Every finding on record at Epic Hospice Care LLC#2

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. 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, 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, observation, and interview. In 3 of 14 (21%) clinical records reviewed, the agency did not ensure an accurate review of the medications the patient was currently using to identify any potential adverse effects and drug reactions. CLINICAL RECORD 8/HOME VISIT 1: During the home visit observation on 10/01/2025 with the Home Health Aide (Personnel Record 8), a medication review was completed by comparing the patient’s current home medications to the hospice medication profile. The patient’s home medications included Sertraline 100 mg tablet, take one tablet daily for depression, last filled 09/17/2025; Hydrocortisone Cream 2.5% perianal, apply to the affected area every 6 hours as needed for discomfort, last filled 06/27/2025; and Albuterol AER HFA 90 mcg, inhale 2 puffs orally every 4 hours as needed, last filled 07/23/2025. Sertraline, Hydrocortisone Cream, and Albuterol AER HFA were not included on the patient’s hospice medication profile and were not included in the medication review process. The hospice medication profile printed on 09/30/2025 included Atorvastatin 40 mg tablet, 40 mg oral nightly, started 03/20/2025; Claritin 10 mg tablet, 10 mg oral daily, started 07/11/2025; and Lisinopril 2.5 mg tablet, 2.5 mg oral daily started 03/02/2025. Atorvastatin, Claritin, and Lisinopril were not included in the patient’s current home medications. CLINICAL RECORD 10/HOME VISIT 3: During the home visit observation on 10/01/2025 with the Registered Nurse (RN) (Personnel Record 5), a medication review was completed by comparing the patient’s current home medications to the hospice medication profile. The patient’s home medications included Levothyroxine 75 mcg tablet, give one daily, last filled 08/20/2025. Levothyroxine was not included on the hospice medication profile and was not included in the medication review process. CLINICAL RECORD 11: The patient elected the hospice benefit on 03/25/2025. The RN documented on the start of care comprehensive assessment dated 03/25/2025, "Intake: Patient is only on IV (intravenous) fluids... Anxiety: Patient is very agitated and will be started on IV Morphine and also Ativan." The RN documented on the nursing visit note dated 03/26/2025, "Patient is receiving an IV Morphine drip at 16 mg/hour." The RN Regular Visit note dated 03/27/2025 documented in part, "Patient continues on an IV Morphine drip at 16 mg/hour." The hospice medication profile did not include Morphine and Ativa, and the medications were not included in the medication review process. During joint record review and interview on 10/01/2025, the Administrator/ Volunteer Coordinator confirmed that the records did not include documentation that the patients’ medication profiles were up-to-date and that the patients’ current medications were reconciled. During joint record review and interview on 10/02/2025, the Director of Clinical Services confirmed that there was no documented evidence that the patients’ current medications were added to the medication profile.

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: drugs and treatment necessary to meet the needs of the patient. 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 individualized plan of care included the drugs and treatments necessary to meet the needs of the patient. CLINICAL RECORD 11: The patient elected the hospice benefit on 03/25/2025. The RN (Registered Nurse) documented on the comprehensive assessment dated 03/25/2025, "Intake: Patient is only on IV (intravenous) fluids... Anxiety: Patient is very agitated and will be started on IV (intravenous) Morphine and also Ativan." The RN documented on the nursing visit note dated 03/26/2025, "Patient is receiving an IV Morphine drip at 16 mg/hour." The RN documented on the nursing visit note dated 03/27/2025, "Patient continues on an IV Morphine drip at 16 mg/hour... Instructed the hospital RN to increase the patient's Morphine dosage. Hospital RN stated that the patient was maxed out on the ordered Morphine dosage. MD (medical doctor) was notified. MD to place an order in the hospital records to increase the IV Morphine dosage." The plan of care and medication profile dated 03/25/2025 did not include Morphine. During a joint record review and interview on 10/02/2025, the Director of Clinical Services confirmed that the drugs and treatment necessary to meet the needs of the patient were not added to the plan of care.

It is required that a hospice may contract for medical director services with either: a self-employed physician; or a physician employed by a professional entity or physician group. The contract specifies the physician who assumes the medical director responsibilities and obligations. This standard was not met as evidenced by document review and interview. The agency did not ensure the Associate Hospice Medical Director’s contract included the name of the physician as required by state regulation. The state’s administrative code, required in part, " (b) A hospice must designate in writing a physician designee to assume the same responsibilities and obligations as the medical director when the medical director is not available. (c) A hospice may contract for a physician to serve as its medical director with either a self-employed physician or a physician employed by a professional entity or physicians' group. The contract for medical director services must specify the name of the physician who assumes the medical director responsibilities and obligations." CONTRACT 11: Associate Hospice Medical Director Agreement dated 05/08/2025 included documentation that read in part, "(Name) County Hospital District d/b/a (Name) Regional Medical Center... Responsibilities of Hospital: 1.01 Hospital agrees to provide an employed medical staff member to serve as Medical Director." The contract did not include the physician's name. During a document review and interview on 09/30/2025, the Alternate Administrator (Personnel Record 11) confirmed that the Associate Hospice Medical Director's name was not listed on the contract and confirmed that the Associate Hospice Medical Director had not yet provided services to the agency's patients. The Alternate Administrator stated that a new contract would be obtained. On 09/30/2025, the agency obtained a new Associate Hospice Medical Director Agreement with the effective date as 09/29/2025 that was signed by both parties on 09/30/2025. During a review of contracts, the Associate Hospice Medical Director Agreement contract with (Name) County Hospital District lacked evidence that the associate medical director was listed by name on the contract. The 26 Texas Administrative Code § 558.858 required that the physician designee(s) or other contracted physicians be listed by name in a hospice contract. On 09/30/2025, the agency obtained a new Associate Hsopice Medical Director Agreement with the effective date as 09/29/2025 that was signed by both parties on 09/30/2025.

It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid certified facility, the hospice forwards to the receiving facility a copy of the hospice discharge summary and the patient’s record, if requested. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical record reviewed with patient transfer, the agency did not ensure the discharge summary was sent to the receiving Medicare/Medicaid certified facility. CLINICAL RECORD 11: The patient elected the hospice benefit on 03/25/2025 and was transferred to a facility on 03/29/2025. The discharge summary included sections titled "discharge summary is sent to Patient/Patient Representative/Facility", "received by", "date", "Contact Person", and "Comments." These sections of the discharge summary were left blank. There was no documented evidence in the clinical record that the discharge summary had been sent to the receiving facility. During a review of the record and interview on 10/02/2025, the Director of Clinical Services confirmed that the record did not include documentation that the discharge summary was sent to the receiving facility.

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 and the patient's record, if requested. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical record reviewed with patient discharge from hospice services, the agency did not ensure the discharge summary was forwarded to the patient’s attending physician. CLINICAL RECORD 12: The patient elected the hospice benefit on 09/25/2024. The patient revoked hospice care and was discharged on 11/02/2025. The discharge summary included sections titled "discharge summary is sent to Patient/Patient Representative/Facility, "received by", "date", and "Contact Person." These sections of the discharge summary were left blank. The comments section of the discharge summary included documentation that "Patient is in the hospital." There was no documented evidence in the clinical record that the discharge summary had been sent to the patient's attending physician. During a record review and interview on 10/02/2025, the Director of Clinical Services confirmed that the record did not include documentation that the discharge summary was sent to the patient’s attending physician.

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 DEFICIENCY. This Condition of Participation was not met as evidenced by review of clinical records, observation, and interview with the Administrator and Director of Clinical Services which revealed the following issues with the development and implementation of patients’ interdisciplinary care plans: Failure of the hospice Interdisciplinary Group to ensure Hospice care and services were provided to patients and families in accordance with the individualized plan of care established by the hospice IDG in collaboration with the attending physician [HCPC.19.I/L543]; Failure of the hospice to ensure the plan of care reflected patient and family goals, and identified planned interventions based on problems identified in the initial comprehensive assessment. [HCPC.21.I/L545]; Failure of the hospice to ensure the plan of care included measurable outcomes [HCPC.21.I/L548]; and Failure of the hospice to ensure the plan of care (POC) included treatment orders [HCPC.21.I/L549]. The cumulative effect of these deficiencies could negatively impact the organization’s ability to develop, update, and implement plans of care to ensure services are provided that will meet the care needs of patients.

It is required that the hospice designates a registered nurse member of the IDG to ensure the implementation of the interdisciplinary plan of care. Hospice care and services provided to patients and families follow the individualized plan of care established by the hospice IDG in collaboration with the attending physician (if any); the patient or patient representative; the primary caregiver in accordance with the patient’s needs. This standard was not met as evidenced by a review of clinical records, observation, and interviews. 2 of 11 (18%) clinical records reviewed revealed the hospice did not ensure that care and services were provided as ordered. Record 2: The patient elected hospice care on 9/23/2022. The plan of care listed the patient's primary diagnosis as "severe protein-calorie malnutrition." The initial comprehensive assessment completed on 9/23/2022 revealed 4 wounds. A physician’s wound care order dated 9/23/2022 for the left heel (Site #1) ordered “Cleanse venous ulcer to left heel with wound cleanser. Apply medihoney and calcium alginate. Cover with bordered dressing 3 x week by hospice nurse.” The skilled nursing (SN) visit notes dated 10/8/2022, 10/10/2022, 10/17/2022 and 10/24/2022 did not include documented evidence that the nurse applied medihoney to the left heel wound as ordered. The SN visit note dated 10/3/2022 did not include documented evidence that wound care was provided to left heel. A physician’s wound care order for the left foot (Site #2) dated 9/23/2022 ordered “Cleanse venous ulcer to left foot with wound cleanser. Apply medihoney and calcium alginate. Cover with bordered dressing 3 x week by hospice nurse.” The SN visit notes dated 10/3/2022, 10/8/2022, 10/10/2022, 10/17/2022 and 10/24/2022 did not include documented evidence the SN applied medihoney to the left foot wound as ordered. In addition, the SN visit note date 10/21/2022, did not include documented evidence that wound care was provided to the left foot. A physician’s wound care order dated 9/23/2022 for the right foot (Site #3) ordered “Cleanse venous ulcer to right foot with wound cleanser. Apply medihoney and calcium alginate. Cover with bordered dressing 3 x week by hospice nurse.” The SN visit notes dated 10/8/2022, 10/10/2022, 10/17/2022 and 10/24/2022 did not include documented evidence the SN applied medihoney to the right foot wound as ordered. In addition, the SN visit note date 10/21/2022, did not include documented evidence that wound care was provided to the right foot. A physician’s wound care order dated 9/23/2022 for the excoriated coccyx (Site #4) ordered, “Apply calmoseptine to excoriation to coccyx twice daily and as needed for redness/excoriation.” The Registered Nurse (RN) documented in the visit note dated 10/3/2022, “deep tissue injury to left ankle, cleansed with wound cleanser, pat dry and covered with calcium alginate and bordered gauze dressing” and the visit note dated 10/24/2022, “deep tissue injury to right heel with moderate serosanguineous drainage, cleaned with wound cleanser, pat dry, covered with calcium alginate and bordered dressing.” The plan of care did not include treatment orders or interventions/goals for the wound. During the home visit (HV 3) on 11/16/2022, the patient reported the wound on her bottom and left ankle causes her pain. The caregiver stated she was one of multiple caregivers that care for the patient....no one taught me what to do, they just keep dropping off all these creams and ointments.....so I just do whatever I can if the nurse isn’t coming that day....I’ve been asking the aide if they told the nurse the bottom wound was worse...I had to get pain medicine from the hospice to give her because she has started having pain on her bottom where the wound is." The RN stated he would be contacting the physician. The Director of Clinical Services was interviewed on 11/17/2022 and stated, "we do not have a specific policy on wound care.... we don't audit to see that wound care is completed, we wear many hats and are busy with multiple other locations." The Administrator was interviewed on 11/17/2022 and confirmed these findings. The Administrator stated, "we will be working on our wound protocol after this." Record 6: The patient elected hospice care on 11/23/2021. A physician’s order dated 12/1/2021 ordered chaplain visits "1M1." There was no evidence of a chaplain visit in December and no documented reason for the missed visit. The chaplain visit frequency was increased to twice monthly per the patient's request effective 1/2/2022. Review of the chaplain visits revealed missed visit documentation dated 2/3/2022 stating “chaplain was unable to make the schedule visit due to his baby was born last week,” 2/15/2022 which stated in part “new baby in hospital,” and 2/22/2022. There was no evidence the two patient requested visits were completed in February 2022. In addition, the visit ordered frequency for the chaplain as of 10/1/2022 was "1M1." There was no evidence of a chaplain visit in October 2022. During an interview, the Director of Clinical Services confirmed the finding and stated, “the visits should have been rescheduled for another day. Record 6: The patient’s date of election was 11/23/2021. A physician’s order effective 12/1/2021 ordered SP (Chaplain) visits 1v1m. There was no documented evidence of a SP (Chaplain) visit in December or documented reason for the missed visit. IDG visit frequency increase to twice monthly per patient request effective 1/2/2022. Missed visit documentation on 2/3/2022 revealed “chaplain was unable to make the schedule visit due to his baby was born last week.” Missed visit documentation on 2/15/2022 revealed “new baby in hospital.” Missed visit documentation 2/22/2022 revealed “needed to move the visit to wed or thurs due to having to watch baby and the weather prevented me to go make visits on either of those days.” There was no documented evidence the two requested visits were completed in February 2022. The visit order frequency for SP (Chaplain) 10/1/2022 ordered 1vx1m. Missed visit documentation for October 2022 revealed “prn chap unable to make visit this week due to death of his mother in law.” There was no documented evidence of a SP (Chaplain) visit in October 2022. The Director of Clinical Services was interviewed on 11/17/2022 and stated, “the visits should have been rescheduled for another day since we cancelled, not the patient,” “it is difficult because all chaplains are prn in that area.” The Director of Clinical Services agreed, hospice care and services were not provided to the patient as ordered. Record 6: The patient’s date of election was 11/23/2021. The hospice aide plan of care dated 1/13/2022 ordered aide visits 5 x weekly. Missed visit documentation on 8/5/2022 revealed “clinician had a family emergency and we did not have a schedule backup.” Missed visit documentation on 9/6/2022 revealed “family emergency-no aide available.” Missed visit documentation on 10/3/2022 revealed “aide had a family emergency and had to return home.” The Director of Clinical Services was interviewed on 11/17/2022 and stated, “the visits should have been rescheduled since we cancelled, not the patient,” “it is difficult because this location is further away.” The Director of Clinical Services agreed, hospice care and services were not provided to the patient as ordered.

This standard was not met as evidenced by a review of clinical records and interviews. 1 of 11 (9%) clinical records reviewed revealed the hospice did not ensure the plan of care reflected patient and family goals, and identified planned interventions based on problems identified in the initial comprehensive assessment. Record 1: The patient elected hospice care on 5/17/2022 with a terminal diagnosis of malignant neoplasm of unspecified part of unspecified bronchus or lung. The medication profile revealed the patient was taking "Albuterol inhaler every 4 hours as needed for shortness of breath/COPD, Hydrocodone-Acetaminophen four times daily and Morphine every three hours" The POC did not include "respiratory/shortness of breath" as a problem with planned interventions and goals. The initial comprehensive assessment completed on 5/17/2022 documented, "pain to wound on right foot." The plan of care did not reflect the patient's and family's goals for pain management. The Director of Clinical Services was interviewed on 11/17/2022 and agreed, the plan of care did not include goals to manage the pain or respiratory status.

It is required that each patient’s individualized written plan of care reflects patient and family goals. Includes all services necessary for the palliation and management of the terminal illness, including measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by a review of clinical records and interviews. 5 of 11 (45%) clinical records reviewed revealed the hospice did not ensure the plan of care included measurable outcomes anticipated from implementing and coordinating the plan of care. Record 4: The patient elected hospice care on 9/9/2021. Review of the plan of care (POC) identified the problem "spiritual grief" on 9/13/2021. The plan of care documented, "Spiritual Grief.. Goal.. Patient/caregiver will achieve experience optimal grief reaction during plan of care." The POC did not include a measurable outcome for the goal. Record 5: The patient elected hospice care on 8/12/2022. Review of the plan of care (POC) identified the problems "Grief Issues" on 11/9/2022 and "Skin Integrity" on 8/12/2022. The plan of care documented, "Grief issues... Goal.. Patient/caregiver will achieve optimal grief reaction prior to patient’s death" and "Skin integrity...Goal.. Patient will achieve and maintain optimal skin integrity as disease progresses." The POC did not include measurable outcomes for the goals. Record 6: The patient elected hospice care on 11/23/2021. Review of the plan of care (POC) identified the problem "Respiratory" on 11/23/2021. The plan of care documented, "Respiratory.. Goal...Patient’s respiratory function will be maximized, and respiratory anxiety decreased." The POC did not include a measurable outcome for the goal. Record 9: The patient elected hospice care on 9/10/2021. Review of the plan of care (POC) identified the problems "Grief Issues" on 9/11/2021. The plan of care documented, "Grief issues.. Goal...Patient/caregiver will achieve experience optimal grief reaction during plan of care." The POC did not include a measurable outcome for goal. Record 11: The patient elected hospice care on 8/15/2022. Review of the plan of care (POC) identified the problem "Skin Integrity" on 8/15/2022. The plan of care documented, "Skin integrity...Goal...Patient will achieve and maintain optimal skin integrity as disease progresses." The POC did not include a measurable outcome for the goal. The Director of Clinical Services was interviewed on 11/17/2022 and confirmed the goals did not include outcomes that were measurable. Record 4: The patient’s date of election was 9/9/2021. The plan of care was reviewed and revealed a problem identified on 9/13/2021: Spiritual Grief. Goal: Patient/caregiver will achieve experience optimal grief reaction during plan of care. Record 5: The patient’s date of election was 8/12/2022. The plan of care was reviewed and revealed a problem identified on 11/9/2022: Grief issues. Goal: Patient/caregiver will achieve optimal grief reaction prior to patient’s death; problem identified on 8/12/2022: Skin integrity. Goal: Patient will achieve and maintain optimal skin integrity as disease progresses. Record 6: The patient’s date of election was 11/23/2021. The plan of care was reviewed and revealed a problem identified on 11/23/2021: Respiratory. Goal: Patient’s respiratory function will be maximized, and respiratory anxiety decreased. Record 9: The patient’s date of election was 9/10/2021. The plan of care was reviewed and revealed a problem identified on 9/11/2021: Grief issues. Goal: Patient/caregiver will achieve experience optimal grief reaction during plan of care. Record 11: The patient’s date of election was 8/15/2022. The plan of care was reviewed and revealed a problem identified on 8/15/2022: Skin integrity. Goal: Patient will achieve and maintain optimal skin integrity as disease progresses. The Director of Clinical Services was interviewed on 11/17/2022 and agreed, the goals identified did not reflect patient or family goals that were measurable.

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; Includes all services necessary for the palliation and management of the terminal illness, including the following drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by a review of clinical records and interviews. 4 of 11 (36%) clinical records reviewed revealed the hospice did not ensure the plan of care (POC) included treatment orders. Record 1: The patient elected hospice care on 5/17/2022. The initial comprehensive assessment completed on 5/17/2022, identified a wound to inner aspect of right foot near great toe with daily wound care provided by the Skilled Nursing Facility (SNF). The hospice plan of care did not include treatment orders or interventions/goals for the wound. Record 2: The patient elected hospice care on 9/23/2022. The Registered Nurse (RN) visit note dated 10/3/2022 documented "deep tissue injury to left ankle, cleansed with wound cleanser, pat dry and covered with calcium alginate and bordered gauze dressing." The skilled nurse visit note dated 10/24/2022, documented "deep tissue injury to right heel with moderate serosanguineous drainage, cleaned with wound cleanser, pat dry, covered with calcium alginate and bordered dressing." The plan of care did not include treatment orders or interventions/goals for the wound. Record 4: The patient elected hospice care on 9/9/2021. The initial comprehensive assessment completed on 9/9/2021, documented the patient had a "18F suprapubic catheter." The skilled nurse (SN) visit note dated 6/19/2022, documented the SN changed the catheter. The plan of care did not include treatment orders or interventions/goals for the Foley catheter. During an interview on 11/17/2022, the Director of Clinical Services confirmed there were no orders or interventions/goals for care and maintenance of the Foley catheter. Record 10: The patient elected hospice care on 9/8/2021. The initial comprehensive assessment completed on 9/8/2021, documented an ulcer to the left lower leg and a sore below the ulcer. The plan of care did not include treatment orders or interventions/goals for the wound. During an interview on 11/17/2022, the Director of Clinical Services confirmed there were no orders or interventions/goals for the wound identified. Record 1: The patient’s date of election was 5/17/2022 with a terminal diagnosis of malignant neoplasm of unspecified part of unspecified bronchus or lung. The initial comprehensive assessment on 5/17/2022 identified a wound to inner aspect of right foot near great toe with daily wound care by the Skilled Nursing Facility. The plan of care did not include treatment orders or interventions/goals for the wound. The Director of Clinical Services was interviewed on 11/17/2022 and agreed, there were no orders or interventions/goals for the wound identified. Record 2: The patient’s date of election was 9/23/2022 with a terminal diagnosis of unspecified severe-protein calorie malnutrition. The Registered Nurse documentation on 10/3/2022 identified deep tissue injury to left ankle, cleansed with wound cleanser, pat dry and covered with calcium alginate and bordered gauze dressing. The skilled nurse documentation on 10/24 revealed deep tissue injury to right heel with moderate serosanguineous drainage, cleaned with wound cleanser, pat dry, covered with calcium alginate and bordered dressing. The plan of care did not include treatment orders or interventions/goals for the wound. The Director of Clinical Services was interviewed on 11/17/2022 and agreed, there were no orders or interventions/goals for the wound identified. Record 4: The patient’s date of election was 9/9/2021 with a terminal diagnosis of Alzheimer’s disease. The initial comprehensive assessment on 9/9/2021 revealed a 18F suprapubic catheter. The skilled nurse documentation on 6/19/2022 revealed the catheter was changed. The plan of care did not include treatment orders or interventions/goals for the foley catheter. The Director of Clinical Services was interviewed on 11/17/2022 and agreed, there were no orders or interventions/goals for the foley catheter. Record 10: The patient’s date of election was 9/8/2021 with a terminal diagnosis of pulmonary fibrosis unspecified. The initial comprehensive assessment on 9/8/2021 identified an ulcer to the left lower leg and a sore below the ulcer. The plan of care did not include treatment orders or interventions/goals for the wound. The Director of Clinical Services was interviewed on 11/17/2022 and agreed, there were no orders or interventions/goals for the wound identified.

It is required that a hospice aide provides services ordered by the Interdisciplinary Group and included in the plan of care. THIS IS A CONDITION LEVEL DEFICIENCY This CONDITION of participation was not met as evidenced by clinical record reviews, observation, and interview. The agency failed: to ensure written patient care instructions were prepared by a RN who was responsible for the supervision of the hospice aide [HCDT.15.I/625]; and to ensure that the hospice aide reported changes in the patient's needs to the registered nurse [HCDT.18.I/L628]. The cumulative effect of these deficiencies could impact the organization's ability to ensure the provision of high quality care and services.

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by a review of clinical records and interviews. 3 of 11 (27%) clinical records reviewed of patients who received hospice aide services revealed the agency did not ensure the hospice aide received specific written patient instructions. . Record 3: The patient elected hospice care on 9/13/2021. The aide plan of care dated 8/10/2022 assigned the tasks, "bed bath every visit, chair bath every visit, complete bath every visit, seated shower every visit, sponge bath every visit." The aide did not receive specific instructions for the patient's type of bath. Record 4: The patient elected hospice care on 9/9/2021. The hospice aide plan of care dated 5/18/2022 assigned the tasks, "bed bath every visit, shower every visit, shampoo in bed every visit, shampoo in tub every visit." The aide did not receive specific instructions for the patient's type of bath. Record 6: The patient elected hospice care on 11/23/2021. The hospice aide plan of care dated 1/13/2022 assigned the tasks "bed bath every visit, seated shower Sun. Mon. Wed. Fri, sponge bath Tues. Thurs. Sat." The aide did not receive specific instructions for the patient's type of bath. The Director of Clinical Services was interviewed on 11/17/2022 and confirmed the finding and stated the RN did not assign specific instructions for the aide to follow in the records identified. Record 3: The patient’s date of election was 9/13/2021. The hospice aide plan of care was reviewed for a visit on 8/10/2022. The aide plan of care assigned bed bath every visit, chair bath every visit, complete bath every visit, seated shower every visit, sponge bath every visit. Record 4: The patent’s date of election was 9/9/2021. The hospice aide plan of care dated 5/18/2022 assigned bed bath every visit, shower every visit, shampoo in bed every visit, shampoo in tub every visit. Record 6: The patient’s date of election was 11/23/2021. The hospice aide plan of care dated 1/13/2022 assigned bed bath every visit, seated shower sun mon wed fri, sponge bath tues thurs sat. The Director of Clinical Services was interviewed on 11/17/2022 and agreed, the RN did not assign specific instructions for the aide to follow in the records identified.

It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. This standard was not met as evidenced by a review of clinical records and interviews. 3 of 11 (27%) records reviewed of patients receiving hospice aide services revealed the hospice did not ensure the hospice aide reported changes to the registered nurse (RN). Record 1: The patient elected hospice care on 5/17/2022. The hospice aide visit note dated 6/29/2022 documented, "Yes...is there uncontrollable pain....pt hurts when I move her, she states it bothers her when I move her.” There was no evidence that the hospice aide notified the registered nurse. The hospice aide documentation on 6/24/2022 and 6/27/2022 revealed seated shower was refused, brush teeth was refused. The hospice aide documentation on 7/1/2022 revealed seated shower was refused. There was no documented evidence that the hospice aide notified the registered nurse of the changes. Record 2: The patient elected hospice care on 9/23/2022. The hospice aide visit note dated 11/9/2022 documented “Yes.... is there constipation > 3 days....11/1/2022 of last bowel movement." The hospice aide documented on 11/2/2022, “pt has another skin tear on back of calf left side buttocks sore is getting dark and has another open sore applied skin barrier.” There was no documented evidence that the hospice aide notified the registered nurse of the changes. Record 3: The patient elected hospice care on 9/13/2021. The hospice aide frequency ordered effective 7/17/2022 was 2vx1w, 3vx1w, 3vx5w. The hospice aide documentation on 7/29/2022 revealed a missed visit, patient declined visit. The hospice aide documentation on 8/1/2022 revealed a missed visit, caregiver not available, declined to reschedule visit. The hospice aide documentation on 8/12/2022 revealed a missed visit, patient/caregiver refused aide visit. The hospice aide documentation on 8/26/2022 revealed a missed visit, caregiver not available, declined to reschedule. There was no documented evidence the aide notified the registered nurse of the declined and refused missed visits. The Director of Clinical Services was interviewed on 11/17/2022 and agreed, there was no documented evidence the hospice aide notified the registered nurse with the change in condition or missed visits. Record 1: The patient’s date of election was 5/17/2022. The hospice aide documentation on 6/29/2022 answered YES to “is there uncontrollable pain,” and documented “pt hurts when I move her, she states it bothers her when I move her.” There was no documented evidence that the hospice aide notified the registered nurse. The hospice aide documentation on 6/24/2022 and 6/27/2022 revealed seated shower was refused, brush teeth was refused. The hospice aide documentation on 7/1/2022 revealed seated shower was refused. There was no documented evidence that the hospice aide notified the registered nurse. Record 2: The patient’s date of election was 9/23/2022. The hospice aide documentation on 11/9/2022 answered “YES to “is there constipation > 3 days”, with the date 11/1/2022 of last bowel movement. The hospice aide documentation on 11/2/2022 revealed “pt has another skin tear on back of calf left side buttocks sore is getting dark and has another open sore applied skin barrier.” There was no documented evidence that the hospice aide notified the registered nurse. Record 3: The patient’s date of election was 9/13/2021. The hospice aide frequency ordered effective 7/17/2022 was 2vx1w, 3vx1w, 3vx5w. The hospice aide documentation on 7/29/2022 revealed a missed visit, patient declined visit. The hospice aide documentation on 8/1/2022 revealed a missed visit, caregiver not available, declined to reschedule visit. The hospice aide documentation on 8/12/2022 revealed a missed visit, patient/caregiver refused aide visit. The hospice aide documentation on 8/26/2022 revealed a missed visit, caregiver not available, declined to reschedule. There was no documented evidence the aide notified the registered nurse of the missed visits. The Director of Clinical Services was interviewed on 11/17/2022 and agreed, there was no documented evidence the hospice aide notified the registered nurse with the change in condition or missed visits.

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: signed copies of the notice of patient rights and the hospice election statement. This standard was not met as evidenced by a review of clinical records and interviews. 3 of 11 (27%) clinical records reviewed revealed the hospice did not ensure the notification of hospice non-covered items were provided to the patient within 5 days of the request upon admission. Record 3: The patient elected hospice care on 9/13/2021. The hospice election statement was reviewed and identified the patient/representative requested the addendum on 9/13/2021. There was no documented evidence the notification of hospice non-covered items was completed and provided to the patient. Record 7: The patient elected hospice care on 9/30/2022. The hospice election statement was reviewed and identified the patient/representative requested the addendum on 9/30/2022. There was no documented evidence the notification of hospice non-covered items was completed and provided to the patient. Record 8: The patient elected hospice care on 2/4/2022. The hospice election statement was reviewed and identified the patient/representative requested the addendum on 2/4/2022. There was no documented evidence the notification of hospice non-covered items was completed and provided to the patient. The Director of Clinical Services was interviewed on 11/17/2022 and confirmed there was no evidence the notification of hospice non-covered items was completed. Record 3: The patient’s date of election was 9/13/2021. The hospice election statement was reviewed and identified the patient/representative requested the addendum on 9/13/2021. There was no documented evidence the notification of hospice non-covered items was completed and provided to the patient. Record 7: The patient’s date of election was 9/30/2022. The hospice election statement was reviewed and identified the patient/representative requested the addendum on 9/30/2022. There was no documented evidence the notification of hospice non-covered items was completed and provided to the patient. Record 8: The patient’s date of election was 2/4/2022. The hospice election statement was reviewed and identified the patient/representative requested the addendum on 2/4/2022. There was no documented evidence the notification of hospice non-covered items was completed and provided to the patient. The Director of Clinical Services was interviewed on 11/17/2022 and agreed, there was no documented evidence the notification of hospice non-covered items was completed and provided to the patient within 5 days of their request at the time of admission.

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; the patient’s latest physician orders; 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 a review of clinical records and interviews. 2 of 2 (100%) clinical records reviewed of patients with a discharge revealed the hospice did not ensure a discharge summary was provided to the facility or patient’s community attending physician. Record 8: The patient elected hospice care on 2/4/2022. The discharge was reviewed and revealed the patient was discharged due to revocation on 5/31/2022. There was no evidence the discharge summary was sent to the facility (hospital) or patient’s community attending physician. Record 9: The patient elected hospice care on 9/10/2021. The discharge was reviewed and revealed the patient was discharged for extended prognosis on 10/30/2022. There was no evidence the discharge summary was sent to the patient’s community attending physician. The Director of Clinical Services was interviewed on 11/17/2022 and confirmed the discharge summary was not sent to the facility or patient’s community attending physician. Record 8: The patient’s date of election was 2/4/2022. The discharge was reviewed and revealed the patient was discharged, revocation seeking aggressive treatment on 5/31/2022. There was no documented evidence the discharge summary was sent to the facility (hospital) or patient’s community attending physician. Record 9: The patient’s date of election was 9/10/2021. The discharge was reviewed and revealed the patient was discharged for extended prognosis on 10/30/2022. There was no documented evidence the discharge summary was sent to the patient’s community attending physician. The Director of Clinical Services was interviewed on 11/17/2022 and agreed, there was no documented evidence the discharge summary, including the current plan of care and latest physician’s orders, was sent to the facility or patient’s community attending physician.

It is required that the designated IDG member provides the SNF/NF or ICF/IDF with the following information for each patient/resident: the most recent hospice plan of care; hospice election form and any advance directives; physician certification and recertification of the terminal illness. This standard was not met as evidenced by a review of clinical records, interviews and observations. 1 of 1 (100%) home visit to a patient residing in a SNF revealed the hospice did not ensure the most recent hospice plan of care. Record 1: The patient elected hospice care on 5/17/2022. During the visit (HV1) conducted on 11/16/2022, the hospice binder in the SNF was reviewed with the hospice Chaplain. The plan of care located in the binder was for the period ending 7/8/2022. There was no evidence the SNF had a current plan of care for the patient. The Chaplain interviewed following the visit stated, “looks like the only items here are from the beginning of care.” The Chaplain confirmed, there was no evidence the most recent hospice plan of care was provided to the SNF. The Director of Clinical Services was interviewed on 11/16/2022 and confirmed the finding. Record 1: The patient’s date of election was 5/17/2022. The hospice binder in the facility was reviewed on 11/16/2022 with the hospice Chaplain. The plan of care located in the binder was for the period ending 7/8/2022. The Chaplain was interviewed on 11/16/2022 and stated, “looks like the only items here are from the beginning of care.” The Chaplain agreed, there was no documented evidence the most recent hospice plan of care, hospice election form, physician certification or recertification of the terminal illness were provided to the SNF. The Director of Clinical Services was interviewed on 11/16/2022 and agreed, there was no documented evidence the most recent hospice plan of care, hospice election form, physician certification and recertification of the terminal illness were provided to the SNF.