Every finding on record at First Health Hospice LLC

Based on personnel file review and staff interview, the facility failed to ensure all staff were trained on reporting allegations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse by anyone furnishing services on behalf of the hospice. This had the potential to affect all patients. The facility census was 28 patients. --- Review of the personnel files for the Director of Nursing, Office Manager (OM) #1, Registered Nurse (RN) #2, RN #4, RN #5, RN #9, State Tested Nursing Assistant (STNA) #3, Licensed Practical Nurse (LPN) #6, Volunteer #7 and Social Worker #8 revealed no documented evidence staff were trained on how and when to report allegations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse by anyone furnishing services on behalf of the hospice. Interview with the Director of Nursing on 03/18/24 at 1:50 P.M. verified no formal training was given to the above employees regarding reporting instances involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse by anyone furnishing services on behalf of the hospice.

Based on medical record review, staff interview, and review of agency policies, the agency failed to conduct and document in writing a patient-specific comprehensive assessment that identifies the patients need for hospice care and services, and the patients need for physical, psychosocial, emotional, and spiritual care which includes all areas of hospice care related to the palliation and management of the terminal illness and related conditions. The agency failed to ensure the hospice interdisciplinary group completed the comprehensive assessment no later than five calendar days after the election of hospice care (L0523). The agency failed to conduct 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 and ensure information gathered from the initial bereavement assessment was incorporated into the plan of care and considered in the bereavement plan of care (L0531). The agency failed to ensure the data elements for each patient must be used in individual patient care planning (L0535). The cumulative effect of these practices resulted in a risk to the health and safety of all facility patients --- .

Review of the medical record reviewed revealed Patient #16 elected the hospice benefit on 12/22/23. The patient was admitted with a terminal diagnosis of end stage renal disease. The Medicare certification period under review was 12/22/23 through 0302/24. --- Review of the comprehensive initial assessments revealed the nurse and medical social worker completed their initial assessments. The medical record chaplain, or spiritual adviser, documented on 12/22/23 they were unable to coordinate visit with patient. Review of the 01/18/24 chaplain/spiritual counselor visit also documented the chaplain was unable to coordinate with the patient. Review of the agency policy titled ";Comprehensive Assessment," dated 11/2020, directed the comprehensive patient assessment will be performed by the interdisciplinary group no later than five calendar days after the election of hospice care in consultation with attending physician. An assessment of the patient's and family/caregiver's spiritual orientation, including, as appropriate, any involvement in a religious group such as a church or synagogue or a support group such as Alcoholics Anonymous and spiritual concerns or needs such as despair, suffering, guilt, etc. Interview with Nursing Staff B on 03/18/24 at 11:00 AM confirmed the agency failed to have the entire IDG complete the initial assessment by the fifth calendar day.

Based on record review and staff interview the facility failed to ensure initial bereavement assessments were completed as required. This affected five patients (#1, #2, #4, #11 and #12) of fourteen sampled patients. The agency census was 28. --- Review of the medical records for Patients #1, #2, #4, #11 and #12 revealed no evidence initial bereavement assessments were completed as required. Review of the agency policy titled ";Bereavement Assessment," dated 11/2020, directed the agency will provide bereavement services for up to one (1) year after the patient's death to surviving family/caregiver members. The hospice bereavement plan of care will be developed based on an initial assessment of the patient and family/caregiver needs, during the course of care, and at the time of the patient's death as part of the comprehensive assessment. The policy directs on admission, the social worker or hospice registered nurse will complete a bereavement risk assessment that is given to the Bereavement Coordinator. At a minimum, it will include: A. Patient and family/caregiver loss issues, B. Survivor needs, C. Social, spiritual, and cultural factors, D. Services to be provided including individual counseling, support groups, and letters and cards, E. Referrals to be made, F. Grief risk factors and potential for pathological grief reactions. The bereavement counselor will review the bereavement risk assessment to determine potential needs of the survivors. Interview on 03/12/24 at 9:34 AM with Staff B and Staff C confirmed the agency was unable to provide initial bereavement risk assessments or the inclusion of the bereavement risk on the plan of care for Patients #1, #2, #4, #11 and #12.

Based on medical record review, review of agency policy, and staff interview, the agency failed to individualize the comprehensive initial and recertification assessments. This deficient practice affected 10 patients (#1, #2, #3, #4, #5, #6, #7, #8, #9, and #10) out of a sample of 10 active patients. The agency census was 28. --- Review of the medical records and comprehensive assessments of 10 active patients (#1, #2, #3, #4, #5, #6, #7, #8, #9, and #10) revealed the agency nurses had failed to individualize the patient assessments. The agencys electronic assessment template used by registered nurses (RN) required manual input of assessment data collected by the RN during skilled nursing visits to the patients. These areas on the electronic template were highlighted for the nurse to provide the patients individualized patient assessment and medical information data that would be used in formation of the plan of care for each patient. The nurses failed to individualize the assessments for any of the 10 patients under review. Review of the agency policy titled ";Comprehensive Assessment," dated 11/2020, directed during the comprehensive patient assessment, all baseline data and other relevant information will be documented, through interview and observation, in the patient's clinical record, including at least the following information, as relevant: A. An assessment of pain, including the origin, location, duration, severity, and relief measures; B. An assessment of severity of secondary symptoms, such as nausea, vomiting, respiratory distress, and nutritional status; C. Nature and condition causing admission; D. Alleviating and exacerbating factors for physical symptoms; E. Current treatment and patient response to that treatment; F. An assessment of the patient's response to palliative treatment; G. A physical assessment including relevant data related to pertinent physical findings and the patient's terminal illness; H. Imminence of death; I. Patient's functional status including, but not limited to, the degree of self-care and the amount and level of assistance needed; J. Complication and risk factors that affect patient's diagnosis and any present co- morbid medical conditions and psychosocial history; K. Patient's diagnosis past and any present co-morbid medical conditions and psychosocial history; L. Name and address of the patient's attending physician; M. Name of the patient hospital and other agencies or persons involved in the past and present; N. An the evaluation patient to of the include: home environment and assessment of emergency preparedness. The policy also directs the comprehensive assessment to include a review of current and past medications, including prescription and over the counter, and allergy history. A bereavement assessment of the needs of the patient's family and other individuals should also be included. Interview with Nursing Staff B on 03/14/24 at 1:34 PM revealed she was new to the agency and hospice and was unaware the assessments and plans of care required individualization and data collection.

Based on medical record, review of agency policy, and staff interview, the agency failed to develop individualized plans of care for three patients (#1, #4 and #15) of sixteen medical records reviewed for individualization of the care plan. The agency census was 28. --- 1. Review of the medical record for Patient #1 revealed an election of benefit date of 02/18/24 and a terminal diagnosis of acute on chronic diastolic heart failure as well as co-morbidities of atrial fibrillation and hypertension. The Medicare certification period was 02/18/24 through 05/17/24. Review of the medical record and initial assessment documented the patient utilized home oxygen at two to four liters per nasal cannula as needed. Review of the initial start of care assessment identified a comprehensive plan of care for alteration in comfort, oxygenation, urinary elimination, spirituality, mobility, skin, and musculoskeletal status. The plan of care failed individualize the reason for the areas identified on the care plan as identified on the care assessment. The care plan also failed to address bereavement risk for Patient #1 and the Durable Medical Equipment (DME) for the use of oxygen in the home and the associated safety interventions. 2. Review of the medical record for Patient #4s revealed the Medicare certification benefit period from 12/31/23 through 03/29/24 documented the patients terminal diagnosis of cardio vascular accident (CVA-stroke), with secondary co-morbidities which included chronic obstructive pulmonary disease (COPD), heart failure and hemiplegia. Review of the comprehensive assessment, dated 12/20/23, failed to address the bereavement risk for Patient #4. 3. Review of the medical record for Patient #15 revealed an election of the hospice benefit on 02/02/24. The patient had terminal diagnosis which included Merkle cell carcinoma of the tongue, dementia, and chronic kidney failure. The Medicare certification benefit period from 02/02/24 through 05/01/24 was reviewed. The medical record documented Patient #15 had a physician order dated 02/02/24 for morphine sulfate 20 milligram (mg)/milliliter (mL), administer 0.3 mL (6 mg) as needed every three hours for shortness of breath. The patient also had a physician order dated 02/02/24 for the antianxiety medication lorazepam 0.5 milligrams, to administer one tablet every six hours as needed. Review of the comprehensive assessment, dated 02/02/24, identified the following concerns to be addressed in the comprehensive plan of care: alteration pain and comfort, alteration in mobility, activities of daily living (ADLs) alterations, alteration in skin, and alteration in nutrition. The plan of care failed individualize the reason for the areas identified on the care plan as identified in the initial assessment. Additionally, the plan of care failed to contain any documentation of the patients bereavement risk assessment, the use of the morphine sulfate and lorazepam, Additionally, review of the skilled nursing visits dated 02/09/24 documented the nurse had set up the patients medication box for one week. Review of the plan of care revealed the need to pre-fill the patients medication box was not listed as an ordered task. Review of the communication notes dated 02/15/24 documented the skilled nurse had instructed the patients son on the use of a Hoyer lift (mechanical lift used to transfer patients from surface to surface). The initial assessment failed to assess or document the need for a mechanical lift for the patient. The plan of care failed to order or direct the need for a Hoyer lift. Review of the agency policy titled ";The Plan of Care," dated 11/2020, directed a written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The plan of care will be based on the initial, comprehensive and ongoing comprehensive assessments performed by members of the interdisciplinary group and will be reviewed on a regular basis but no less than every fifteen (15) days. This plan will focus on identified problems, goals, and interventions. The plan of care will include all services necessary for the palliation and management of terminal illness and related conditions. Identification of patient and family/caregiver needs will be on the plan including physical, bereavement and counseling, and DME and medical supplies necessary to meet patient needs. Interview with Staff B on 03/18/24 at 11:00 AM confirmed the plans of care for the above referenced patients were not individualized per the assessments and the agency had failed to include bereavement risks in the plan of care.

Based on medical record review, staff interview, and review of agency policy, the agency failed to agency failed to ensure it obtained data to guide its quality assessment and performance improvement program (QAPI) (L0563). Failed to ensure it conducted a self-assessment of the effectiveness of its QAPI program on at least an annual basis (L0574). Failed to ensure staff adhered to the agencys infection control process for bag technique during patient visits (L0579. The Agency failed to ensure infection control practices/data was incorporated into the agencys QAPI program (L0580). The cumulative effect of these practices resulted in a risk to the health and safety of all facility patients --- .

Based on record review, policy review and staff interview, the agency failed to ensure it obtained data to guide its quality assessment and performance improvement program (QAPI). This had the potential to affect all patients served by the agency. The current agency census was 28. --- Review of the QAPI policies, procedures and meeting minutes for the previous 12 months revealed no evidence of any data tracking to guide and design the agencies QAPI program. Interview with the agencys owner on 03/18/24 at 11:30 A.M. revealed the facility does not track any quantitative data to use in its QAPI program. Review of the policy titled ";Improving organizational performance," dated 11/01/20, revealed the agency will collect data to monitor the effectiveness and safety of services and quality of care as well as to identify opportunities for improvement.

Based on record review, policy review and staff interview the agency failed to ensure it conducted a self-assessment of the effectiveness of its Quality Assessment and Performance Improvement (QAPI) program on at least an annual basis. This had the potential to affect all patients served by the agency. The current agency census was 28. --- Review of the QAPI policies, procedures and meeting minutes for the previous 12 months revealed no evidence the agency conducted a self-assessment of the effectiveness of its QAPI program. Review of the policy titled ";Improving Organizational Performance," dated 11/01/20, revealed the Governing Body is responsible for ensuring that the QAPI program is defined, implemented and maintained, and is evaluated annually. Interview with the agencys owner on 03/18/24 at 11:30 A.M. verified no self-assessment was completed as required.

Based on observation, review of agency policy, and staff interview, the agency failed to ensure staff adhered to the agencys infection control process for bag technique during patient home visits. This deficient practice negatively affected two patients (#1and #2) and had the risk to affect any of the agencys 28 patients. The agency census was 28. --- 1. 1. Observations by two surveyors on 03/11/24 at 11:23 AM during a home visit at the private residence of Patient #1 revealed Nursing Staff D was observed to enter the home and greet the patient. Staff D proceeded to place her nursing bag, which was used daily and for all patients residing in a variety of locations, directly on the wood surface of Patient #1s kitchen table. Staff D then proceeded to withdraw a hard sided case and withdrew a wrist style blood pressure cuff, pulse oximeter, and her stethoscope and obtained Patient #1s vital signs. Staff D completed her assessment of Patient #1 and placed her now soiled equipment back into the hard case, which was then placed into the nursing bag. There was no sanitization of the equipment after patient use as required. 2. Observations by two surveyors on 03/11/24 at 12:03 PM during a home visit to the skilled nursing facility where Patient #2 resided, revealed Nursing Staff E proceeded to Patent #2s room, knocked, and entered the room. Staff E placed her nursing equipment bag directly on a pile of linens, which were on the bedside chair adjacent to the patients bed. Staff E proceeded to withdraw vital sign equipment which included a stethoscope, blood pressure cuff, pulse oximeter and thermometer. Staff E returned to the patients bedside and laid her equipment on the patients bed. Staff E collected the patients vital signs, placed all the equipment on the bed, and proceeded with her head-to-toe assessment. Staff E proceeded to don gloves without hand hygiene and inspected the patients skin which included the buttocks, groin area, and feet. Without changing or removing the gloves, Staff E proceeded to assess the patients neck and head area. Staff E doffed her gloves, picked up her equipment from the bed and replaced the equipment back into her nursing bag. There was no sanitization of equipment performed. Staff E performed hand hygiene as she exited the patient room and verbalized she was on to her next assignment. Review of the agency policy titled ";Bag Technique," dated 11/2020, directed the bag will be placed on a clean surface (i.e., a surface that can be easily disinfected) in the car and in the home. The bag will contain a designated clean and dirty area. The clean area contains unused or cleaned supplies/equipment, and the dirty area is designated for contaminated materials (i.e., used equipment, etc.). When the visit is completed, reusable equipment will be cleaned using alcohol, soap and water, or other appropriate solution, hands will be washed, and equipment and supplies will be returned to the bag. Hands will be decontaminated prior to returning clean equipment to bag. If paper towels/newspapers have been used as protective barrier for bag placement in the patient's home, they will be discarded. Interview on 03/18/24 at 11:00 AM, Staff B verbalized staff was not monitored in the field for infection control and bag technique. Staff B verbalized she was unaware if staff were educated on bag technique and infection control guidelines.

Based on record review and staff interview, the agency failed to ensure infection control practices/data was incorporated into the agencys quality improvement and performance improvement program (QAPI). This had the potential to affect all patients served by the agency. The facility census was 28 patients. --- Review of the QAPI policies, procedures and meeting minutes for the previous 12 months revealed no evidence of any data related to the agencies infection control practices/data. Interview with the agencys owner on 03/18/24 at 11:30 A.M. revealed the facility does not track any quantitative data related to infection control for use in its QAPI program.

Based on medical record review and staff interview, the agency failed to ensure a chaplain visit as requested by the family occurred for one patient (#16) in a sample of 16 patients reviewed for coordination of care. The agency census was 28. --- Review of the medical record for Patient #16 revealed the patient elected the hospice benefit on 12/22/23. The patient was admitted with a terminal diagnosis of end stage renal disease. The Medicare Certification period was 12/22/23 through 03/20/24. Review of the nurses notes for a nursing visit completed on 01/27/244 documented the family was struggling and requested a chaplain visit. The nurses note documented a chaplain visit was scheduled. Review of the chaplains progress and visit notes revealed the chaplain had failed to visit the family per request. There were no chaplain services provided between the election of benefit on 12/22/23 through the patients death on 02/02/24. Interview with Staff B on 03/18/24 at 11:00 AM confirmed the lack of chaplain services as requested by the family.

Based on personnel file review, review of volunteer list, review of agency policy, and staff interview, the agency failed to ensure volunteer orientation and training that is consistent with hospice industry standards (L0643). The agency failed to provide documentation of ongoing efforts to recruit and retain volunteers (L0645) and failed to document the cost savings achieved through the use of volunteers (L0646). The cumulative effect of these practices resulted in a risk to the health and safety of all facility patients. --- .

Based on personnel file review and staff Interview, the agency failed to provide volunteer orientation and training that is consistent with hospice industry standards. This had the potential to affect all patients. The facility census was 28 patients. --- Review of the personnel file for Volunteer #7 revealed no evidence any orientation was given to Volunteer #7 related to facility and hospice industry standards. Interview on 03/14/24 at 10:30 AM, Office Manager (OM) #1 verified there was no evidence of orientation and training for Volunteer #7 that was consistent with hospice industry standards.

Based on list of agency volunteers, policy review, and staff interview, the agency failed to provide documentation of ongoing efforts to recruit and retain volunteers. This had the potential to affect all patients. The facility census was 28. --- Review of the personnel list of current employees noted only one volunteer (Volunteer #7). Review of the policy titled ";Volunteer Staff," dated 11/2020, revealed there will be active and ongoing efforts to recruit, train, and retain volunteers. All efforts will be documented. Written information will be available to the community outlining the involvement of the family member or caregiver serving as a volunteer in public relations or in other nontherapeutic activities. Interview with Staff A, Staff B, and Office Manager #1 on 03/13/24 at 10:00 AM revealed they had been ";working" on recruiting volunteers at local churches, nursing schools, and sororities at the local university. No specific plans or ongoing efforts were expressed and no documentation of previous volunteer recruiting efforts was provided.

Based on review of volunteer list, policy review, and staff interview, the facility failed to document the cost savings achieved through the use of volunteers. This had the potential to affect all patients. The facility census was 28. --- Review of the personnel list of current employees noted one volunteer (Volunteer #7). Review of the undated policy titled ";Documentation of Volunteer Utilization" revealed the Agency will document the cost savings achieved. The hours of volunteer services will exceed 5% of the total patient care hours of paid and contracted hospice personnel. Interview with Staff A, Staff B, and Office Manager #1 on 03/13/24 at 10:00 AM revealed Volunteer #7 was the only volunteer utilized by the agency. Volunteer #7s interactions were not documented or tracked and thus cost savings documentation from the use of volunteers was not documented or able to be calculated.

Based on personnel file review and staff interview, the agency failed to provide orientation about the hospice philosophy to all employees and contracted staff who have patient and family contact. This affected eight (the Director of Nursing (Staff B),Office Manager (OM) #1, Registered Nurse (RN) #2, RN #4, RN #5, RN #9, State Tested Nursing Assistant (STNA) #3, Social Worker (SW) #8, and Licensed Practical Nurse (LPN) #6) of eight employee personnel files reviewed. This had the potential to affect all patients. The facility census was 28 patients. --- Review of the personnel files for Staff B, OM #1, RN #2, RN #4, RN #5, RN #9, STNA #3, SW #8, and LPN #6, revealed no evidence an orientation was given that contained information/elements of the hospice philosophy. Interview on 03/14/24 at 10:30 AM, OM #1 verified no orientation was given to the above employees that contained information/elements of the hospice philosophy

Based on policy review, personnel file review and staff interview. the agency failed to provide an initial orientation for each employee that addresses the employees specific job duties as required. This affected eight (the Director of Nursing (Staff B),Office Manager (OM) #1, Registered Nurse (RN) #2, RN #4, RN #5, RN #9, State Tested Nursing Assistant (STNA) #3, Social Worker (SW) #8, and Licensed Practical Nurse (LPN) #6) of eight employee personnel files reviewed. This had the potential to affect all patients. The facility census was 28 patients. --- Based on policy review, personnel file review and staff interview. the agency failed to provide an initial orientation for each employee that addresses the employees specific job duties as required. This affected eight (the Director of Nursing (Staff B),Office Manager (OM) #1, Registered Nurse (RN) #2, RN #4, RN #5, RN #9, State Tested Nursing Assistant (STNA) #3, Social Worker (SW) #8, and Licensed Practical Nurse (LPN) #6) of eight employee personnel files reviewed. This had the potential to affect all patients. The facility census was 28 patients. Review of the personnel files for Staff B, OM #1, RN #2, RN #4, RN #5, RN #9, STNA #3, SW #8, and LPN #6, revealed no evidence an initial orientation was given for each employee that addressed the employees specific job duties or specific job duties were signed and attested to by the aforementioned employees. Review of the policy titled ";Orientation," dated 11/01/20, revealed all personnel will be required to attend an orientation program upon employment and at the time of reassignment. The goal of orientation will be to inform and instruct new personnel regarding (the agencies) mission, policies and procedures, benefits (if applicable), the performance appraisal process, competency testing, as well as individual responsibilities and relationships to other personnel. Review of the policy titled ";Job Descriptions," dated 11/01/20, revealed at the time of hire, each individual will receive and sign a job description specific to his/her position. In an interview on 03/14/24 at 10:30 AM Office Manager (OM) #1 verified no initial orientation was given for each employee that addressed the employees specific job duties.

Based on medical record review, staff interview, and review of agency policy, the agency failed to monitor the usage of controlled substances and failed to dispose of controlled medications for one (#15) of three patients reviewed for destruction of controlled medications. The agency census was 28. --- Review of the medical record for Patient #15 revealed an election of the hospice benefit on 02/02/24. The patient had terminal diagnosis which included Merkle cell carcinoma of the tongue, dementia, and chronic kidney failure. The Medicare certification period under review was 02/00/24 through 05/01/24. Patient #15 passed on 02/26/24. The medical record documented Patient #15 had a physician order dated 02/02/24 for morphine sulfate 20 milligram (mg)/milliliter (mL), administer 0.3 mL (6 mg) as needed every three hours for shortness of breath. The patient also had a physician order dated 02/02/24 for the antianxiety medication lorazepam 0.5 milligrams, to administer one tablet every six hours as needed. The record contained no documentation that Patient #15s controlled substances were monitored and the usage and medication counts documented in the medical record. There was also no evidence of the destruction of Patient #15s controlled medications upon his death. Review of the agency policy titled ";Home Use and Disposal of Controlled Substances," dated 11/2020, directed the admitting nurse/case manager will provide a copy of the written policies and procedures on the management and disposal of controlled drugs to the patient/representative and family. The admitting nurse/case manager will verbally discuss the policy with the patient/representative and family/caregiver in a language and manner that they understand to ensure the safe use and disposal of controlled drugs. The admitting nurse/case manager will document in the clinical record that the patient/representative and family have received a copy of the policies and procedures. The policy also directs the hospice nurse, social worker, or chaplain attending the death of a hospice patient to inform the family/caregiver of their responsibility to dispose of all the patient's prescribed medications and will document this instruction in a clinical note. If the family/caregiver requests assistance with the disposal, the hospice employee will observe and provide verbal assistance as the family/caregiver properly dispose of the prescribed medications. The disposal will be documented in a clinical note. Interview with Staff B on 03/18/24 at 11:00 AM revealed the agency policy directed skilled nurses to monitor patients use of controlled medications during their home visits and include the controlled substances usage and count in the patients medical record at each visit. Following a death of a patient or the discontinued use of controlled medications the medications were destroyed. Staff B verbalized the agency maintained a logbook of destroyed medications. Interview with Staff B on 03/18/24 at 11:00 AM confirmed the agency was unable to provide any documentation that Patient #15s controlled substances were monitored and the usage and medication counts documented in the medical record. Staff B confirmed the agency was unable to provide documentation Patient #15s controlled substances were destroyed following the death of Patient #15 on 02/26/24.

It is required that the patient’s pain is assessed as part of a comprehensive assessment. The documented assessment of the patient’s pain includes history of pain and its treatment (both pharmacological and non-pharmacological); use of a standardized pain assessment tool appropriate to the patient’s developmental and cognitive status; characteristics of the pain, including location, frequency, and intensity and how pain impacts the patient’s ability to engage in usual activities and function (e.g., appetite, sleeping); the patient’s/family’s goals for pain management and their satisfaction with the current level of pain control. This standard was not met as evidenced by clinical record review and interview. In 3 of 10 (30%) clinical records reviewed, it was revealed that the hospice documentation provided conflicting information about the patient's pain. Record #46868 was reviewed and revealed that the initial comprehensive assessment, dated 10/13/21, provided conflicting information about the patient's pain. The HIS section of the assessment stated the patient had no pain. The narrative stated that the patient had pain in the bilateral hips. The medication profile indicated the patient was taking oxycodone/acetaminophen 5/325mg PRN. MD noted in the CTI that the patient was recently admitted to the hospital related to pain. Record #81905 was reviewed and revealed that the initial comprehensive assessment, dated 10/22/21, provided conflicting information about the patient's pain. The comprehensive assessment indicates that the patient has no pain; however, the MD CTI on 10/28/21 indicated that the patient has a history of back pain. Record #88693 was reviewed and revealed that the initial comprehensive assessment on 11/11/21 stated that the patient has no pain however the drug profile has the patient using Voltaren Gel 1% qid starting on 11/11/21. The clinical manager was interviewed on 12/21/2021 and stated that the documentation was conflicting regarding the patient's pain and that there was no additional information to provide.

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 and interview. 2 of 8 (25%) of applicable clinical records reviewed revealed that a bereavement assessment was not completed. Record #81356 was reviewed and identified the patient elected hospice care on 11/4/21. The clinical record revealed that on 11/8/21 the MSW documented that she was unable to reach the PCG for an assessment. No other discipline completed the Bereavement Assessment. Record #45174 was reviewed and identified that the patient elected hospice care on 11/4/21. The clinical record review revealed that there was no bereavement assessment completed. The alternate administrator was interviewed on 12/22/21 and stated that there were no bereavement assessments within the identified records and there was no additional information to provide.

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. 8 of 10 (80%) of records reviewed revealed that there was no individualized written plan of care that identified planned interventions based on problems identified in the initial and updated comprehensive assessments. Record #81356 was reviewed and identified that the patient elected hospice care on 11/4/2021. The initial comprehensive assessment completed on 11/4/2021 revealed the patient had a fall risk of 7. There was no problem identified for safety or falls on the most recent POC dated 12/22/21. Record #46868 was reviewed and identified that the patient elected hospice care on 10/13/2021. The initial comprehensive assessment completed on 10/13/2021 revealed the patient had a fall risk of 6. There was no problem identified for safety or falls on the most recent POC dated 12/22/21. Record #87472 was reviewed and identified that the patient elected hospice care on 11/4/2021 . The initial comprehensive assessment completed on 11/4/2021 revealed the patient had a fall risk of 5. There was no problem identified for safety or falls on the most recent POC dated 12/22/21. Record #81905 was reviewed and identified that the patient elected hospice care on 10/22/2021. The initial comprehensive assessment completed on 10/22/2021 revealed the patient had a fall risk of 6. There was no problem identified for safety or falls on the most recent POC dated 12/22/21. Record #88693 was reviewed and identified that the patient elected hospice care on 11/11/2021 . The initial comprehensive assessment completed on 11/11/2021 revealed the patient had a fall risk of 5. There was no problem identified for safety or falls on the most recent POC dated 12/22/21. Record #70015 : 13379 was reviewed and identified that the patient elected hospice care on 10/22/2021 . The initial comprehensive assessment completed on 10/22/2021 revealed the patient had a fall risk of 7. There was no problem identified for safety or falls on the most recent POC dated 12/22/21. Record #15076 was reviewed and identified that the patient elected hospice care on 10/20/2021 . The initial comprehensive assessment completed on 10/20/2021 revealed the patient had a fall risk of 5. There was no problem identified for safety or falls on the most recent POC dated 12/22/21. Record #13379 was reviewed and identified that the patient elected hospice care on 8/11/2021 . The initial comprehensive assessment completed on 8/11/2021 revealed the patient had a fall risk of 7. There was no problem identified for safety or falls on the most recent POC dated 12/22/21. The alternate administrator was interviewed on 12/22/21 and stated that there were no safety problems opened in the identified clinical records and the there was not additional information to provide.

It is required that the hospice documents and maintains an effective infection control program that protects patients, families, visitors, and hospice staff by preventing and controlling infections and communicable diseases. The infection control program includes: Education of employees, contracted providers, patients, families, and other caregivers in infection control. This standard was not met as evidenced by personnel record review, interview, and document review. 1 of 10 (10%) Staff files reviewed revealed no evidence that infection control in-service had been completed. Record #57879 was reviewed and identified that the personnel record did not contain information on infection control education. Policy #6-027.5-Infection Control stated in part "...hospice will educate all personnel on infection control policies, procedures and their responsibilities for implementation as contained throughout this section..." The administrator was interviewed on 12/23/21 and confirmed that there was not an orientation checklist available in the personnel record which indicated that the employee had been educated on the agencies infection control program and 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. 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. 2 of 2 (100%) of applicable clinical records reviewed revealed that there were no bereavement plans of care. Record # 70015 was reviewed and identified the patient passed on 10/27/21. There was not bereavement plan of care established. Record #13379 was reviewed and identified the patient passed on 8/14/21. There was not bereavement plan of care established. The alternate administrator was interviewed on 12/22/21 and stated that there were no bereavement plans of care within the identified records nor was there any additional information to provide.

It is required that a hospice aide provides services ordered by the Interdisciplinary Group and included in the plan of care; This standard was not met as evidenced by 6 of 6 (100%) of applicable clinical records reviewed indicated a concern with hospice aide services. Record #81356 was reviewed and identified that the patient elected hospice care on 11/4/21. The order for aide services was established on 11/4/21 with a frequency of two times a week. Two aide visits were missed on the week of 11/21/2021 and two aide visits were missed on the week of 11/28/2021. Record #45174 was reviewed and identified that the patient elected hospice care on 11/4/21. The order for aide services was established on 11/4/21 with a frequency of two times a week. Two aide visits were missed on the week of 11/21/2021 and two aide visits were missed on the week of 11/28/2021 Record #46868 was reviewed and identified that the patient elected hospice care on 10/13/21. The order for aide services was established on 10/13/21 with a frequency of two times a week. One aide visit was missed on the week of 11/21/2021 Record #87472 was reviewed and identified that the patient elected hospice care on 11/4/21. The order for aide services was established on 11/4/21 with a frequency of two times a week. Two aide visits were missed on the week of 11/21/2021 and two aide visits were missed on the week of 11/28/2021 Record #88693 was reviewed and identified that the patient elected hospice care on 11/11/21. The order for aide services was established on 11/11/21 with a frequency of two times a week. Two aide visits were missed on the week of 11/14/2021, two aide visits were missed on the week of 11/21/2021 and two aide visits were missed on the week of 11/28/2021 Record #15076 was reviewed and identified that the patient elected hospice care on 10/20/21. The order for aide services was established on 10/20/21 with a frequency of two times a week. Two aide visits were missed on the week of 11/21/2021; two aide visits were missed on the week of 11/28/2021 and two aide visits were missed on the week of 12/05/2021.

It is required that the hospice provides an initial orientation for each employee that addresses the employee’s specific job duties, including infection control and organization procedures and policies and procedures on advance directives. Orientation on the hospice philosophy is also provided to all employees and contracted staff who have patient and family contact. Orientation includes the following, as appropriate to the employee’s specific job duties: The needs and concerns of patients and families coping with a terminal illness and education regarding the hospice’s policies and procedures on advance directives. This standard was not met as evidenced by 1 of 9 (11%) Staff files reviewed indicated a concern with orientation. Record # 57879 was reviewed and identified that there was no documentation of completed orientation. Policy #1-022.4-Orientation was reviewed and stated in part "A Personnel Orientation Checklist will be completed for all new personnel. New personnel will sign and date when their orientation has been completed." The administrator was interviewed on 12/23 and confirmed that the orientation checklist was not present in the personnel record and had no additional information to provide.

It is required that the Interdisciplinary Group determines the ability of the patient and/or family to safely self-administer drugs and biologicals to the patient in their home. The plan of care identifies the IDG’s finding regarding safe self-administration and/or family administration of drugs and biologicals. This standard was not met as evidenced by clinical record review and interview. 2 of 10 (20%) clinical records reviewed revealed the plan of care failed to identify the ability of the patient and/or family to safely self-administer drugs and biologicals to the patient in their home. Record #48876 was reviewed and identified the patient elected hospice care on 11/15/2021. There was not a problem within the POC that indicated who was responsible for administering medications or that any education was provided to the PCG about medication administration. Record #46868 was reviewed and identified the patient elected hospice care on 10/13/2021. There was not a problem within the POC that indicated who was responsible for administering medications or that any education was provided to the PCG about medication administration. The clinical manager was interviewed on 12/21/2021 and stated that there was no additional information to provide.