Every finding on record at Golden Diamond Hospice, Inc

Based on interview and record review, the hospice agency (HHA) failed to ensure the emergency preparedness training for all staffs was conducted at least annually. This failure had the potential to result in the hospice staffs lack of knowledge to readily and effectively respond during an emergency crisis situation. --- During a review of the agency's emergency preparedness program documentation, the agency had no documented evidence the emergency preparedness training was conducted for all staff. On 2/14/23, at 12:30 p.m., during an interview with the administrator, she stated the agency's emergency preparedness plan is not complete and needs work. During a review of the agency's policy entitled "Emergency Management Plan" with a revised date of 11/2020, it indicated the agency will comply with all applicable, Federal, State, and local emergency preparedness requirements and will establish and maintain an emergency preparedness program that meets those regulations.

Based on observation, interview and record review, the hospice agency failed to ensure the Condition of Participation regarding Initial and Comprehensive Assessment of Patients were met as followed: 1. The hospice agency failed to conduct an accurate assessment of the patient's eligibility for hospice services related to, the palliation and management of the terminal illness and related conditions, for one of 14 sampled patients (Patient 14). (Refer to L 524) 2. The hospice agency failed to provide initial bereavement assessments for seven of 14 sample patients (Patient 2, 5, 8, 9, 11, 13 and 14). (Refer to L 531) The cumulative effects of these systemic practices resulted in the hospice agency admitting patients without properly conducting a comprehensive assessment and assessing admission criteria and conducting an initial bereavement assessment. --- .

Based on an interview, and record review, the hospice agency (HA) failed to conduct an accurate assessment of the patient's eligibility for hospice services, related to the palliation and management of the terminal illness and related conditions for one of 14 sampled patients (Patient 14). This deficient practice had potential to result in the misuse of the hospice provision of services that could result in a substandard provision of patient care. --- A review of Patient 14's clinical record indicated a Start of Care date (SOC) of 2/07/2023, with diagnosis of atherosclerosis of the aorta (the gradual buildup of plaque in the aorta [largest artery in the body]). A review of Patient 14's Comprehensive Hospice Assessment dated 2/07/2023 for the certification period of 2/07/2023 to 5/07/2023, indicated a skilled nurse (SN) was scheduled to visit Patient 14 two times a month and an aide one time a week for three months. IT further indicated Patient 14 was receiving routine care. The Comprehensive Hospice Assessment indicated on the section Advanced Directive (written statement of a person's wishes regarding medical treatment) indicated, Patient 14 was a DNR (do not resuscitate) and the sections Religious/Spiritual Support and Sensory Status was blank and incomplete. Further review of Patient 14s Comprehensive Hospice Assessment indicated Patient 14 had nutritional changes as evidenced by weight loss not due to reversible causes from 133 pounds to 118 pounds (unit of measurement) and Patient 14 was appropriate for hospice care, and met the criteria for LCD (Local Coverage Determination - determining terminal status) eligibility. A review of Patient 14s Physician Order for Life-Sustaining Treatment (POLST, is a written medical order from a physician that helps give people with serious illnesses more control over their own care by specifying the types of medical treatment they want to receive during serious illness) dated, 2/07/2023, Section A, which indicated whether Patient 14 wanted to attempt resuscitation or not attempt resuscitation was blank. During an interview with Caregiver (CG 1) on 2/15/2023, at 1:20 p.m., she stated Patient 14s hospice binder did not have Patient 14's POLST. Caregiver 1 further stated, the binder did not have a POLST but on the front of the binder there was a sign that indicated, DNR. During a concurrent record review and interview with the Director of Patient Care Services (DPCS) on 2/15/2023, at 12:10 p.m., 1:50 p.m., and 3:10 p.m., she stated the POLST should be filled out during admission and the original should be kept in the patients binder in the home. DPCS stated, she not sure why Patient 14s POLST was blank and since there is no check mark indicating CPR or DNR, the patient should have full treatment. DPCS stated, she completed the comprehensive assessment for Patient 14 and the information regarding the weight loss from 133 pounds to 118 pounds came from the patients family member and the agency did not have Patient 14s history and physical, and could not verify accuracy of the patient family member's statement about the weight loss. DPCS further stated, the LCD was incorporated in the comprehensive assessment and helps determine hospice eligibility, but Patient 14 did not have an LCD when the clinical record was checked. A review of the agencys policy and procedure titled ";Initial Assessment," dated 11/2020, indicated the purpose of the policy and procedure was to provide guidelines for initial assessment to evaluate the patients physical, psychosocial and emotional needs and determine immediate care and support needs. A review of the agencys policy and procedure titled ";Admission Criteria and Process," dated 11/2020, indicated the purpose of the policy and procedure is to establish standards and is a process by which a patient can be evaluated and accepted for admission. The policy and procedure indicated the hospice agency will admit any patient with a life-limiting illness that meets the admission criteria. The policy and procedure further indicated that part of the admission criteria includes the patient must have a life-limiting illness with a life expectancy of six months or less, as determined by the attending physician and hospice Medical Director, utilizing standard clinical prognosis criteria developed by LCD.

Based on interview and record review, the Hospice Agency (HA) failed to provide an initial bereavement (refer to the state of having experienced the loss of a loved one) assessment for seven of 14 sample patients (Patient 2, 5, 8, 9, 11, 13 and 14). This deficient practice had the potential to impact a family members abilities to cope with the patients' death. --- a). A review of Patient 8's clinical record indicated a Start of care date (SOC) of 2/5/23, with a primary diagnosis of COPD (Chronic obstructive pulmonary disease, is a chronic inflammatory lung disease that causes obstructed airflow from the lungs). A review of Patient 8's Plan of Care (POC)/Interdisciplinary Group (IDG) Review for the certification period 2/5/2023 to 5/5/2023, included an order for a Skilled Nurse (SN) to visit Patient 8 once a week for 90 days to assess all systems, evaluate patients care needs and to provide pain management and comfort measures. A review of Patient 8's clinical records indicated that there was no initial bereavement risk assessment conducted. b. A review of Patient 9's clinical record indicated a Start of Care date (SOC) of 2/5/23, with a primary diagnosis of COPD (Chronic obstructive pulmonary disease, is a chronic inflammatory lung disease that causes obstructed airflow from the lungs). A review of Patient 9's Plan of Care (POC)/Interdisciplinary Group (IDG) Review for certification period 2/5/2023 to 5/5/2023, included an order for a Skilled Nurse (SN) to visit Patient 9 once a week for 90 days to assess all systems, evaluate Patient 9's care needs and to provide pain management and comfort measures. A review of Patient 9's clinical records indicated there was no initial bereavement risk assessment conducted. During a concurrent electronic record review and interview with the Administrator/Director of Patient Care Services (ADM/DPCS) on 2/15/23, at 1:00 p.m., the ADM/DPCS stated a bereavement assessment should be conducted on admission. Upon review of Patient 8 and 9s electronic clinical records with the ADM/DPCS, there was no initial bereavement assessment conducted on admission. During a telephone interview with the Medical Social Worker on 2/15/23, at 11:45 a.m., the MSW stated the patients and their families refused to have a bereavement assessment and he thought that bereavement assessment should be conducted by the spiritual chaplain, however, there was no indication of any documented evidence or communication that notes were made. A review of the agency's policy and procedure titled "Bereavement Services," revised November 2020, indicated a bereavement risk assessment will be completed by the hospice social worker at the time of admission to hospice. a. A review of Patient 2's clinical record indicated a start of care date (SOC) of 09/24/2020, with diagnosis of atherosclerotic heart disease (blood vessels that carry oxygen and nutrients from the heart to the rest of the body become thick and stiff restricting blood flow to the organs and tissues). A review of Patient 2's Plan of Care for the certification period of 07/16/2022 to 09/13/2022, indicated that a skilled nurse (SN) is scheduled to visit patient two times a month, chaplain one time a month and medical social worker (MSW) one time a month for two months and was receiving routine care. A review of Patient 2s clinical record indicated that there was no initial bereavement assessment conducted. b. A review of Patient 5's clinical record indicated a start of care date (SOC) of 12/12/2020, with diagnosis of atherosclerotic heart disease. A review of Patient 5's Plan of Care for the certification period of 08/04/2022 to 10/02/2022, indicated that a skilled nurse (SN) is scheduled to visit patient two times a month, chaplain one time a month and medical social worker (MSW) one time a month for two months and was receiving routine care. A review of Patient 5s clinical record indicated that there was no initial bereavement assessment conducted. e. A review of Patient 11's clinical record indicated a start of care date (SOC) of 01/15/2021, with diagnosis of heart failure. A review of Patient 11's Plan of Care for the certification period of 05/10/2022 to 07/08/2022, indicated that a skilled nurse (SN) is scheduled to visit patient two times a month for two months and was receiving routine care. A review of Patient11s clinical record indicated that there was no initial bereavement assessment conducted. f. A review of Patient 13's clinical record indicated a start of care date (SOC) of 04/01/2022, with diagnosis of atherosclerotic heart disease. A review of Patient 13's Plan of Care for the certification period of 06/30/2022 to 09/27/2022, indicated that a skilled nurse (SN) is scheduled to visit patient one time a week and chaplain one time a month three months and was receiving routine care. A review of Patient 13s clinical record indicated that there was no initial bereavement assessment conducted. g. A review of Patient 14's clinical record indicated a start of care date (SOC) of 02/07/2023, with diagnosis of atherosclerosis of aorta (the gradual buildup of plaque in the aorta [largest artery in the body]). A review of Patient 14's Comprehensive Hospice Assessment for the certification period of 02/07/2023 to 05/07/2023, indicated that a skilled nurse (SN) is scheduled to visit patient two times a month and aide one time a week for three months and was receiving routine care. A review of Patient 14s clinical record indicated that there was no initial bereavement assessment conducted. During a concurrent record review and interview with the Director of Patient Care Services (DPCS) on 02/14/2023, at 2:30 p.m., she stated that Patient 2, 5, 11, 13 and 14 did not have initial bereavement assessments. DPCS further stated that bereavement assessments should be done within five days of admission.

Based on interview and record review, the Hospice agency failed to conduct an Interdisciplinary group (IDG) meeting that included all required disciplines and to ensure the IDG members signed the IDG review for three of 14 sampled patients (Patient 2, 8 and 14). This deficient practice had a potential to result in a lack of coordination in the patient's care plan and the services provided by the IDG disciplines. --- a. A review of patient 2s face sheet indicated she was admitted to the hospice agency on 9/24/20, with an admitting diagnosis of atherosclerotic heart disease (blood vessels that carry oxygen and nutrients from the heart to the rest of the body become thick and stiff restricting blood flow to the organs and tissues). A review of Patient 2s plan of care indicated the skilled nurse to visit Patient 2 twice per month and the chaplain would visit one time per month, and the MSW would visit one time a month. A review of Patient 2s IDG conference note for the following dates 7/6/22 and 8/3/22 were missing signatures for the MD, MSW, and spiritual counselor. On 2/15/23 at 3:50 p.m. an interview was conducted with the ADM. She acknowledged that signatures for the IDG meetings were missing and should have been signed to indicate participation in the IDG review for Patient 2. b. A review of Patient 8's clinical record indicated a Start of Care date (SOC) of 2/5/23, with a primary diagnosis of COPD (Chronic obstructive pulmonary disease, is a chronic inflammatory lung disease that causes obstructed airflow from the lungs). A review of Patient 8's Plan of Care (POC)/Interdisciplinary Group (IDG) Review for the certification period from 2/5/2023 to 5/5/2023, included an order for a Skilled Nurse (SN) to visit Patient 8 once a week for 90 days, to assess all systems, evaluate patients care needs and to provide pain management and comfort measures. A review of Patient 8's Plan of Care (POC)/Interdisciplinary Group (IDG) Review for the dates and indications below revealed: 11/30/2022 – indicated no signatures for the Registered Nurse (RN), Licensed Vocational Nurse (LVN), Medical Social Worker (MSW) and Chaplain. 12/14/2022 – indicated no signatures for the RN, LVN and MSW. 12/28/2022 – indicated no signatures for the RN, LVN and MSW. 2/5/2023 – indicated no signatures for the chaplain and MSW. A review of Patient 8's POC/IDG Review dated 11/30/2022, 12/14/2022, 12/28/2022 and 2/5/2023 indicated there was no documentation or communication notes that the MSW, RN, LVN and the Chaplain attended the IDT meetings on the above mentioned dates. During a telephone interview with the MSW on 2/15/2023 at 11:45 am, he stated the hospice agency conducted the IDG meeting every 15 days via a zoom video conference. He stated that IDT members included the RN, MD, MSW, chaplain and skilled nurse. He stated that he is not familiar with the electronic charting and stated he signs the IDG document when he comes to the office. He stated he is unable to recall if there is an actual sign in sheet, but joining the video conference validates his attendance. He stated he always attended the IDT meetings. During an interview on 2/15/2023 at 12:30 pm with the Administrator/Director of Patient Care Services (ADM/DPCS), she stated they held a teleconference IDG meeting and discussed any updates about the patients and later when she saw an Interdisciplinary member, she had them sign the IDG meetings for the dates he/she attended electronically. She stated IDG members/attendees must sign a sign-in sheet to validate their attendance, or an office clerk will keep track of the IDG attendees by signing in for them since it is a video teleconference. The DPCSD stated it was important to have IDG meetings, so we know what is going on with the patient and to update the patient's plan of care as needed. She also stated it is important the IDG members/attendees sign both the sign in sheet and the IDG/POC to document their participation in formulating a patients plan of care. The ADM/DPCS was unable to provide documentation for the IDG attendance form sign in sheet. A review of the hospice agencys policy and procedure titled ";Interdisciplinary Group Meeting, revised on November 2020, indicated the IDG will meet on a regular basis to discuss patient and family/caregiver changes, progress and updates to the plan of care, deaths and changes in patient and family/caregiver circumstances, referrals, and admission/certification and recertification of patients on the hospice program. The meeting will be facilitated by the hospice clinical supervisor or designee, hospice medical director and all hospice IDG members will be present including volunteers and attending physicians. It is also indicated that members at the IDG meeting will sign an attendance form that will be kept by the hospice clinical supervisor. c. A review of Patient 14's clinical record indicated a Start of Care date (SOC) of 2/07/2023, with diagnosis of atherosclerosis of aorta (the gradual buildup of plaque in the aorta [largest artery in the body]). A review of Patient 14's Comprehensive Hospice Assessment for the certification period of 2/07/2023 to 5/07/2023, indicated a skilled nurse (SN) is scheduled to visit Patient 14, who receives routine care, two times a month and an aide was to visit one time a week for three months. A review of Patient 14s Initial Physician Order and IDG Notification dated 2/07/2023 indicated that the chaplain and social workers signatures were missing.

Based on observation, interview and record review, the skilled nurse (SN) failed to follow orders for nursing visit frequency. There were missed visits that occurred but there was no reason documented for not visiting one of 14 sampled patients (Patient 8). This deficient practice placed the patients at a potential risk for complications that could affect their overall health status --- A review of Patient 8's clinical record indicated a start of care date (SOC) of 2/5/23, with a primary diagnosis of COPD (Chronic obstructive pulmonary disease, is a chronic inflammatory lung disease that causes obstructed airflow from the lungs). A review of Patient 8's Plan of Care (POC)/Interdisciplinary Group (IDG) Review for certification period from 10/24/22 to 12/29/22, included an order for a Skilled Nurse (SN) to visit once a week for 90 days to assess all systems, evaluate patients care needs and to provide pain management and comfort measures. On 2/14/23, at 10:00 a.m., a home visit was conducted with at Patient 8's residence with LVN 1 (Licensed Vocational Nurse). Patient 8 was observed resting on her bed and she looked well-groomed, on oxygen via nasal cannula at 2liters/minute, saturating at 92-93%, in no apparent distress. At 10:30 a.m., during an interview with patient 8, she stated that the SN only visits her every week now per doctors order, but sometimes she refused because she just wanted to rest and does not want to be bothered. A concurrent review of Patient 8's electronic medical records with the Administrator/Director of Patient Care Services from dates 11/27/22 through 12/29/2022, indicated there were no home visits conducted on the following weeks below: from 11/27/22 to 12/3/22 from 12/4/22 to 12/10/22 from 12/11/22 to 12/17/22 from 12/18/22 to 12/24/22 from 12/25/22 to 12/29/22. A further review of the Patient 8's clinical record indicated no documentation or communication notes found to justify reason for the missed SN visits. During an interview with the Administrator/Director of Patient Care Services (ADM/DPCS) on 2/15/23, at 2:00 p.m., stated that patient 8 refused visits on those dates and the skilled nurse needs to document in communication note indicating the reason. The hospice agency was unable to provide a policy and procedure that addresses missed/extra visits for patients.

Based on interview and record review, the Hospice Agency failed to develop and implement policies and procedures for COVID-19 (corona virus disease - highly contagious respiratory disease caused by a virus that can spread from person to person). The deficient practice had the potential to place the patients and staff at risk for infection. --- On 02/13/2023, a review of the agencys infection control policy and procedure was conducted and there was no policy and procedure regarding COVID-19. During an interview with the Assistant Administrator on 2/13/2023, at 2:50 p.m., she stated they do not have a policy and procedure for COVID-19. It is somewhere and she will provide tomorrow. During an interview with the Director of Patient Care Services (DPCS) on 2/13/2023, at 4:05 p.m., she stated the agency does not have a policy and procedure for COVID-19 and they only have a general infection control policy and procedure.

Based on interview and record review, the hospice agency failed to ensure the governing body and the Administrator were knowledgeable about hospice regulations, and to ensure governing body meetings were being conducted. This deficient practice resulted in the Administrator/Director of Patient Care Services (DPCS) being unaware of hospice regulations and of the agency being unable to provide governing body meeting minutes. --- During an observation and interview with the Administrator/Director of Patient Care Services (DPCS) on 2/13/2023, at 4:15 p.m. and on 2/14/2023 at 4:05 p.m., she stated the agency did not have any governing body minutes. The Administrator/DPCS further stated they do not use the CMS (Centers for Medicare & Medicaid Services) hospice regulations and they only use Joint Commission and ACHC (Accreditation Commission for Health Care) regulations. The Administrator/DPCS was observed looking for the CMS hospice regulations online, but was unable to locate the correct regulations. A review of the agencys policy and procedure titled ";Hospice Administrator," dated 11/2020, indicated the purpose of the policy and procedure is to define the overall responsibilities of the hospice administrator position. The policy and procedure indicated responsibilities of the position included ensuring organizational compliance with legal, regulatory, and accreditation requirements, ensuring that appropriate service policies are developed and implemented to accomplish identified outcome, maintaining ongoing liaison with the governing body, implementing governing body directives, and informing the governing body, staff and professional advisory committee of current organizational, community and industry trends.

Based on interview and record review, the hospice agency failed to ensure the Condition of Participation for Medical Director was met as follows: 1. The hospice agency failed to ensure the medical director had a completed the employee hiring process and service contract. (Refer to L666) 2. The hospice agency failed to ensure the medical director or physician designee assumed the responsibility for the medical component of the hospice's patient care program, that included, conducting an assessment, reviewing, and verifying patient clinical information necessary for initial certification and recertification of terminal illness for one of 14 sampled patients (Patient 14). (Refer L667) The cumulative effect of this systemic practice resulted in the failure of the hospice to deliver statutory mandated compliance with Federal regulations for Medical Director services to ensure highest quality of patient care are provided to the patients certified to receive hospice services. --- .

Based on interview and record review, the hospice agency failed to ensure the medical director completed the employee hiring process and service contract. This deficient practice had the potential to result in lack of assumed responsibilities and obligations to provide quality care and services . --- On 02/15/2023, a review of the Medical Directors employee file and contract provided by the agency indicated the documents in the employee file was for another hospice agency. The documents in the employee file indicated the Medical Director had filled out documents for another agency and had no documents or contracts filled out for the agency currently in. During a concurrent record review and interview with the Director of Patient Care Services (DPCS) on 02/15/2023, at 3:10 p.m., she stated it was important to have a medical director because the medical director determines who qualifies for hospice and they sign orders and decide if patients are appropriate for hospice. DPCS stated that the employee file and contract provided earlier was for another agency and the second contract provided was for the current agency and it was reviewed with the medical director on 8/11/2022. The DPCS stated the Medical Director contract with the current agency is incomplete, and it is not dated and does not indicate when an agreement date was made. The DPCS further stated she is unable to provide the Medical Directors employee file for the current agency. A review of the agencys policy and procedure titled ";Physician Services – Medical Director," dated 11/2020, indicated the purpose of the policy and procedure is to ensure a qualified medical direction and consultation for the delivery of the hospice services and programs. To demonstrate that the Medical Director/hospice team physicians (Physician designee) has overall responsibility for patient care through documentation that demonstrates interaction/communication with the attending physician as necessary for appropriate medical care.

Based on interview and record review, the hospice agency failed to ensure the medical director or physician designee assumed the responsibility for the medical component of the hospice's patient care program, that included, conducting an assessment, reviewing, and verifying patient clinical information necessary for initial certification and recertification of terminal illness for one of 14 sampled patients (Patient 14). This deficient practice resulted in the hospice medical director and/or the hospice attending physicians certifying patients for hospice care, without reviewing and verifying patients clinical information. --- A review of Patient 14's clinical record indicated a start of care date (SOC) of 2/07/2023, with a diagnosis of atherosclerosis of the aorta (the gradual buildup of plaque in the aorta [largest artery in the body]). A review of Patient 14's Comprehensive Hospice Assessment dated 2/07/2023 for the certification period of 2/07/2023 to 5/07/2023, indicated a skilled nurse (SN) was scheduled to visit Patient 14 two times a month and an aide scheduled to visit one time a week for three months and was receiving routine care. A review of Patient 14s Certificate of Terminal Illness (CTI) dated 2/07/2023, indicated he certified Patient 14 was terminally ill and has a life expectancy of six (6) months or less if the terminal illness runs its normal course. The CTI further stated the Medical Director reviewed Patient 14s clinical information and considered the primary terminal condition, related diagnosis, current subjective and objective medical findings, patients medication and treatment orders and information about management of unrelated condition in making the determination for hospice. During an interview with the Medical Director on 2/15/2023, at 11:02 p.m., he stated he has been the medical director of the agency for seven to eight months. The Medical Director stated he determines patient hospice eligibility based on age, history and physical, medications and assessment. The Medical Director further stated he does not use the LCD (Local Coverage Determination - determining terminal status) or any guidelines to determine hospice eligibility and he uses his assessment and medical knowledge. The Medical Director further stated the last time he saw Patient 14 was two to three months ago and that he has not seen the patient this month. During an interview with the Director of Patient Care Services (DPCS) on 2/15/2023, at 3:10 p.m., she stated Patient 14s history and physical was requested but the agency has not received it yet. The DPCS further stated the LCD is incorporated in the comprehensive assessment and helps determine hospice eligibility, but Patient 14 does not have an LCD. A review of the agencys policy and procedure titled ";Physician Services – Medical Director," dated 11/2020, indicated the purpose of the policy and procedure is to ensure a qualified medical direction and consultation for the delivery of the hospice services and programs. To demonstrate the Medical Director/hospice team physicians (Physician designee) has overall responsibility for patient care through documentation that demonstrates interaction/communication with the attending physician as necessary for appropriate medical care. A review of the agencys policy and procedure titled ";Admission Criteria and Process," dated 11/2020, indicated the purpose of the policy and procedure is to establish standards and a process by which a patient can be evaluated and accepted for admission. The policy and procedure indicated the hospice agency will admit any patient with a life-limiting illness that meets the admission criteria. The policy and procedure further indicated part of the admission criteria includes the patient must have a life-limiting illness with a life expectancy of six months or less, as determined by the attending physician and hospice Medical Director, utilizing standard clinical prognosis criteria developed by LCD.

Based on interview and record review, the Hospice Agency failed to develop and implement policies and procedures to ensure there was a process for tracking and securely documenting the coronavirus (COVID-19) (highly contagious respiratory disease caused by a virus that can spread from person to person) vaccination status for all staff. This deficient practice resulted in the agency not having a policy and procedure for COVID-19 employee vaccination. --- On 02/13/2023, a review of the agencys COVID-19 policy and procedure was conducted and there was no policy and procedure regarding COVID-19 employee vaccination. During an interview with the Director of Patient Care Services (DPCS) on 2/13/2023, at 4:45 p.m., she stated the agency does not have a policy and procedure for COVID-19 employee vaccination. The DPCS further stated she was not aware LVN 1 (Licensed Vocational Nurse) was not vaccinated and there was no declination form or exemption in her employee file.