Every finding on record at Greenleaf Hospice LLC

Based on record review and interview, the agency failed to develop a bereavement plan of care that noted the kind of bereavement services and the frequency of service to be delivered for 2 (#12, #13) of 2 deceased patient records reviewed where the family or significant others received bereavement services. The failure placed the surviving family members or significant others at risk of inadequate support and that complicated grief would not be identified. --- Patient #12: Record review of Patient #12's clinical record revealed an updated Plan of Care dated 6/1/2023. The Plan of Care listed Senile Degeneration of the Brain (loss of function in the cells of the brain) as the primary diagnosis. Patient #12's clinical record contained documentation of a visit conducted by Social Worker D on 2/15/2023. Social Worker D identified that a nephew was involved in Patient #12's care. Review of the agency's discharge patient list given to the surveyor on 3/1/2024, indicated that Patient #12 died on 6/10/2023. Patient #12's clinical record did not contain a Bereavement Plan of Care. The surveyor reviewed a binder that was titled "Bereavement Book." The agency had their bereavement program documentation in the binder. A record review of the bereavement book revealed a document titled "General Patient Details" that identified Patient #12. The Bereavement book contained along with the patient details, a copy of 3 letters that contained a first name only of the recipient. The letters were dated 7/10/2023, 9/10/2023, and 12/10/2023. The agency was providing bereavement services to Patient #12's Family Member. The Bereavement Book did not contain a Bereavement Plan of Care. Patient #13: Record review of Patient #13's clinical record did not contain a Plan of Care. The agency provided a Certification of Terminal Illness that was dated 9/28/2023. The Certification of Terminal Illness indicated that Patient #13 was admitted to the agency's services on 9/28/2023. The Certification listed the primary diagnosis as Senile Degeneration of the Brain as the primary diagnosis. Patient #13's record contained documentation of a phone call that Social Worker D made to Patient #13's Family Member on 9/28/2023 regarding bereavement services. Patient #13's Family Member accepted bereavement services. Review of the agency's discharge patient list given to the surveyor on 3/1/2024, indicated that Patient #13 died on 10/1/2023. Patient #13's clinical record did not contain a Bereavement Plan of Care. The surveyor reviewed a binder that was titled "Bereavement Book." The agency had their bereavement program documentation in the binder. A record review of the bereavement book revealed a document titled "General Patient Details" that identified Patient #13. The Bereavement book contained, along with the patient details, copies of 2 letters that contained a first name only of the recipient. The letters were dated 11/1/2023 and 1/1/2024. The agency was providing bereavement services to Patient #13's Family Member. The Bereavement Book did not contain a Bereavement Plan of Care. On 3/4/2024 at 12:33 p.m. the surveyor requested the bereavement documentation. The Administrator stated, "The Chaplain [Chaplain C] has the book of bereavement." The Administrator informed the surveyor that Chaplain C had a family member at the hospital having tests. The Administrator stated, "We have asked him to bring it." On 3/4/2024 at 2:07 p.m., the surveyor asked if the bereavement could be in the computer. The Administrator informed the surveyor that Chaplain C preferred to do written documentation of the bereavement instead of putting it in the computer. During an interview on 3/6/2024 at 10:58 a.m. with the Administrator and Alternate Administrator, the surveyor discussed that the Bereavement Book did not have Bereavement Plans of Care. The Administrator looked in the computer and could not find Bereavement Plans of Care. The surveyor asked if Patient #12 and Patient #13 had Bereavement Plans of Care. The Administrator stated, "No." During an interview on 3/7/2024 at 11:08 a.m. with Chaplain C, the surveyor discussed that the Bereavement Plans of Care for Patient #12 and Patient #13 were not in the Bereavement Book and were not in the clinical records. The surveyor asked if Chaplain C had developed Bereavement Plans of Care. Chaplain C stated, "I'm sure I did, I may have a paper Bereavement Plan of Care." Chaplain C stated, "I'm not organized." Chaplain C did not state how it could impact the agency. Bereavement Plans of Care were not developed. The agency had a policy titled "Bereavement" that was labeled TX.26 with a revision/reviewed date of 2/1/2023. The policy read in part; "Purpose To insure appropriate bereavement assessment and support for surviving hospice family members and significant others. Policy...Following the death, the Agency will develop and implement the bereavement plan of care based on the post death risk assessments...Procedure...5. The bereavement plan of care will be developed and implemented following the death according to individual risk assessment score. 6. The plan of care will include delineation of services and frequency to be provided..."

It is required that the hospice Interdisciplinary Group, in consultation with the individual's attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review and interview. 1 of 1 (100%) clinical records reviewed revealed that the hospice interdisciplinary group did not ensure that the comprehensive assessment was completed within 5 calendar days of election of hospice care. Clinical Record 4: The patient elected the hospice benefit 10/23/2023 with a diagnosis of Malignant Neoplasm of Bladder. The initial RN comprehensive assessment was dated 10/23/2023. A chaplain evaluation was ordered on the plan of care dated 10/26/2023. There was no documented evidence in the RN or social work assessment that the patient's spiritual needs was completed within 5 calendar days of the election of benefit date. During an interview and joint clinical record review, the Director of Nursing agreed that the comprehensive assessment did not include the spiritual assessment within 5days.

It is required that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the patient’s terminal illness that are addressed to promote the patient’s well-being, comfort, and dignity throughout the dying process. This standard was not met as evidenced by clinical record review and interview. 1 of 1 (100%) clinical records reviewed, the hospice did not ensure comprehensive assessments were performed initially identified the spiritual needs related to the patient’s terminal illness. Clinical Record 4: The patient elected the hospice benefit 10/23/2023 with a diagnosis of Malignant Neoplasm of Bladder. The initial RN comprehensive assessment was dated 10/23/2023. A chaplain evaluation was ordered on the plan of care dated 10/26/2023. There was no documented evidence that the RN assessment or the social work assessment included the patient's spiritual needs. The clinical record did not contain a chaplain assessment visit. During a clinical record review the Director of Nursing agreed that no spiritual assessment was completed.

It is required that each patient’s individualized written plan of care reflects patient and family goals; and 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. 6 of 8 (75%) clinical records reviewed revealed that the hospice did not ensure that the plan of care (POC) included goals and interventions based on problems identified in the comprehensive assessment. Clinical Record 1: Patient elected the hospice benefit on 10/10/2023 with a diagnosis of Nontraumatic Subarachnoid hemorrhage. A nursing assessment dated 11/2/2023 identified the following problems: shortness of breath, use of oxygen, dyspnea on exertion, and dysphagia. The POC lacked these identified problems with associated interventions and goals. In addition, the interdisciplinary group (IDG) document dated 11/2/2023 was missing identification of these identified problems. Clinical Record 2: The patient elected the hospice benefit on 10/22/2022 with a diagnosis of Senile Degeneration of Brain. An RN comprehensive assessment dated 11/1/2023 identified problems of shortness of breath with activity, poor balance leading to fall risk, productive cough, and pain. The POC reviewed and updated by the IDG on 11/2/2023 lacked evidence that these identified problems with associated interventions and goals were included on the POC. In addition, problems identified on the POC of Deficit related to nutrition/hydration, deficit related to disruption of spiritual trust/anger, lacked evidence of associated interventions and goals. Clinical Record 3: The patient elected the hospice benefit on 8/9/2023 with a diagnosis of Senile Degeneration of Brain. The RN comprehensive assessment 11/4/2023 identified problems of dyspnea with activity. The POC reviewed and updated by the IDG on 11/2/2023 lacked evidence of this identified problem with associated interventions and goals. Clinical Record 4: The patient elected the hospice benefit on 10/23/2023 with a diagnosis of Senile Degeneration of the Brain. The nursing comprehensive assessment dated 10/23/2023 identified problems of dyspnea with walking, hopelessness and helplessness. The POC reviewed and updated by the IDG on 11/2/2023 lacked evidence of these identified problems with associated interventions and goals. Clinical Record 5: The patient elected the hospice benefit on 8/25/2023 with a diagnosis of Acute ischemic heart disease. The nursing comprehensive assessment dated 11/2/2023 identified problems of dyspnea, chronic pain and dyspnea. The POC reviewed and updated by the IDG on 11/2/2023 lacked evidence of these identified problems with associated interventions and goals. Clinical Record 6: The patient elected the hospice benefit on 5/17/2022 with a diagnosis of Senile Degeneration of Brain. The nursing comprehensive assessment dated 11/2/2023 identified problems of dyspnea on exertion and high risk of falls. The POC reviewed and updated by the IDG on 11/2/2023 lacked evidence of these identified problems with associated interventions and goals. Problems identified on the POC of physical comfort alteration due to pain, skin integrity, and deficit related to spiritual unworthiness anxiety lacked evidence of associated interventions and goals. The Director of Nursing stated in an interview on 11/1/3/2023 that she had performed an audit on the plans of care and did not think they were missing anything.

It is required that the hospice develops, implements, and maintains an effective, ongoing, hospice-wide, data-driven quality assurance and performance improvement program (QAPI). The hospice governing body is responsible for ensuring that the program: Addresses efforts and sets priorities for improved quality of care and patient safety, and ensures all improvement actions are evaluated for effectiveness; Focuses on indicators related to improved palliative outcomes; Includes investigation and analysis of sentinel and adverse events; Includes defined data detail and frequency of collection, and approves such; Has evidence of action taken that results in improvement in hospice performance; Is evaluated annually. This standard was not met as evidenced by document review and interview which revealed that the hospice did not ensure that the QAPI program focused on quality improvement in care and patient safety. During a joint review on 11/14/2023, the Director of Nursing (DON) of the hospice QAPI program confirmed that she was appointed by the governing body to oversee the hospice QAPI program. However, the QAPI program documents provided by the DON did not include evidence that the program addressed related efforts or set priorities for improved quality of care and patient safety. There were no active performance improvement plans in place to track action taken to make improvements in patient care or the hospice's performance. During the interview with the Director of Nursing she stated, "I have been so worried with all those audits and everything else that I haven't had time for anything else especially anything in that notebook." During a joint review of the hospice QAPI program and interview with the Director of Nursing on 11/14/2023 it was confirmed that she was appointed by the governing body to oversee the hospice QAPI program. During review of documents that the DON supplied associated with the QAPI program, there was no evidence that the program addresses efforts or had set priorities for improved quality of care and patient safety. There were no active performance improvement plans in place to track action taken to make improvements in patient care or the hospice's performance. During the interview with the Director of Nursing she stated, "I have been so worried with all those audits and everything else that I haven't had time for anything else especially anything in that notebook."

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. Each patient’s record includes, at a minimum: The initial plan of care, updated plans of care, initial assessment, comprehensive assessment, updated comprehensive assessments, and clinical notes including the care and services provided; Signed copies of the notice of patient rights and the hospice election statement; Responses to medications, symptom management, treatments, and services; Physician certification and recertification of terminal illness as required; and Physician orders. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This CONDITION was not met as evidenced by interview, document review, and clinical record review. The Governing Body failed to ensure that all records contained at a minimum initial and updated plans of care and updated comprehensive assessments and clinical notes [HSIM.3.I/L672] 25 % noncompliance; and failed to ensure that the Election of Hospice Benefit Statement included the effective date [HSIM.4.I/L679], 50% noncompliance. The cumulative effect of these deficiencies resulted in the hospice's inability to ensure the provision of quality of care for the Condition of Participation CFR 418.104: Clinical Records. The collective deficient practice illustrated systemic process failures that had the potential to affect all patients receiving hospice service from the agency.

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, the initial plan of care, updated plans of care, initial assessment, comprehensive assessment, updated comprehensive assessments, and clinical notes, including the care and services provided. This standard was not met, as evidenced by clinical record review and interview. 2 of 8 (25%) clinical records reviewed revealed that the hospice FAILED to ensure the clinical record included the clinical notes, including the care and services provided. A review of an audit tool developed as a part of the abatement plan for tracking nursing documentation showed results that all nursing documentation is current. However, the clinical record review identified that nursing notes were missing back to September 2023. During an interview on 11/14/2023, when the DON became aware that these visits would result in a deficiency, she stated, “It’s my fault. I should have told her not to document those visits until after you were gone. You would have never known then.” Clinical Record 8: The patient elected the hospice benefit on 4/25/2023 with a diagnosis of Cerebrovascular Disease. During the review of the clinical record, it was found that the RN did not ensure that documentation of the RN assessments was entered in a timely manner. On 11/13/2023, the RN entered assessments notes from visits made on 9/5/2023, 9/12/2023, 9/22/2023, 9/29/2023, 10/3/2023, 10/13/2023, 10/17/2023, 10/24/2023, 10/31/2023, and 11/7/2023. Clinical Record 5: The patient elected the hospice benefit on 8/25/2023 with a diagnosis of Acute Ischemic Heart Disease. On review of the clinical record, it was found that the RN and hospice aide did not ensure that the documentation of RN assessments and hospice aide visits was entered in a timely manner. On 11/13/2023, the RN entered assessment notes from visits made on 11/2/2023, 11/6/2023, 11/7/2023, 11/8/2023, 11/9/2023, and 11/9/2023. On 11/12/2023 the hospice aide entered visit notes from 10/31/2023, 11/1/2023, 11/2/2023, 11/3/2023, 11/6/2023, 11/8/2023, 11/9/2023, and 11/10/2023. In an interview with the Director of Nursing on 11/14/2023, she stated that there had been issues with some staff members not documenting in a timely manner. When the DON was asked for the documentation policy, she stated, "It's 48 hours". She was unable to produce the policy. She said that no disciplinary action had been taken against the repeat offenders. She stated, "The medical director does not allow it." She also stated, “If you put that in your report, I will lie and say you all just make up stories."

It is required that all entries in the patient record are legible, complete, and appropriately authenticated and dated by the person performing the care/service in accordance with hospice policy and with currently acceptable standards of practice. This standard was not met as evidenced by clinical record review and interview. 4 of 8 (50%) clinical records reviewed revealed that hospice FAILED to ensure that the Election of Hospice Benefit Statement was dated to indicate the effective date. Clinical Record 1: No effective date on election of benefits statement that was obtained on 10/10/2023. Clinical Record 2: No effective date on election of benefits statement that was obtained on 10/22/2022. Clinical Record 4: No effective date on election of benefits statement obtained on 10/23/2023. Clinical Record 7: No effective date on election of benefits statement obtained on 10/26/2023. In an interview and joint review of election of benefits statements with the Director of Nursing (DON) on 11/13/2023 she stated, "I have told the RN over and over to get put the date in that blank." She did not offer any other explanation. The DON

It is required that the written Patient Bill of Rights includes the right to have a confidential record per state and federal law and regulation. This standard was not met as evidenced by document review and interview which revealed the Governing Body failed to ensure that protection of patients rights to have a confidential clinical record as specified in federal, state, and local regulations. . Document 5: Agency policy, “MOI Policy 757 Electronic Medical Records – Individual Authentication of Users,” stated in part, “Every individual employed by agency shall have a unique identifier (or log-on ID) for use in logging onto agency information systems. This approach will make it possible to hold individual users accountable for their actions on-line and to implement access controls based on individual needs. Agency shall discipline employees who share their identifiers.” Document 6: Agency policy, “MOI Policy 712 Medical Record Information Confidentiality,” stated in part, “Agency will ensure that all client identifiable information in the clinical record will remain confidential and will be secured and controlled whether in hard copy, in electronic format or a combination of both in compliance with the Privacy Rule of the Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Agency will comply with Health Information Technology for Economic and Clinical Health Act (HITECH Act) Breach Notification Rules requiring a covered entity to notify an individual when unsecured PHI (Protected Health Information) has been improperly disclosed. Agency will comply with all HB 300 regulations and laws effective September 1, 2012. Client computer data will be accessed, entered, or retrieved by authorized persons only. Agency computers/laptops/iPad provided to employees will be locked with password access. Employee will utilize electronic signature passcode and log in authentication password to serve as the legal signature. These passwords are not to be shared with any person, written down or left in areas accessible to others. If Agency acknowledges there has been a violation of the HIPAA Privacy Rule or HB300, a risk assessment will be performed. Thorough documentation will be maintained after investigation of a disclosure to determine whether there is a breach. If Agency determines that a breach has occurred, the agency will notify the individual who is the subject of the breach without unreasonable delay, but no later than 30 days after discovery and the Security of the HHS concurrently.” Document 7: Agency policy, "MOI Policy 742 Sanctions for Privacy Violations," stated in part, 'Sanctions are applied against any staff member who violates hospice's privacy practices. Sanctions may include verbal warnings, written warnings, probationary periods or termination of employment. Any sanctions applied are documented and retained for a period of six years." During an interview on 10/26/2023, the Administrator stated, “I know she uses a scribe to log in to the EMR (electronic medical record) and document for her. I know because she told me she did.” The Administrator agreed, the scribe is not an employee of the hospice, nor do they have a business associate agreement or contract with the “scribe”. Additionally, during an interview on 10/26/2023, the Administrator stated, she has 3 patients on her caseload right now (including Record 1, 8. 9). which revealed the organization did not ensure that the hospice and its staff operate and provide care and services in compliance with local, state, and federal law and regulation related to the health and safety of patients.

It is required that the hospice Interdisciplinary Group, in consultation with the individual's attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review and interview. 4 of 9 (44%) clinical records reviewed revealed the organization did not ensure the Interdisciplinary Group (IDG) completed an initial psychosocial assessment no later than five calendar days after the election of hospice care. Clinical Record 1: The patient’s date of election was 2/23/2023. There was no documented evidence that an initial psychosocial assessment was completed no later than five days after the election of hospice care and have not been completed as of 10/25/2023. There was no documentation of attempts to contact the patient made by the Medical Social Worker and no patient or caregiver refusal of Medical Social Worker visits. Clinical Record 2: The patient’s date of election was 8/23/2022. There was no documented evidence that an initial psychosocial assessment was completed no later than five days after the election of hospice care and have not been completed as of 10/25/2023. There was no documentation of attempts to contact the patient made by the Medical Social Worker and no patient or caregiver refusal of Medical Social Worker visits. Clinical Record 6: The patient’s date of election was 10/11/2023. There was no documented evidence that an initial psychosocial assessment was completed no later than five days after the election of hospice care and have not been completed as of 10/25/2023. There was no documentation of attempts to contact the patient made by the Medical Social Worker and no patient or caregiver refusal of Medical Social Worker visits. Clinical Record 7: The patient’s date of election was 8/22/2023. There was no documented evidence that an initial psychosocial assessment was completed no later than five days after the election of hospice care and have not been completed as of 10/25/2023. There was no documentation of attempts to contact the patient made by the Medical Social Worker and no patient or caregiver refusal of Medical Social Worker visits. During a joint record review and an interview on 10/26/2023, the Administrator agreed there was no documented evidence that the initial psychosocial assessments were completed. Additionally, during interview on 10/26/2023, the Administrator stated, I don’t know why the social work visits aren’t there, she doesn’t document on time.

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 and interview. 2 of 9 (22%) clinical records reviewed revealed the organization did not ensure a medication reconciliation was completed and medications updated to the medication profile. Clinical Record 1: The patient’s date of election was 2/23/2023. The medication profile did not list any medications. There was documentation that Hydrocodone/APAP 10-325mg was filled on 3/8/2023, 6/12/2023 and 8/21/2023. There was no documented evidence the Hydrocodone/APAP was updated to the medication profile. Clinical Record 8: The patient’s date of election was 4/25/2023. The medication profile did not list any medications. There was documentation that Tramadol 50mg tablets were filled on 9/6/2023 and 5/2/2023, Levofloxacin was filled on 6/29/2023, Baclofen 10mg tablets were filled on 5/2/2023. There was no documented evidence the Tramadol, Levofloxacin, and Baclofen were updated to the medication profile. During a joint review of the record and an interview on 10/26/2023, the Administrator agreed, there was no documented evidence a medication reconciliation was completed, and medications updated to the medication profile. Additionally, during interview on 10/26/2023, the Administrator stated, it looks like the nurse is ordering refills from the pharmacy but not putting the meds on the profile.

It is required the hospice designates an Interdisciplinary Group (IDG) composed of individuals who work together to meet the physical, medical, psychosocial, emotional, and spiritual needs of the patient/family facing terminal illness and bereavement. IDG members provide the care and services offered by the organization, and the IDG, in its entirety, supervises the care and services provided to the patient and family. THIS IS A CMS CONDITION LEVEL DEFICIENCY. It is required the hospice designates an Interdisciplinary Group (IDG) composed of individuals who work together to meet the physical, medical, psychosocial, emotional, and spiritual needs of the patient/family facing terminal illness and bereavement. IDG members provide the care and services offered by the organization,

It is required that the hospice designates an Interdisciplinary Group (IDG) composed of individuals who work together to meet the physical, medical, psychosocial, emotional, and spiritual needs of the patient/family facing terminal illness and bereavement. IDG members provide the care and services offered by the organization. The IDG, in its entirety, supervises the care and services provided to the patient and family. This standard was not met as evidenced by clinical record review and interview. 9 of 9 (100%) clinical records reviewed revealed the Governing Body did not ensure the IDG, in it’s entirety, provided and documented evidence of supervision and coordination of hospice care and services provided to the patient and family. Clinical Record 1: The patient’s date of election was 2/23/2023. There was no documentation by the Registered Nurse, Social Worker, Chaplain, or Medical Director documenting a review of the Plan of Care. There was no documented evidence that a plan of care was developed. There was no documented evidence that the IDG supervised the care and services provided to the patient and family. Clinical Record 2: The patient’s date of election was 8/23/2022. There was no documentation by the Registered Nurse, Social Worker, Chaplain, or Medical Director documenting a review of the Plan of Care. There was no documented evidence that a plan of care was developed. There was no documented evidence that the IDG supervised the care and services provided to the patient and family. Clinical Record 3: The patient’s date of election was 5/4/2021. There was no documentation by the Registered Nurse, Social Worker, Chaplain, or Medical Director documenting a review of the Plan of Care. There was no documented evidence that a plan of care was developed. There was no documented evidence that the IDG supervised the care and services provided to the patient and family. Clinical Record 4: The patient’s date of election was 9/10/2022. There was no documentation by the Registered Nurse, Social Worker, Chaplain, or Medical Director documenting a review of the Plan of Care. There was no documented evidence that a plan of care was developed. There was no documented evidence that the IDG supervised the care and services provided to the patient and family. Clinical Record 5: The patient’s date of election was 5/17/2022. There was no documentation by the Registered Nurse, Social Worker, Chaplain, or Medical Director documenting a review of the Plan of Care. There was no documented evidence that a plan of care was developed. There was no documented evidence that the IDG supervised the care and services provided to the patient and family. Clinical Record 6: The patient’s date of election was 10/11/2023. There was no documentation by the Registered Nurse, Social Worker, Chaplain, or Medical Director documenting a review of the Plan of Care. There was no documented evidence that a plan of care was developed. There was no documented evidence that the IDG supervised the care and services provided to the patient and family. Clinical Record 7: The patient’s date of election was 8/22/2023. There was no documentation by the Registered Nurse, Social Worker, Chaplain, or Medical Director documenting a review of the Plan of Care. There was no documented evidence that a plan of care was developed. There was no documented evidence that the IDG supervised the care and services provided to the patient and family. Clinical Record 8: The patient’s date of election was 4/25/2023. There was no documentation by the Registered Nurse, Social Worker, Chaplain, or Medical Director documenting a review of the Plan of Care. There was no documented evidence that a plan of care was developed. There was no documented evidence that the IDG supervised the care and services provided to the patient and family. Clinical Record 9: The patient’s date of election was 8/25/2023. There was no documentation by the Registered Nurse, Social Worker, Chaplain, or Medical Director documenting a review of the Plan of Care. There was no documented evidence that a plan of care was developed. There was no documented evidence that the IDG supervised the care and services provided to the patient and family. During a joint review of the record and an interview on 10/26/2023, the Administrator agreed there was no documented evidence the IDG supervised and coordinated hospice care and services provided to the patient and family. Additionally, during interview on 10/26/2023, the Administrator stated, “we don’t require them sign in or complete any documentation of IDG.”

It is required that the hospice designates a registered nurse member of the IDG to provide coordination of care; ensure continuous assessment of each patient’s and family’s needs; ensure the implementation of the interdisciplinary plan of care. This standard was not met as evidenced by clinical record review, document review and interview. 9 of 9 (100%) clinical records reviewed revealed the organization did not ensure a Registered Nurse was designated to provide coordination of care and to ensure continuous assessment of each patient’s and family’s needs and implementation of the interdisciplinary plan of care. Document 2: Agency policy, “RN Case Management Role,” stated in part, “Nursing needs are reassessed frequently and the IDT POC updated and changed as needed.” Clinical Record 1: The patient’s date of election was 2/23/2023. There was no documented evidence that the RN ensured the implementation of the interdisciplinary plan of care. There was no documented evidence that the plan of care was developed. Clinical Record 2: The patient’s date of election was 8/23/2022. There was no documented evidence that the RN ensured the implementation of the interdisciplinary plan of care. There was no documented evidence that the plan of care was developed. Clinical Record 3: The patient’s date of election was 5/4/2021. There was no documented evidence that the RN ensured the implementation of the interdisciplinary plan of care. There was no documented evidence that the plan of care was developed. Clinical Record 4: The patient’s date of election was 9/10/2022. There was no documented evidence that the RN ensured the implementation of the interdisciplinary plan of care. There was no documented evidence that the plan of care was developed. Clinical Record 5: The patient’s date of election was 5/17/2022. There was no documented evidence that the RN ensured the implementation of the interdisciplinary plan of care. There was no documented evidence that the plan of care was developed. Clinical Record 6: The patient’s date of election was 10/11/2023. There was no documented evidence that the RN ensured the implementation of the interdisciplinary plan of care. There was no documented evidence that the plan of care was developed. Clinical Record 7: The patient’s date of election was 8/22/2023. There was no documented evidence that the RN ensured the implementation of the interdisciplinary plan of care. There was no documented evidence that the plan of care was developed. Clinical Record 8: The patient’s date of election was 4/25/2023. There was no documented evidence that the RN ensured the implementation of the interdisciplinary plan of care. There was no documented evidence that the plan of care was developed. Clinical Record 9: The patient’s date of election was 8/25/2023. There was no documented evidence that the RN ensured the implementation of the interdisciplinary plan of care. There was no documented evidence that the plan of care was developed. During a joint review of the record and an interview on 10/26/2023, the Administrator agreed there was no documented evidence that a Registered Nurse coordinated care and implemented a Plan of Care.

It is required that the hospice designates a registered nurse member of the IDG to: provide coordination of care; ensure continuous assessment of each patient’s and family’s needs; 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 clinical record review and interview. 6 of 9 (67%) clinical records reviewed revealed the organization did not ensure hospice care and services provided to patients and families followed 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. Clinical Record 1: The patient’s date of election was 2/23/2023. A physician’s order on 2/23/2023 ordered social worker 1 visit monthly. There was no documented evidence social work visits were made 1 x monthly between 2/23/2023-10/25/2023. A physician’s order on 2/23/2023 ordered RN (registered nurse) 1 visit weekly. The last nursing visit was documented was 9/27/2023. There was no documented evidence nursing visits were made 1 x weekly between 9/28/2023-10/24/2023. Clinical Record 2: The patient’s date of election was 8/23/2022. A physician’s order on 8/23/2022 ordered social worker 1 visit monthly. There was no documented evidence social work visits were made 1 x monthly between 8/23/2022-10/25/2023. The visit frequency ordered nursing visits 1 visit weekly. The last nursing visit documented was 10/10/2023. There was no documented evidence nursing visits were made 1 x weekly between 10/15/2023-10/21/2023. Clinical Record 3: The patient’s date of election was 5/4/2021. The visit frequency ordered nursing visits 1 visit weekly. The last nursing visit documented was 10/10/2023. There was no documented evidence nursing visits were made 1 x weekly between 10/15/2023-10/21/2023. Clinical Record 6: The patient’s date of election was 10/11/2023. Upon the election of hospice care, patient/caregiver accepted social work services. A physician’s order on 10/11/2023 ordered social worker 1 visit monthly. There was no documented evidence that an initial psychosocial assessment was completed. There was no documentation of attempts to contact the patient made by the Medical Social Worker and no patient or caregiver refusal of Medical Social Worker visits. There was no documented evidence social work services were provided. Clinical Record 7: The patient’s date of election was 8/22/2023. Upon the election of hospice care, patient/caregiver accepted social work services. A physician’s order effective 8/22/2023 ordered social worker 2 visits monthly. There was no documented evidence that an initial psychosocial assessment was completed. There was no documentation of attempts to contact the patient made by the Medical Social Worker and no patient or caregiver refusal of Medical Social Worker visits. There was no documented evidence social work visits were made 2 x monthly between 8/22/2023-10/25/2023. Clinical Record 8: The patient’s date of election was 4/25/2023. Upon the election of hospice care, patient/caregiver accepted social work services. The initial social worker assessment on 4/28/2023 documented social work visits will be made one time per month to provide social and emotional support to the family. There was no documented evidence social work visits were made once time monthly between 5/1/2023-10/25/2023. A physician’s order on 4/25/2023 ordered nursing visit 1 visit weekly. The last nursing visit documented was 9/26/2023. There was no documented evidence nursing visits were made 1 x weekly between 10/1/2023-10/24/2023. During a joint review of the record and an interview on 10/26/2023, the Administrator agreed there was no documented evidence the hospice care and services were provided based on needs identified. Additionally, during interview on 10/26/2023, the Administrator stated, “I know the nurse is visiting, but she is not documenting on time, I don’t know why the social work visits aren’t there, she doesn’t document on time either.”

It is required that each patient’s individualized written plan of care reflects patient and family goals; identifies planned interventions based on problems identified in the initial and updated comprehensive assessments; and includes all services necessary for the palliation and management of the terminal illness. This standard was not met as evidenced by clinical record review, document review and interview. 9 of 9 (100%) clinical records reviewed revealed the Governing Body did not ensure the Interdisciplinary Group (IDG) prepared a written plan of care for each patient as identified in the comprehensive assessments in consultation with the patient’s attending physician. Document 1: Agency policy, “MOI Policy 727 Timelines,” stated in part, “The IDT POC will be developed within 15 days of the start of care and updated at least every 15 days.” Clinical Record 1: The patient’s date of election was 2/23/2023. There was no documented evidence that a plan of care was developed. Clinical Record 2: The patient’s date of election was 8/23/2022. There was no documented evidence that a plan of care was developed. Clinical Record 3: The patient’s date of election was 5/4/2021. There was no documented evidence that a plan of care was developed. Clinical Record 4: The patient’s date of election was 9/10/2022. There was no documented evidence that a plan of care was developed. Clinical Record 5: The patient’s date of election was 5/17/2022. There was no documented evidence that a plan of care was developed. Clinical Record 6: The patient’s date of election was 10/11/2023. There was no documented evidence that a plan of care was developed. Clinical Record 7: The patient’s date of election was 8/22/2023. There was no documented evidence that a plan of care was developed. Clinical Record 8: The patient’s date of election was 4/25/2023. There was no documented evidence that a plan of care was developed. Clinical Record 9: The patient’s date of election was 8/25/2023. There was no documented evidence that a plan of care was developed. During a joint record review and an interview on 10/26/2023, the Administrator agreed there was no documented evidence of a plan of care in the clinical records. Additionally, during interview on 10/26/2023, the Administrator stated, “I did not know it was required or how to enter them before today.”

It is required that the Interdisciplinary Group, in collaboration with the individual's attending physician (if any), reviews, revises, and documents the individualized care plan as frequently as the patient's condition requires; but no less frequently than every 15 calendar days. This standard was not met as evidenced by clinical record review and interview. 9 of 9 (100%) clinical records reviewed revealed the organization did not ensure the individualized plan of care was reviewed and documented by the IDG no less frequently than every 15 calendar days. Clinical Record 1: The patient’s date of election was 2/23/2023. There was no documented evidence that the IDG reviewed, revised, and documented the individualized care plan. There was no documented evidence that a plan of care was developed. Additionally, there was no documented evidence of an IDG meeting between 4/21/2023-10/26/2023. Clinical Record 2: The patient’s date of election was 8/23/2022. There was no documented evidence that the IDG reviewed, revised, and documented the individualized care plan. There was no documented evidence that a plan of care was developed. Additionally, there was no documented evidence of an IDG meeting between 11/18/2022-1/25/2023. Clinical Record 3: The patient’s date of election was 5/4/2021. There was no documented evidence that the IDG reviewed, revised, and documented the individualized care plan. There was no documented evidence that a plan of care was developed. Additionally, there was no documented evidence of an IDG meeting between 11/18/2022-1/11/2023. Clinical Record 4: The patient’s date of election was 9/10/2022. There was no documented evidence that the IDG reviewed, revised, and documented the individualized care plan. There was no documented evidence that a plan of care was developed. Additionally, there was no documented evidence of an IDG note between 11/18/2022-1/25/2023. Clinical Record 5: The patient’s date of election was 5/17/2022. There was no documented evidence that the IDG reviewed, revised, and documented the individualized care plan. There was no documented evidence that a plan of care was developed. Additionally, there was no documented evidence of an IDG note between 2/24/2023-4/5/2023. Clinical Record 6: The patient’s date of election was 10/11/2023. There was no documented evidence that the IDG reviewed, revised, and documented the individualized care plan. There was no documented evidence that a plan of care was developed. Clinical Record 7: The patient’s date of election was 8/22/2023. There was no documented evidence that the IDG reviewed, revised, and documented the individualized care plan. There was no documented evidence that a plan of care was developed. Additionally, there was no documented evidence of an IDG note between 9/8/2023-10/4/2023. Clinical Record 8: The patient’s date of election was 4/25/2023. There was no documented evidence that the IDG reviewed, revised, and documented the individualized care plan. There was no documented evidence that a plan of care was developed. Clinical Record 9: The patient’s date of election was 8/25/2023. There was no documented evidence that the IDG reviewed, revised, and documented the individualized care plan. There was no documented evidence that a plan of care was developed. During a joint review of the record and an interview on 10/26/2023, the Administrator agreed there was no documented evidence the IDG met to review the Plan of Care no less frequently than every 15 calendar days. Additionally, the Administrator agreed, there was no plan of care developed to review.

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as hand hygiene. This standard was not met as evidenced by document review, interview and observation. 2 of 2 (100%) home visit observations revealed the organization did not ensure the staff followed the hand hygiene policy. Document 3: Agency policy, “Hand Hygiene ICP Policy 806,” stated in part, “Decontaminate hands after removing gloves.” Home Visit 1: During the home visit (Clinical Record 7) on 10/26/2023 with the Registered Nurse (RN) (Staff 9), the RN was observed donning gloves, removing soiled wound dressing from left heel, removed gloves, donned new gloves, continued wound care. The RN was observed donning gloves, removing soiled wound dressing from left ischium, removed gloves, donned new gloves, continued wound care. The RN was observed removing gloves, returning wound supplies to the facility wound care at the door of the patient’s room. The RN was not observed performing hand hygiene after removing gloves. Home Visit 2: During the home visit (Clinical Record 9) on 10/26/2023 with the Hospice Aide (HA) (Staff 6), the HA was observed donning gloves, emptying urinal into toilet, removed gloves, donned new gloves, began bathing the patient with a washcloth, washed peri area with wet wipe, removed gloves, donned new gloves, continued with dressing the patient. The HA was not observed performing hand hygiene after removing gloves. During an interview on 10/26/2023, the Administrator agreed the staff did not follow the hand hygiene policy.

It is required that medical social services are provided based on a psychosocial assessment, according to the patient’s and family’s needs and acceptance of these services, per the plan of care, under the direction of a physician. The psychosocial assessment addresses the patient’s and the family’s adjustment to the terminal illness, the social and emotional factors related to the terminal illness, the presence or absence of adequate coping mechanisms, family dynamics and communication patterns, financial resources and any constraints, the caregiver’s ability to function effectively, obstacles and risk factors that may affect compliance with the plan of care, family support systems to facilitate coping with end-of-life issues. The psychosocial assessment is revised as new information is acquired and as progress toward goals is made. This standard was not met as evidenced by clinical record review and interview. 5 of 9 (56%) clinical records reviewed revealed the organization did not ensure that medical social services were provided based on a psychosocial assessment, according to the patient’s and family’s needs and acceptance of these services. Clinical Record 1: The patient’s date of election was 2/23/2023. Upon the election of hospice care, patient/caregiver accepted social work services. A physician’s order on 2/23/2023 ordered social worker 1 visit monthly. There was no documented evidence that an initial psychosocial assessment was completed. There was no documentation of attempts to contact the patient made by the Medical Social Worker and no patient or caregiver refusal of Medical Social Worker visits. There was no documented evidence social work visits were made 1 x monthly between 2/23/2023-10/25/2023. Clinical Record 2: The patient’s date of election was 8/23/2022. Upon the election of hospice care, patient/caregiver accepted social work services. A physician’s order on 8/23/2022 ordered social worker 1 visit monthly. There was no documented evidence that an initial psychosocial assessment was completed. There was no documentation of attempts to contact the patient made by the Medical Social Worker and no patient or caregiver refusal of Medical Social Worker visits. There was no documented evidence social work visits were made 1 x monthly between 8/23/2022-10/25/2023. Clinical Record 6: The patient’s date of election was 10/11/2023. Upon the election of hospice care, patient/caregiver accepted social work services. A physician’s order on 10/11/2023 ordered social worker 1 visit monthly. There was no documented evidence that an initial psychosocial assessment was completed. There was no documentation of attempts to contact the patient made by the Medical Social Worker and no patient or caregiver refusal of Medical Social Worker visits. There was no documented evidence social work services were provided. Clinical Record 7: The patient’s date of election was 8/22/2023. Upon the election of hospice care, patient/caregiver accepted social work services. A physician’s order effective 8/22/2023 ordered social worker 2 visits monthly. There was no documented evidence that an initial psychosocial assessment was completed. There was no documentation of attempts to contact the patient made by the Medical Social Worker and no patient or caregiver refusal of Medical Social Worker visits. There was no documented evidence social work visits were made 2 x monthly between 8/22/2023-10/25/2023. Clinical Record 8: The patient’s date of election was 4/25/2023. Upon the election of hospice care, patient/caregiver accepted social work services. The initial social worker assessment on 4/28/2023 documented social work visits will be made one time per month to provide social and emotional support to the family. There was no documented evidence social work visits were made once time monthly between 5/1/2023-10/25/2023. During a joint record review and an interview on 10/26/2023, the Administrator agreed there was no documented evidence that social work services were provided during the times identified. Additionally, during interview on 10/26/2023, the Administrator stated, I don’t know why the social work visits aren’t there, she doesn’t document on time.

It is required that the hospice organizes, manages, and administers its resources to provide the hospice care and services to patients, families, and caregivers necessary for the palliation and management of the terminal illness and related conditions. THIS IS A CONDITION LEVEL DEFICIENCY. This CONDITION was not met as evidenced by interview, document review, clinical records review, personnel record review, and interview which revealed a failure by the Governing Body and the Administrator/DON to ensure the hospice managed and administered its resources to provide hospice services to patients, caregivers, and families for the palliation and management of terminal illness and related conditions. The governing body failed to assume full legal authority and responsibility for the management of the hospice, the provision of all hospice services, its fiscal operations, and continuous quality assessment and performance improvement activity HSLG.2.I/L651]. The cumulative effect and scope of this deficiency could negatively impact the agency's ability to provide safe, quality care that meets the needs of patients, families, and caregivers for the palliation and management of the terminal illness and related conditions.

It is required that the hospice’s governance (or designated person(s) so functioning) assumes full legal authority and responsibility for the organization’s overall management and operation and provision of care and services. This standard was not met as evidenced by clinical record review, interview, and document review. 9 of 9 (100%) clinical records reviewed revealed the governing body did not provide oversight and management of hospice operations to ensure the provision of care and services followed individualized plans of care and physician orders and were in compliance with state and federal regulations. 9 of 9 (100%) clinical records reviewed revealed the organization did not ensure a hospice plan of care was developed. [Records 1, 2, 3, 4, 5, 6, 7, 8, and 9] 7 of 9 (78%) clinical records reviewed revealed the organization did not ensure the patient’s record included physician’s orders. [Records 1, 2, 3, 4, 6, 7, and 8] 2 of 9 (22%) clinical records reviewed revealed that there was no documented evidence of a medication reconciliation or drug regimen review performed [Records 1, and 8]. 9 of 9 (100%) clinical records reviewed revealed the organization did not ensure the patient’s record includes the initial plan of care, updated plans of care and clinical notes. [Records 1, 2, 3, 4, 5, 6, 7, 8, and 9] 3 of 9 (100%) clinical records reviewed revealed the organization did not ensure that the hospice and its staff operate and provide care and services in compliance with local, state, and federal law and regulation related to the health and safety of patients. [Records 1, 8, and 9] 6 of 9 (67%) clinical records reviewed revealed the organization did not ensure hospice care and services provided to patients and families followed 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. [Records 1, 2, 3, 6, 7, and 8] Document 8: Agency policy, "D&S Policy 303 Administrator Role," stated in part, "Administrator Administrator will assume overall responsibility and authority for administrative and leadership functions, supervision of the established organizational plan. Agency defines the responsibilities of the Administrator to include, but not be limited to: plan, organize, direct, supervise and evaluate operations to ensure the provision of adequate and appropriate care and services; ensure agency is in compliance with all applicable federal, state, and local laws and regulatory agencies; assure appropriate staff supervision during all operating hours; ensure documentation of services is accurate and timely; responsibility and authority for the administrative and leadership functions of the agency. 9 of 9 (100%) clinical records reviewed revealed the organization did not ensure a hospice plan of care was developed. [Records 1, 2, 3, 4, 5, 6, 7, 8, and 9] 7 of 9 (78%) clinical records reviewed revealed the organization did not ensure the patient’s record included physician’s orders. [Records 1, 2, 3, 4, 6, 7, and 8] 2 of 9 (33%) clinical records reviewed revealed that there was no documented evidence of a medication reconciliation or drug regimen review performed [Records 1, and 8]. 9 of 9 (100%) clinical records reviewed revealed the organization did not ensure the patient’s record includes the initial plan of care, updated plans of care and clinical notes. [Records 1, 2, 3, 4, 5, 6, 7, 8, and 9] 3 of 9 (100%) clinical records reviewed revealed the organization did not ensure that the hospice and its staff operate and provide care and services in compliance with local, state, and federal law and regulation related to the health and safety of patients. [Records 1, 8, and 9] 6 of 9 (67%) clinical records reviewed revealed the organization did not ensure hospice care and services provided to patients and families followed 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. [Records 1, 2, 3, 6, 7, and 8]

It is required that the hospice medical director, physician employees, and contracted physician(s), in conjunction with the patient’s attending physician, are responsible for the palliation and management of the terminal illness as well as conditions related to the terminal illness. If the attending physician is unavailable, the medical director, contracted physician, and/or hospice physician employee is responsible for meeting the medical needs of the patient. THIS IS A CMS CONDITION LEVEL FINDING. This CONDITION was not met as evidenced by clinical record review and interview; which revealed the Governing Body's failure to ensure the hospice medical director assumed responsibility for the medical component of the hospice's patient care program [HCPC.4.I/L669]. The cumulative effect of these deficiencies resulted in the hospice's inability to ensure the provision of quality of care for the Condition of Participation CFR 418.102: Medical Director. The cumulative effect of this deficiency could result in the physician providing oversight of the patients, not having a full understanding of their needs and/or potential changes in their condition negatively impaction patient quality outcomes, injury and death.

It is required that the medical director or physician designee had responsibility for the medical component of the hospice’s patient care program. This standard was not met as evidenced by clinical record review, document review and interview which revealed the medical director or a designee assumed the responsibility for the medical component of the delivery of hospice services as consistent with the agency's policy. 9 of 9 (100%) clinical records reviewed revealed the organization did not ensure physician participation IDG review of the plan of care and medications no less frequently than every 15 calendar days. [Records 1, 2, 3, 4, 5, 6, 7, 8, and 9] 9 of 9 (100%) clinical records reviewed revealed the organization did not ensure the IDG supervised the care and services provided to the patient and family. [Records 1, 2, 3, 4, 5, 6, 7, 8, and 9] 9 of 9 (100%) clinical records reviewed revealed the organization did not ensure a hospice plan of care was developed. [Records 1, 2, 3, 4, 5, 6, 7, 8, and 9] 7 of 9 (78%) clinical records reviewed revealed the organization did not ensure the patient’s record includes physician’s orders. [Records 1, 2, 3, 4, 6, 7, and 8.] Document 1: Agency policy, “MOI Policy 727 Timelines,” stated in part, “The IDT POC will be developed within 15 days of the start of care and updated at least every 15 days. Physician signatures are obtained on IDT Plan of Care at the Interdisciplinary team meeting.” Document 6: Agency policy, “Medical Director & Physician’s Role,” stated in part, “The Medical Director is employed by the hospice to have overall responsibility for the medical direction of the care and treatment rendered by the hospice agency. The Medical Director shall attend Hospice Interdisciplinary Team conferences where the active care of all clients is reviewed. The Medical Director shall coordinate the medical portion of the client care plan with the hospice nurse, participate in the overall development of the plan and sign the care plan as appropriate for staff implementation. To join agency in promotion of safety and quality of care including medication reconciliation.” Clinical Record 1: The patient’s date of election was 2/23/2023. There was no documented evidence that a plan of care was developed. There was no documentation by the Registered Nurse, Social Worker, Chaplain, or Medical Director documenting a review of the Plan of Care. There was no documented evidence that the IDG supervised the care and services provided to the patient and family. Additionally, there was no documented evidence of an IDG meeting between 4/21/2023-10/26/2023. The medication profile did not list any medications. There was no documented evidence of any physician orders for medications. There was documentation that Hydrocodone/APAP 10-325mg was filled on 3/8/2023, 6/12/2023 and 8/21/2023. There was no documented evidence of a physician order for the Hydrocodone/APAP. Clinical Record 2: The patient’s date of election was 8/23/2022. There was no documented evidence that a plan of care was developed. There was no documentation by the Registered Nurse, Social Worker, Chaplain, or Medical Director documenting a review of the Plan of Care. There was no documented evidence that the IDG supervised the care and services provided to the patient and family. Additionally, there was no documented evidence of an IDG meeting between 11/18/2022-1/25/2023. The medication profile listed Olanzapine 5mg daily, Methocarbamol 500mg 2 tabs 4 x day, Hydroxyzine 50mg at bedtime. There was no documented evidence of a physician order for the Olanzapine, Methocarbamol, Hydroxyzine, and Olanzapine. Clinical Record 3: The patient’s date of election was 5/4/2021. There was no documented evidence that a plan of care was developed. There was no documentation by the Registered Nurse, Social Worker, Chaplain, or Medical Director documenting a review of the Plan of Care. There was no documented evidence that the IDG supervised the care and services provided to the patient and family. Additionally, there was no documented evidence of an IDG meeting between 11/18/2022-1/11/2023. The medication profile listed Lorazepam 2mg/ml 0.25-1ml as needed. There was no documented evidence of a physician order for the Lorazepam. Clinical Record 4: The patient’s date of election was 9/10/2022. There was no documented evidence that a plan of care was developed. There was no documentation by the Registered Nurse, Social Worker, Chaplain, or Medical Director documenting a review of the Plan of Care. There was no documented evidence that the IDG supervised the care and services provided to the patient and family. Additionally, there was no documented evidence of an IDG note between 11/18/2022-1/25/2023. The medication profile listed Norco 10-325 1 tablet po bid, Amlodipine 5mg 1 tablet every day. There was no documented evidence of a physician order for the Norco and Amlodipine. Clinical Record 5: The patient’s date of election was 5/17/2022. There was no documented evidence that a plan of care was developed. There was no documentation by the Registered Nurse, Social Worker, Chaplain, or Medical Director documenting a review of the Plan of Care. There was no documented evidence that the IDG supervised the care and services provided to the patient and family. Additionally, there was no documented evidence of an IDG note between 2/24/2023-4/5/2023. Clinical Record 6: The patient’s date of election was 10/11/2023. There was no documented evidence that a plan of care was developed. There was no documentation by the Registered Nurse, Social Worker, Chaplain, or Medical Director documenting a review of the Plan of Care. There was no documented evidence that the IDG supervised the care and services provided to the patient and family. The medication profile listed Gabapentin 100mg BID, Metformin 500mg BID, Risperidone 0.5mg every day, Lantus Solostart 100unit/ml 18-unit subcutaneous BID, and Eliquis 5mg BID. There was no documented evidence of a physician order for the Gabapentin, Metformin, Risperidone, Lantus Solostar and Eliquis. Clinical Record 7: The patient’s date of election was 8/22/2023. There was no documented evidence that a plan of care was developed. There was no documentation by the Registered Nurse, Social Worker, Chaplain, or Medical Director documenting a review of the Plan of Care. There was no documented evidence that the IDG supervised the care and services provided to the patient and family. Additionally, there was no documented evidence of an IDG note between 9/8/2023-10/4/2023. The medication profile listed Atorvastatin 40mg every day. There was no documented evidence of any physician order for the Atorvastatin or other medications listed on the medication profile. Clinical Record 8: The patient’s date of election was 4/25/2023. There was no documented evidence that a plan of care was developed. There was no documentation by the Registered Nurse, Social Worker, Chaplain, or Medical Director documenting a review of the Plan of Care. There was no documented evidence that the IDG supervised the care and services provided to the patient and family. The medication profile did not list any medications. There was no documented evidence of any physician orders for medications. There was documentation that Tramadol 50mg tablets were filled on 9/6/2023 and 5/2/2023, Levofloxacin was filled on 6/29/2023, Baclofen 10mg tablets were filled on 5/2/2023. There was no documented evidence of a physician order for the Tramadol, Levofloxacin, and Baclofen. Clinical Record 9: The patient’s date of election was 8/25/2023. There was no documented evidence that a plan of care was developed. There was no documentation by the Registered Nurse, Social Worker, Chaplain, or Medical Director documenting a review of the Plan of Care. There was no documented evidence that the IDG supervised the care and services provided to the patient and family. During a joint review of the record and an interview on 10/26/2023, the Hospice Medical Director stated, he only reviews medications if they are in the medication profile. Additionally, during interview on 10/26/2023, the Hospice Medical Director stated, “I do not put in narcotic orders, only the alternate does.”

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. Each patient’s record includes, at a minimum: The initial plan of care, updated plans of care, initial assessment, comprehensive assessment, updated comprehensive assessments, and clinical notes including the care and services provided; Signed copies of the notice of patient rights and the hospice election statement; Responses to medications, symptom management, treatments, and services; Physician certification and recertification of terminal illness as required; and Physician orders. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This CONDITION was not met as evidenced by interview, document review, and clinical record review. The Governing Body failed to ensure that all records contained at a minimum initial and updated plans of care and updated comprehensive assessments [HSIM.3.I/L672]; failure to ensure the clinical records contained physician orders [HSIM.3.I/L678]; and that the patients' clinical records were safeguarded from alteration [HSIM.5.I/L680]. The cumulative effect of these deficiencies resulted in the hospice's inability to ensure the provision of quality of care for the Condition of Participation CFR 418.104: Clinical Records. The collective deficient practice illustrated systemic process failures that had the potential to affect all patients receiving hospice service from the agency.

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, the initial plan of care, updated plans of care, initial assessment, comprehensive assessment, updated comprehensive assessments, and clinical notes including the care and services provided. This standard was not met as evidenced by clinical record review and interview which revealed the Governing Body's failure to ensure the patient's record included he initial plan of care, updated plans of care, an clinical notes. 4 of 9 (44%) clinical records reviewed revealed the organization did not ensure the clinical record included the initial psychosocial assessment. 5 of 9 (56%) clinical records reviewed revealed the organization did not ensure the clinical record included the clinical notes including the care and services provided. 9 of 9 (100%) clinical records reviewed revealed the organization did not ensure the clinical record included the initial and updated plan of care. Clinical Record 1: The patient’s date of election was 2/23/2023. There was no documented evidence that a plan of care was developed. There was no documented evidence that an initial psychosocial assessment was completed. There was no documented evidence social work visits were made 1 x monthly between 2/23/2023-10/25/2023. The last nursing visit was documented was 9/27/2023. There was no documented evidence nursing visits were made 1 x weekly for the weeks 10/1/2023-10/7/2023, 10/8/2023-10/14/2023, and 10/15/2023-10/21/2023 as ordered. Clinical Record 2: The patient’s date of election was 8/23/2022. There was no documented evidence that a plan of care was developed. There was no documented evidence that an initial psychosocial assessment was completed. There was no documented evidence social work visits were made 1 x monthly between 8/23/2022-10/25/2023. The last nursing visit documented was 10/10/2023. There was no documented evidence nursing visits were made 1 x weekly for the week 10/15/2023-10/21/2023. Clinical Record 3: The patient’s date of election was 5/4/2021. There was no documented evidence that a plan of care was developed. The last nursing visit documented was 10/10/2023. The visit frequency ordered nursing visits 1 visit weekly. The last nursing visit documented was 10/10/2023. There was no documented evidence nursing visits were made 1 x weekly between 10/15/2023-10/21/2023. Clinical Record 4: The patient’s date of election was 9/10/2022. There was no documented evidence that a plan of care was developed. Clinical Record 5: The patient’s date of election was 5/17/2022. There was no documented evidence that a plan of care was developed. Clinical Record 6: The patient’s date of election was 10/11/2023. There was no documented evidence that a plan of care was developed. There was no documented evidence that an initial psychosocial assessment was completed. Clinical Record 7: The patient’s date of election was 8/22/2023. There was no documented evidence that a plan of care was developed. There was no documented evidence that an initial psychosocial assessment was completed. There was no documented evidence social work visits were made 2 x monthly between 8/22/2023-10/25/2023. Clinical Record 8: The patient’s date of election was 4/25/2023. There was no documented evidence that a plan of care was developed. There was no documented evidence social work visits were made once time monthly between 5/1/2023-10/25/2023. The last nursing visit documented was 9/26/2023. There was no documented evidence nursing visits were made 1 x weekly between 10/1/2023-10/24/2023. Clinical Record 9: The patient’s date of election was 8/25/2023. There was no documented evidence that a plan of care was developed. During a joint record review and an interview on 10/26/2023, the Administrator agreed there was no documented evidence of a plan of care in the clinical records. Additionally, during interview on 10/26/2023, the Administrator stated, “I did not know it was required or how to enter them before today.” During interview on 10/26/2023, the Administrator stated, “I know the nurse is visiting, but she is not documenting on time, I don’t know why the social work visits aren’t there, she doesn’t document on time either.”

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum, physician orders. This standard was not met as evidenced by clinical record review and interview. 7 of 9 (78%) clinical records reviewed revealed the organization did not ensure the patient’s record includes physician’s orders. Clinical Record 1: The patient’s date of election was 2/23/2023. The medication profile did not list any medications. There was no documented evidence of any physician orders for medications. There was documentation that Hydrocodone/APAP 10-325mg was filled on 3/8/2023, 6/12/2023 and 8/21/2023. There was no documented evidence of a physician order for the Hydrocodone/APAP. Clinical Record 2: The patient’s date of election was 8/23/2022. The medication profile listed Olanzapine 5mg daily, Methocarbamol 500mg 2 tabs 4 x day, Hydroxyzine 50mg at bedtime. There was no documented evidence of a physician order for the Olanzapine, Methocarbamol, Hydroxyzine, and Olanzapine. Clinical Record 3: The patient’s date of election was 5/4/2021. The medication profile listed Lorazepam 2mg/ml 0.25-1ml as needed. There was no documented evidence of a physician order for the Lorazepam. Clinical Record 4: The patient’s date of election was 9/10/2022. The medication profile listed Norco 10-325 1 tablet po bid, Amlodipine 5mg 1 tablet every day. There was no documented evidence of a physician order for the Norco and Amlodipine. Clinical Record 6: The patient’s date of election was 10/11/2023. The medication profile listed Gabapentin 100mg BID, Metformin 500mg BID, Risperidone 0.5mg every day, Lantus Solostart 100unit/ml 18-unit subcutaneous BID, and Eliquis 5mg BID. There was no documented evidence of a physician order for the Gabapentin, Metformin, Risperidone, Lantus Solostar and Eliquis. Clinical Record 7: The patient’s date of election was 8/22/2023. The medication profile listed Atorvastatin 40mg every day. There was no documented evidence of any physician order for the Atorvastatin or other medications listed on the medication profile. Clinical Record 8: The patient’s date of election was 4/25/2023. The medication profile did not list any medications. There was no documented evidence of any physician orders for medications. There was documentation that Tramadol 50mg tablets were filled on 9/6/2023 and 5/2/2023, Levofloxacin was filled on 6/29/2023, Baclofen 10mg tablets were filled on 5/2/2023. There was no documented evidence of a physician order for the Tramadol, Levofloxacin, and Baclofen. During a joint review of the record and an interview on 10/26/2023, the Administrator agreed, there was no documented evidence of physician’s orders for the medications identified.

It is required that the clinical patient record, its content, and the information it contains is safeguarded against loss or unauthorized use. The hospice addresses leaving and protecting patient record information in the home, prevention of physical or electronic altering of the patient record. The hospice complies with state and federal law and regulation addressing privacy, including the Health Insurance and Portability and Accountability Act (HIPAA) and the Health Information Technology for Economic and Clinical Health Act (HITECH). This standard was not met as evidenced by document review, clinical record review, and interview, which revealed the Governing Body failed to ensure the clinical patient record, its content, and the information it contains was safeguarded against loss or unauthorized use. Document 5: Agency policy, “MOI Policy 757 Electronic Medical Records – Individual Authentication of Users,” stated in part, “Every individual employed by agency shall have a unique identifier (or log-on ID) for use in logging onto agency information systems. This approach will make it possible to hold individual users accountable for their actions on-line and to implement access controls based on individual needs. Agency shall discipline employees who share their identifiers.” Document 6: Agency policy, “MOI Policy 712 Medical Record Information Confidentiality,” stated in part, “Agency will ensure that all client identifiable information in the clinical record will remain confidential and will be secured and controlled whether in hard copy, in electronic format or a combination of both in compliance with the Privacy Rule of the Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Agency will comply with Health Information Technology for Economic and Clinical Health Act (HITECH Act) Breach Notification Rules requiring a covered entity to notify an individual when unsecured PHI (Protected Health Information) has been improperly disclosed. Agency will comply with all HB 300 regulations and laws effective September 1, 2012. Client computer data will be accessed, entered, or retrieved by authorized persons only. Agency computers/laptops/iPad provided to employees will be locked with password access. Employee will utilize electronic signature passcode and log in authentication password to serve as the legal signature. These passwords are not to be shared with any person, written down or left in areas accessible to others. If Agency acknowledges there has been a violation of the HIPAA Privacy Rule or HB300, a risk assessment will be performed. Thorough documentation will be maintained after investigation of a disclosure to determine whether there is a breach. If Agency determines that a breach has occurred, the agency will notify the individual who is the subject of the breach without unreasonable delay, but no later than 30 days after discovery and the Security of the HHS concurrently.” Document 7: Agency policy, "MOI Policy 742 Sanctions for Privacy Violations," stated in part, 'Sanctions are applied against any staff member who violates hospice's privacy practices. Sanctions may include verbal warnings, written warnings, probationary periods or termination of employment. Any sanctions applied are documented and retained for a period of six years." During an interview on 10/25/2023, the late documentation by the Alternate Administrator/Alternate DON/RN was discussed with the Administrator. The Administrator stated, she’s always been like that, documenting late or never, it was brought to our attention earlier this year around August that her notes were copy pasted with a change in vital signs, someone mentioned she used a scribe to log in and document for her and just change around the vital signs. Additionally, during an interview on 10/25/2023, the Administrator stated, “the CEO knows it happened. I wanted to let her go but the CEO did not, nothing was done, she took a break” but returned to using the access to enter documentation. During an interview on 10/26/2023, the Administrator stated, “I know she uses a scribe to log in to the EMR (electronic medical record) and document for her. I know because she told me she did.” The Administrator agreed, the scribe is not an employee of the hospice, nor do they have a business associate agreement or contract with the “scribe”. Additionally, during an interview on 10/26/2023, the Administrator stated, she has 4 patients on her caseload right now (including Clinical Records #: 8 and 9). which revealed the organization did not ensure the clinical patient record, its content, and the information it contains was safeguarded against loss or unauthorized use.

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 medication information. This standard was not met as evidenced by clinical record review, interview and observation. 1 of 1 (100%) clinical records of patients residing in a SNF reviewed during a home visit revealed the organization did not ensure the Interdisciplinary Group (IDG) provided the SNF with the most recent hospice plan of care and hospice medication information. Clinical Record 7: The patient’s date of election was 8/22/2023. There was no documented evidence that a plan of care was developed. Home Visit 1: During the home visit (Clinical Record 7) on 10/26/2023 with the Registered Nurse (RN) (Staff 9), the patient’s hospice binder at the SNF was reviewed. There was no documented evidence of a plan of care or medication list in the binder. The RN (Staff 9) reviewed the binder and was unable to locate a plan of care or medication list. During a joint record review and an interview on 10/26/2023, the Administrator agreed there was no documented evidence of a plan of care in the clinical records.

It is required that the hospice and its staff operate and provide care and services: in compliance with local, state, and federal law and regulation related to the health and safety of patients. THIS IS A CONDITION LEVEL DEFICIENCY. This CONDITION was not met as evidenced by interview, and document review which revealed the Governing Body's failure to ensure the hospice and its staff operated and provided care and services in compliance with local, state, and federal law and regulation related to the health and safety of patients and protection of protected health information [HPFC.2.D/L516]. The cumulative effect of these deficiencies could negatively impact the organization’s ability to provide confidential, safe and effective quality patient care services in accordance with 45 CFR Parts 160 and 164.

It is required that the hospice Interdisciplinary Group, in consultation with the individual's attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by review of clinical records and interview. 4 of 5 (80%) records reviewed failed to provide documentation that the initial comprehensive assessment was completed no later than 5 calendar days after the election of hospice care. In review of Record #90669, it was identified that the patient was admitted 2/7/2022. There was no documentation of a MSW visit to complete a psychosocial assessment by 2/12/2022 which was 5 calendar days after the election of hospice care. In review of Record #11198, it was identified that the patient was admitted 1/31/2022. There was no documentation of a MSW visit to complete a psychosocial assessment by 2/5/2022 which was 5 calendar days after the election of hospice care. In review of Record #44753, it was identified that the patient was admitted 2/7/2022. There was no documentation of a MSW visit to complete a psychosocial assessment by 2/12/2022 which was 5 calendar days after the election of hospice care. In review of Record #92134, it was identified that the patient was admitted 3/14/2022. There was no documentation of a MSW visit to complete a psychosocial assessment by 3/19/2022 which was 5 calendar days after the election of hospice care. An interview was conducted with the Administrator/Director of Nursing on 3/29/2022 and it was confirmed that the initial comprehensive assessment was not completed no later than 5 calendar days after the election of hospice care and no additional information was provided.

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current: 1. Prescription and over-the-counter (OTC) drugs; 2. Supplements; 3. Herbal remedies; 4. Other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following: 1. The effectiveness of drug therapy; 2. Drug side effects; 3. Actual or potential drug interactions; 4. Duplicate drug therapy; 5. 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 record review and interview. 1 of 5 (20%) records reviewed failed to provide a drug profile. In review of Record #44753, it was identified that the drug profile was not present in the clinical record. The RN initial comprehensive assessment dated 3/7/2022 stated that the patient was taking Metoprolol succinate 500 mg which was changed from [BIB] to TID Q4H. and routine pain medicine. These medications were not included in the drug profile. In an in interview with the Administrator/Director of Nursing on 3/29/2022 it was confirmed that the nurse had documented the medications in the assessment but had not completed the drug profile and there was no additional information provided.

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. CONTINUING PRIOR REQUIRED ACTION This standard was not met as evidenced by review of clinical records and interview. In 1 of 5 (20%) clinical records reviewed, the POC failed to address the needs identified in the assessment. In review of Record #11198, the RN initial comprehensive assessment dated 1/31/2022 identified the patient was having increased pain in legs and documented the patient had prostate cancer with metastasis to the bones with a pain score of 4/10. The physician was notified and Norco 7.5mg/325mg 2 tabs every 4 hours was ordered. The POC did not provide the hospice care and services that were necessary to meet the patient's need for pain relief. An interview was conducted with the Administrator/Director of Nursing on 3/29/2022 and it was confirmed that the POC did not address the patient's pain and there was no further information provided.

It is required that medical social services are provided: 1. Based on a psychosocial assessment; 2. According to the patient’s and family’s needs and acceptance of these services; 3. Per the plan of care; 4. Under the direction of a physician. This standard was not met as evidenced by record review and interview. 1 of 5 (20%) records reviewed failed to provide documentation that medical social services were provided per the plan of care. In review of Record #11198 it was identified that the patient/family requested medical social services. The POC dated 1/31/2022 included MSW visit frequency orders for 1XM. There was no documentation of a MSW visit from 1/31/2022 to 3/5/2022 which was 33 days without a MSW visit. The Administrator/Director of Nursing was interviewed on 3/29/2022 and confirmed the MSW did not provide care as per the plan of care with no additional information provided.

It is required that the hospice documents and demonstrates viable and ongoing efforts to recruit and retain volunteers. THIS IS A CONTINUED REQUIRED ACTION. This standard was not met as evidenced by interview with the Administrator/Director of Nursing and the Volunteer Coordinator and review of the Volunteer Program. In an interview conducted on 3/29/2022, the Volunteer Coordinator stated that recruitment and retention activities were being done, but there was no documentation of the ongoing efforts to recruit and retain volunteers. The Administrator/Director of Nursing was interviewed on 3/29/2022 and stated the hospice was part of Volunteermatch.com but there was no documentation present that the agency demonstrated viable and ongoing efforts to recruit and retain volunteers.

It is required that the hospice medical director or physician designee reviews the clinical information for each patient being evaluated for admission and provides written certification that it is anticipated that the patient's life expectancy is six months or less if the illness runs its normal course. The physician considers the following when making this determination: 1. The primary terminal condition; 2. Related diagnosis(es), if any; 3. Current subjective and objective medical findings; 4. Current medication and treatment orders; 5. Information about the medical management of any of the patient's conditions unrelated to the terminal illness. This standard was not met as evidenced by review of clinical records and interview. In 1 of 5 (20%) clinical records reviewed, the physician evaluation of clinical information for the CTI did not include the required elements: the primary terminal diagnosis, related diagnosis, current subjective and objective medical findings, current medications and treatment orders. In review of Record #11198, the initial CTI narrative documented "patient fell and hit head again and is confused and unknown safety limits". This written narrative did not include the primary terminal diagnosis, related diagnoses, current subjective and objective medical findings or current medication and treatment orders. The Administrator/Director of Nursing was interviewed on 3/29/2022 and confirmed that the physician did not provide evidence that the required elements were considered when making a determination that the patient's life expectancy was six months or less and no additional information was provided. .

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. THIS IS A CONTINUED REQUIRED ACTION This standard was not met as evidenced by record review and interview. 1 of 1 (100%) of records reviewed in which the patient revoked services did not provide documentation that a discharge summary was forwarded to the attending physician. In review of Record #68623 it was identified that the patient was discharged on 8/14/2021. There was evidence of a discharge summary, but no documentation could be found that a discharge summary was provided to the attending physician. An interview was conducted with the Administrator/Director of Nursing on 3/29/2022 and it was confirmed that the clinical record did not contain evidence that the physician was sent a copy of the discharge summary and no additional information was provided.