outcomes expected. Clinical Record 4: The patient elected the hospice benefit on 09/06/2024 with a diagnosis of malnutrition. The plan of care dated 12/05/2024 to 03/04/2025 included the following goals "Hospice RN [Registered Nurse] to evaluate patient and develop a nursing plan of care. Hospice nurse to monitor patients' pain level and report negative pain control to the physician." The goals on the plan of care were not measurable when they did not include a timeframe for completion and did not identify a patient specific acceptable level of pain. Clinical Record 5: The patient elected the hospice benefit on 12/01/2024 with a diagnosis of ovarian cancer. The plan of care dated 12/01/2024 to 02/21/2025 included the following goals "A nursing plan of care will be established. Pain will be managed at a level acceptable to the patient. Patient/caregiver will verbalize/demonstrate understanding of management. Patient/caregiver will verbalize understanding of effects of urinary incontinence. Patient will receive assistance with personal care and hygiene and other activities of daily living." The goals on the plan of care were not measurable when they did not include a timeframe for completion and/or identify patient specific outcomes expected. Clinical Record 6: The patient elected the hospice benefit on 02/14/2024 with diagnosis of malnutrition and sarcopenia. The plan of care dated 12/10/2024 to 02/07/2025 included the following goals "Pain will be managed at a level acceptable to the patient. Patient and caregiver will verbalize/demonstrate appropriate pain management. Caregiver will verbalize/demonstrate measures to prevent/manage skin breakdown. Patient will receive assistance with personal care and hygiene and other activities of daily living as needed." The goals on the plan of care were not measurable when they did not include a timeframe for completion, did not identify a patient specific acceptable level of pain, and did not identify patient specific activities of daily living that needed assistance. Clinical Record 7: The patient elected the hospice benefit on 11/16/2024 with a diagnosis of malnutrition. The plan of care dated 11/16/2024 to 02/13/2025 included the following goals "A nursing plan of care will be established. Pain will be managed at a level acceptable to the patient. Patient/caregiver will verbalize understanding of the effects of urinary incontinence. Patient will receive assistance with personal care and hygiene and other activities of daily living as needed." The goals on the plan of care were not measurable when they did not include a timeframe for completion and/or identify patient specific outcomes expected. Clinical Record 8: The patient elected the hospice benefit on 04/07/2023 with a diagnosis of neurocognitive disorder with Lewy bodies. The plan of care dated 01/26/2025 to 03/26/2025 included the following goals "A nursing plan of care will be established. Pain will be managed at a level acceptable to the patient. Patient/caregiver will verbalize understanding of effects of urinary incontinence. Caregiver will verbalize/demonstrate measures to prevent/manage skin breakdown. Medications will be managed appropriately as evidenced by steady symptom control. Patient/caregiver will verbalize and demonstrate compliance with medication regimen. Patient will receive assistance with personal care and hygiene and other activities of daily living as needed." The goals on the plan of care were not measurable when they did not include a timeframe for completion and/or identify patient specific outcomes expected. Clinical Record 9: The patient elected the hospice benefit on 09/27/2024 with a diagnosis of respiratory failure and chronic obstructive pulmonary disease. The plan of care dated 01/25/2025 to 03/25/2025 included the following goals "A nursing plan of care will be established. Pain will be managed at a level acceptable to the patient. Patient will verbalize/demonstrate reduction or relief of cardiopulmonary symptoms. Caregiver will verbalize/demonstrate measures to prevent/manage skin breakdown." The goals on the plan of care were not measurable when they did not include a timeframe for completion and/or identify patient specific outcomes expected. Clinical Record 10: The patient elected the hospice benefit on 01/22/2025 with a diagnosis of neurocognitive disease with Lewy bodies. The plan of care dated 01/22/2025 to 04/21/2025 included the following goals "A nursing plan of care will be established. Anxiety/agitation is minimized/controlled, and caregiver verbalizes understanding of its effects/origin/treatment. Caregiver will verbalize and demonstrate measures to prevent and manage skin breakdown." The goals on the plan of care were not measurable when they did not include a timeframe for completion and/or identify patient specific outcomes expected. During an interview and review of records on 02/05/2025, the Director of Nursing "We can use the electronic medical record (EMR) to develop more specific, measurable goals. We will need more training from [the EMR vendor]."

It is required that the hospice maintains documentation that demonstrates the requirements of competency evaluation are met (items 3-5). 2) A training program that addresses each of the following subject areas: (L613) a) Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff; b) Observation, reporting, and documentation of patient status and the care or service provided; c) Reading and recording temperature, pulse, and respiration; d) Basic infection control procedures; e) Basic elements of body function and changes in body function that must be reported to an aide’s supervisor; f) Maintenance of a clean, healthy, and safe environment; g) Recognizing emergencies and the knowledge of emergency procedures and their application; h) The physical, emotional, and developmental needs of—and ways to work with—the populations served by the hospice, including the need for respect for the patient, his or her privacy, and his or her property; i) Appropriate and safe techniques in performing personal hygiene and grooming tasks, including items on the following basic checklist: i. Bed bath; ii. Sponge, tub, and shower bath; iii. Hair shampoo (sink, tub, and bed); iv. Nail and skin care; v. Oral hygiene; vi. Toileting and elimination; j) Safe transfer techniques and ambulation; k) Normal range of motion and positioning; l) Adequate nutrition and fluid intake; m) Any other task that the hospice may choose to have an aide perform not addressed item 2.i (a-f) above, the basic checklist. 3) The competency evaluation addresses each of the following subject areas from item 2, above; they are evaluated by observation of an aide’s performance with a patient or pseudo-patient, including: a) Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff; b) Reading and recording temperature, pulse, and respiration; c) Appropriate and safe techniques in performing personal hygiene and grooming tasks, including items on the following basic checklist: i. Bed bath; ii. Sponge, tub, and shower bath; iii. Hair shampoo (sink, tub, and bed); iv. Nail and skin care; v. Oral hygiene; vi. Toileting and elimination; d) Safe transfer techniques and ambulation; e) Normal range of motion and positioning. 4) The remaining subject areas in item 2 above may be evaluated through written examination, oral examination, or after observation of a hospice aide with a patient or a pseudo-patient during a simulation. AND 5) The competency evaluation is performed by a registered nurse in consultation with other skilled professionals, as appropriate. This standard was not met as evidenced by interview and personnel record review. In 1 of 1 (100%) personnel record reviewed for hospice aide, the agency did not ensure the Registered Nurse documented an evaluation of aide competency assessment as required by agency policy. Agency policy No. 3-005 Annual Core Competence, dated 04/2021, required in part, "Hospice personnel will demonstrate proficiency in the performance criteria/skills during the orientation period, and at least annually thereafter as part of the annual performance evaluation process." Personnel Record 6: Hospice Aide date of hire 02/15/2024. Personnel record review revealed no documented evidence that a Hospice Aide competency evaluation was completed. The personnel record included a certificate that the aide had completed a Certified Nursing Assistant program. During an interview on 02/05/2025, the Director of Nursing stated, "The aide was signed off by a Registered Nurse on the tasks of the competency checklist, but it was not documented."

It is required that a hospice aide provides services ordered by the Interdisciplinary Group, included in the plan of care, permitted to be performed under state law and regulation, and consistent with the hospice aide training. This standard was not met as evidenced by clinical record review, observation, and interview. In 3 of 10 (30%) clinical records reviewed with hospice aide services provided, the agency did not ensure the Hospice Aide (HA) provided services included in the plan of care. Clinical Record 2: The patient elected the hospice benefit on 12/24/2024 with a diagnosis of neurocognitive disorder with Lewy bodies. The plan of care dated 12/24/2024 to 03/23/2025 included an order for hospice aide services at a frequency of 2wk13 [twice a week for 13 weeks]. Clinical record review revealed the HA documented one aide visit was provided during the first two weeks of service. The clinical record contained no further documentation of HA visits after 12/30/2024. There was no documented evidence in the clinical record, that the physician was notified of missed visits during the first two weeks of service and no documented evidence of an order to discontinue HA services after 12/30/2024. The HA did not provide aide visits at the frequency ordered on the plan of care. Clinical Record 3/Home Visit 2: The patient elected the hospice benefit on 08/09/2024 with a diagnosis of chronic obstructive pulmonary disease. A physician ordered dated 01/20/2025 ordered hospice aide services at a frequency of two times per week. During the home visit observation visit on 02/05/2025 with the Hospice Aide (HA) (Personnel Record 6), the HA was observed to remove the patient's oxygen and provided personal cares to the patient while the patient remained in the chair. The HA was then observed to wash the patient's hair in the kitchen sink. The patient’s medication profile included an order that the patient was to wear the oxygen at 2-3 liters per minute via nasal cannula continuously. The HA plan of care assignment dated 01/20/2025 did not include instructions for the HA to remove the patient’s oxygen during cares provided by the aide. The Director of Nursing was interviewed on 02/04/2024 and stated, "The aide plan of care should have included instructions to the aide indicating if the oxygen could be removed during personal care." Clinical Record 5: The patient elected the hospice benefit on 12/01/2024 with a diagnosis of ovarian cancer. The plan of care dated 12/01/2024 to 02/21/2025 included an order for hospice aide services at a frequency of 4wk12 [four times a week for 12 weeks]. Clinical record review revealed the HA documented two aide visits were provided the first week of care, three aide visits were provided the second week of care, three aide visits were provided the fourth week of care, and two aide visits were provided in the fifth and sixth weeks of care. The clinical record contained no further documentation of HA visits after 12/30/2024. There was no documented evidence in the clinical record, that the physician was notified of missed visits and no documented evidence of an order to discontinue HA services after 12/30/2024. The HA did not provide aide visits at the frequency ordered on the plan of care. During an interview on 02/04/2024, the Director of Nursing stated, "The visits were provided for the two patients into January (2025), but the aide is behind in documentation of the visits she provided."

It is required that a social worker who holds a bachelor’s degree is supervised by a CMS-qualified MSW [Master of 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, personnel record review, clinical record review, and interview. In 4 of 6 (67%) clinical records reviewed with social work services provided, the agency did not ensure the bachelor’s prepared Social Worker was supervised by a master’s prepared Social Worker as required by agency policy. Agency policy No. 1-031 Responsibilities/Supervision of Clinical Services Policy, dated 04/2021, required in part, "The Clinical Director will assure that the following supervision is maintained within the organization: Supervisory contacts and visits will be documented, dated, and signed by the supervising professional." Personnel Record 7: Bachelor Social Worker (BSW) date of hire 03/14/2023. Personnel record review revealed the Social Worker is bachelor’s prepared. Clinical Record 2: The patient elected the hospice benefit on 12/24/2024 with a diagnosis of neurocognitive disorder with Lewy bodies. The plan of care dated 12/24/2024 to 03/23/2025 included an order for social worker services. Clinical record review revealed the BSW provided social service visits to the patient on 12/26/2024 and 01/21/2025. There was no documented evidence in the clinical record of supervisory oversight of the BSW by a master’s prepared social worker (MSW). Clinical Record 5: The patient elected the hospice benefit on 12/01/2024 with a diagnosis of ovarian cancer. The plan of care included an order for Social Work 1w1 (once a week for one week), then 1Q5WK5 (once visit every five weeks for five weeks), then 1Q4WK4 (once every four weeks for four weeks). An interim order dated 01/02/2025 changed the SW visit frequency to weekly. The BSW documented visits were provided to the patient on 12/02/2024, 12/05/2024, 12/09/2024, 01/07/2025, and 01/17/2025. There was no documented evidence in the clinical record of supervisory oversight of the BSW by an MSW. Clinical Record 7: The patient elected the hospice benefit on 11/16/2024 with a diagnosis of malnutrition. The plan of care dated 11/16/2024 to 02/13/2025 included an order for SW 1w1 (once a week for one week). An interim order dated 12/06/2024 changed the SW frequency effective 12/15/2024 to 1w1 (once a week for one week), 1Q4WK4 (once every four weeks for four weeks). The BSW documented visits were provided to the patient on 11/20/2024 and 12/19/2024. There was no documented evidence in the clinical record of supervisory oversight of the BSW by an MSW. Clinical Record 12: The patient elected the hospice benefit on 06/12/2024 with diagnosis of chronic obstructive pulmonary disease. The plan of care dated 09/10/2024 to 12/07/2024 included an order for social work services. The BSW documented visits were provided to the patient on 09/17/2024, 10/15/2024, and 11/15/2024. There was no documented evidence in the clinical record of supervisory oversight of the BSW by an MSW. During an interview and review of findings on 02/05/2025, the Administrator explained that the agency had a master’s prepared Social Worker (MSW) when the agency was started. The MSW resigned and a bachelor’s prepared social worked (BSW) was hired on 03/14/2023 and the agency contracted with another certified hospice program for MSW oversight of the BSW. The Administrator was asked how supervision occurred and was reminded that there was no evidence in the clinical records that the MSW was providing oversight of the BSW. The leadership team provided a printed spreadsheet of patients who had documented BSW visits. The MSW initialed each visit entry on the spreadsheet, indicating that the clinical note was reviewed. The Administrator stated that the MSW did not have access to documents in the medical record but could review the BSW's clinical notes with "read-only" access and agreed there was no documentation in the clinical record of MSW oversight by the BSW. orders for Social Work (SW) services.

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; The medication review process includes the identification of the following the effectiveness of drug therapy; 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, observation and interview. 2 of 11 (18%) clinical records reviewed revealed the hospice did not ensure a drug regimen review was completed for all current medications the patient was taking at the time of the comprehensive assessment. Record #77481 was reviewed and identified that the patient elected the hospice benefit on 1/4/2022. In a communication note dated 1/18/2022 it was revealed that the patient was on oxygen at 3 liters/minute. Oxygen was not present on the medication profile and so a review of all medications did not occur. Record #19901 was reviewed and identified that the patient elected the hospice benefit on 2/16/2022. During a home visit conducted on 3/16/2022 it was observed that the patient was on oxygen. Oxygen did not appear on the medication profile and so nd a review of all medications did not occur. The Director of Nurses was interviewed on 3/16/2022 and stated that she had just learned how to enter oxygen in the EMR as a medication. She had no additional information to provide.

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. Bereavement services are available to the family and other individuals up to one (1) year following the death of the patient. Bereavement counseling extends to residents of a SNF/NF (skilled nursing facility/nursing facility) or ICF/IDF (intermediate care facility/intellectual disability facility) when appropriate and identified in the bereavement plan of care. 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 clinical record review and interview. 1 of 7 (14%) applicable clinical records of deceased patients revealed that there was no bereavement plan of care created. Record #69233 was reviewed and identified that the patient died on 1/24/2022. A bereavement plan of care was not created. The Director of Nurses was interviewed on 3/16/2022 and agreed that the bereavement plan of care was not created. She stated that the family had refused calls from the Bereavement Coordinator but mailings were still being provided.

It is required that counseling services include spiritual counseling. The hospice provides an assessment of the patient’s and family’s spiritual needs. Spiritual counseling to meet spiritual needs is provided in accordance with the patient’s and family’s acceptance of the services and in a manner consistent with the patient and family beliefs and desires. The hospice advises the patient and family of spiritual counseling services and documents the acceptance or refusal of services. The hospice also makes all reasonable efforts to facilitate visits by local clergy, pastoral counselors, or others who can support the patient’s spiritual needs. This standard was not met as evidenced by clinical record review and interview. 1 of 11 (9%) records revealed the agency did not ensure that a spiritual assessment occurred to assess the needs of the patient and family. Record #26726 was reviewed and identified that the patient elected the hospice benefit on 10/31/2021. The initial Plan of Care indicated that the chaplain would see the patient once a month. There was no initial visit or subsequent visits completed by the chaplain and no orders to discontinue the services. The Director of Nurses was interviewed on 3/16/2022 and had no additional information to provide.

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. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: Physician certification and recertification of terminal illness as required in 418.22 and 418.25 and described in 418.102(b) and 418.102(c). This standard was not met as evidenced by clinical record review and interview. 2 of 11 (18%) clinical records reviewed revealed that the written certification of terminal illness (CTI) did not contain a physician narrative. Record #54655 was reviewed and identified that the patient elected the hospice benefit on 12/14/2021. The physician narrative was not present on the CTI. Record #15020 was reviewed and identified that the patient elected the hospice benefit on 3/7/2022. The physician narrative was not present on the CTI. The Director of Nurses was interviewed on 3/16/2022 and agreed that there was not a physician narrative present for the identified patients. She stated that they continue to work with the EMR company to understand how to capture the physician's information on the CTI.